Nursing Investigation Results -

Pennsylvania Department of Health
LUTHER ACRES MANOR
Building Inspection Results

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LUTHER ACRES MANOR
Inspection Results For:

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LUTHER ACRES MANOR - 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 May 29, 2019, at Luther Acres Manor, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


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


Facility ID #122402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 29, 2019, it was determined that Luther Acres Manor 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 one-story, Type III (200), unprotected ordinary structure, with a partial basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: MAIN - Component: 01 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain common wall doors to be within the allowed gap margins, and to positively latch, affecting three of eleven smoke compartments within the component.

Findings include:

1. Observation on May 29, 2019, between 12:00 PM and 12:30 PM, revealed common wall doors exceeded the allowed gap margins, at the following locations:

a. 12:00 PM, separating Nursing from the Rehab Hall, by Resident Room 144;
b. 12:30 PM, separating Nursing from Personal Care, in the front corridor by the Main Entrance.

Interview with the Manager of Property Services on May 29, 2019, at 12:30 PM confirmed the common walls exceeded the allowed gap margins.


2. Observation on May 29, 2019, at 12:25 PM revealed the corridor fire-rated doors, separating Nursing from Katie's Grill, did not positively latch.

Interview with the Manager of Property Services on May 29, 2019, at 12:25 PM confirmed the common wall doors failed to positively latch.




 Plan of Correction - To be completed: 07/28/2019

*Time Limited Waiver Requested - Noted Below

Manager Property Services/designee will adjust the door Separating Nursing from Rehab Hall, by resident room 144 to have proper gap margins.

Manager Property Services/designee will adjust the door Separating Nursing from Personal Care, in the front corridor by the main entrance to have proper gap margins.

Manager Property Services/designee will notify door professional to repair and/or replace the door or replace the door closure Separating Nursing from Katy's Grill to positively latch. *Time Limited Waiver Requested

Manager Property Services/designee will conduct random audits of common wall doors to ensure doors do not exceed allowed gap margins and positively latch weekly for 4 weeks, then monthly routinely. In addition this will also be included as part of our monthly Environmental Safety Rounds. Audit results and corrective action(s) will be reported to the Quality Assurance and Performance Improvement Safety Committee for review and/or further recommendations as needed. Resolution to be determined by committee.



NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to matintain stairtowers to not be used for any other purpose, and stairtower doors to be within the allowed gap margins, on two of two floors within the component.

Findings include:

1. Observation on May 29, 2019, at 12:40 PM revealed storage of two P-tac units in the stairtower to the basement.

Interview with the Manager of Property Services on May 29, 2019, at 12:40 PM confirmed there was storage in the stairtower.

and the double doors had no positive latching at the lower level.



2. Observation on May 29, 2019, between 12:40 PM and 12:45 PM, revealed stairtower doors exceeded the allowed gap margins, at the following locations:

a. 12:40 PM, lower level, stairtower to the basement;
b. 12:45 PM, 1st level, stairtower corridor door, and screw missing from the hinges.

Interview with the Manager of Property Services on August 16, 2018, at 1:05 PM confirmed the doors exceeded the allowed gap margins.



 Plan of Correction - To be completed: 07/28/2019

*Time Limited Waiver Requested - Noted Below

Maintenance worker removed P-tac units from the stair tower on 5/29/19.

Manager of Property Services provided education to not store items in the stair tower to the Maintenance team on 5/29/19. Manager of Property Services also posted a sign in the stair tower indicating no storage permitted on 5/29/19.

Manager Property Services/designee ordered new replacement stair tower double door (lower level) that had no positive latching and that exceeded the allowed gap margins through door professional service. *Time Limited Waiver Requested

Manager Property Services/designee replaced the screw missing from the hinge on the 1st level stair tower corridor door. Ordered new hinges and a new replacement 1st level stair tower corridor door that exceeded the allowed gap margins through door professional service. *Time Limited Waiver Needed

Manager Property Services/designee will conduct a random audit of stair tower to ensure that the stair tower is free of stored items. Audits will be done weekly for 4 weeks, then monthly routinely. In addition this will also be included as part of our monthly Environmental Safety Rounds. Audit results and corrective action(s) will be reported to the Quality Assurance and Performance Improvement Safety Committee for review and/or further recommendations as needed. Resolution to be determined by committee.





NFPA 101 STANDARD Corridor - Doors:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Name: MAIN - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain the required smoke resistance of corridor doors, in four of eleven smoke compartments within the component.

Findings include:

1. Observation on May 29, 2019, between 11:00 AM and 12:20 PM, revealed corridor doors failed to positively latch, at the following locations:

a. 11:00 AM, Mechanical Room 20;
b. 11:55 AM, Resident Room 216;
c. 12:05 PM, Resident Room 131;
d. 12:20 PM, Kitchen, by the roll-down service window.

Interview with the Manager of Property Services on May 29, 2019, at 12:20 PM confirmed the corridor doors failed to positively latch.



 Plan of Correction - To be completed: 07/28/2019

Time Limited Waiver Requested - Noted Below.

Manager Property Services/designee has ordered and will replace the coordinator on the Mechanical Room door 20 when it arrives to ensure positive latching.

Manager Property Services/designee has ordered and will replace the latching hardware on Resident Room door 216 when it arrives to ensure positive latching.

Manager Property Services/designee has ordered and will replace Resident Room door 131 when it arrives to ensure positive latching. *Time Limited Waiver Requested

Dining Services Director/designee changed the location of the trash can in the Kitchen by the roll-down service window and will educate the Dining Services team on maintaining corridors doors to be free of impediment and positive latching.

Manager Property Services/designee will conduct random audits of corridor doors to ensure doors positively latch weekly for 4 weeks, then monthly routinely. In addition this will also be included as part of our monthly Environmental Safety Rounds. Audit results and corrective action(s) will be reported to the Quality Assurance and Performance Improvement Safety Committee for review and/or further recommendations as needed. Resolution to be determined by committee.


NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: MAIN - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors to be resistant to the passage of smoke, affecting four of eleven smoke compartments within the component.

Findings include:

1. Observation on May 29, 2019, at 11:25 AM revealed the double smoke barrier door, by Resident Room 222, did not close to be smoke tight.

Interview with the Manager of Property Services on May 29, 2019, at 11:25 AM confirmed the doors could not resist the passage of smoke.


2. Observation on May 29, 2019, at 11:50 AM revealed the double smoke barrier door by Resident Room 207 did not close to be smoke tight.

Interview with the Manager of Property Services on May 29, 2019, at 11:50 AM confirmed the doors could not resist the passage of smoke.





 Plan of Correction - To be completed: 07/28/2019

Manager Property Services/designee will adjust the double smoke barrier door by Resident Room 222 to close to be smoke tight.

Manager Property Services/designee will adjust the double smoke barrier door by Resident Room 207 to close to be smoke tight.

Manager Property Services/designee will conduct a random audit of smoke barrier doors to ensure doors close to be smoke tight weekly for 4 weeks, then monthly routinely. In addition this will also be included as part of our monthly Environmental Safety Rounds. Audit results and corrective action(s) will be reported to the Quality Assurance and Performance Improvement Safety Committee for review and/or further recommendations as needed. Resolution to be determined by committee.



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