Nursing Investigation Results -

Pennsylvania Department of Health
MANORCARE HEALTH SERVICES-SHADYSIDE
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MANORCARE HEALTH SERVICES-SHADYSIDE
Inspection Results For:

There are  28 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
MANORCARE HEALTH SERVICES-SHADYSIDE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on April 29, 2019, at Manorcare Health Services-Shadyside, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 090302
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 29, 2019, it was determined that Manorcare Health Services-Shadyside was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a four-story, Type II (222), fire resistive building, without a basement, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100


Based on observation and interview, it was determined the facility failed to install carbon monoxide alarms in an area that can be heard by staff in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act, affecting the entire facility.

Findings include:

1. Observation and interview on April 29, 2019, revealed the facility failed to install carbon monoxide alarms that can be heard by staff at all times in the following locations:

a) 9:30 a.m., in the first floor laundry room;
b) 9:37 a.m., in the first floor boiler room.

Interview with the Administrator, Director of Nursing and Maintenance Supervisor on April 29, 2019, at 1:00 p.m., confirmed the carbon monoxide alarm deficiencies.





 Plan of Correction - To be completed: 06/05/2019

The Maintenance Director/designee will ensure that the carbon monoxide alarms in the first floor laundry room and first floor boiler room alarm to an area that can be heard by staff.
Maintenance Director will be educated on the need for carbon monoxide alarms to alarm in an area that can be heard by staff in accordance with the 2016 Act 48 Care Facility Carbon Monoxide Alarms Standards act by the Administrator/designee.
The Maintenance director/designee will complete weekly audits x4 to ensure the carbon monoxide alarms in the first floor laundry room and first floor boiler room alarm to an area that can be heard by staff. Results of these audits will be forwarded to the QAPI committee for review and recommendation.

NFPA 101 STANDARD Vertical Openings - Enclosure:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of vertical openings in four instances in three of four vertical openings in the facility.

Findings include:

1. Observation on April 19, 2019, revealed the fire resistance rating in the following locations was not maintained:

a) 9:45 a.m., there was an 8"x5" opening in the elevator shaft on the first floor, in the space between the cars;
b) 11:50 a.m., there was an 8"x8" hole in the North Stairwell on the third floor, in front of the access panel;
c) 11:55 a.m., there were two holes, aproximately 1 foot square in the North stairwell on the second floor, in front of the access panel;
d) 11:59 a.m., there was a section of the second floor South Stairwell, approximately 16"x36", that was incomplete to the deck above. Observed from the adjacent Nutrition Room.

Interview with the Administrator, Director of Nursing and Maintenance Supervisor on April 29, 2019, at 1:00 p.m., confirmed the vertical opening deficiencies.





 Plan of Correction - To be completed: 06/05/2019

The Maintenance Director/designee will ensure that the identified penetrations are filled and have a fire resistance rating of at least 1 hour.
Maintenance Director will be educated on the need for stairways, elevator shafts, light and ventilation shafts, and other vertical openings between floors to be enclosed with construction having a fire resistance rating of at least 1 hour by the Administrator/designee.
The Maintenance director/designee will complete weekly audits x4 randomly of vertical shaft penetrations to ensure they have a fire resistance rating of at least 1 hour. Results of these audits will be forwarded to the QAPI committee for review and recommendation.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port