Nursing Investigation Results -

Pennsylvania Department of Health
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on May 13, 2019, at Manorcare Health Services-Whitehall Borough, 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# 10230200
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 13, 2019, it was determined that Manorcare Health Services-Whitehall Borough 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 two-story, Type II (111), protected non-combustible building, without a basement, that is fully sprinklered.

 Plan of Correction:

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. 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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with and
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to properly store oxygen cylinders in one instance, affecting one of ten smoke compartments.

Findings include:

1. Observation on May 13, 2019, at 9:49 a.m., revealed an aggregate volume of oxygen greater than 300 cubic feet was being stored in the employee entrance hallway, outside of an approved oxygen storage area.

Interview with the Facility Administrator and Maintenance Director on May 13, 2019, at 1:30 p.m., confirmed more than 300 cubic feet of oxygen was being stored outside of an approved oxygen storage area.

 Plan of Correction - To be completed: 06/26/2019

"The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein."


The Oxygen Cylinders have been removed from the employee entrance hall.

Plans will be submitted to Health Facility Plan Reviewer for the development of an additional Oxygen Storage in accordance with and

Prior to any further construction Oxygen cylinders will be stored appropriately per NFPA guidelines.

Random audits of Oxygen Cylinder Storage areas for compliance with regulations will be conducted by the Maintenance Director or designee weekly x 4 weeks, then monthly x 2 months. Identified trends will be reviewed by the QA&A committee for appropriate follow up monthly.

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