Pennsylvania Department of Health
MORRISONS COVE HOME
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MORRISONS COVE HOME - 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 January 17, 2023, at Morrisons Cove Home 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# 133702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 16 and 17, 2024, it was determined that Morrisons Cove Home 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 three-story, Type II (111), protected non-combustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

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 maintain the interior walls of the facility in one instance, affecting one of twelve smoke compartments.

Findings include:

1. Observation on January 16, 2024, at 11:24 a.m., revealed multiple broken tiles at the bottom of the tile walls in the south wing odd hall shower/whirlpool room allowing water to leak under the wall and floor of the facility.

Interview with the Facility CEO, Maintenance Director, and Facility Staff on January 17, 2024, at 1:30 p.m., confirmed the listed interior wall deficiency.

Plan of Correction - To be completed: 03/01/2024

The maintenance department will remove all broken tiles identified during the inspection in the South wing odd whirlpool room and replace them with new ones. The Maintenance Director will inspect the rest of the whirlpool rooms and report his findings at the next quality assurance committee meeting.

NFPA 101 STANDARD Means of Egress - General:

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.

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain exit access in one instance, affecting four of twelve smoke compartments.

Finding included:

1. Observation on January 16, 2024, at 12:55 p.m., revealed the main entrance stairwell was not in compliance with NFPA 101 section 7.7.3. The exit discharge for the main entrance stairwell is located on the first floor and the stairs continue uninterrupted to the basement.

Interview with the Facility CEO, Maintenance Director, and Facility Staff on January 17, 2024, at 1:30 p.m., confirmed the listed exit access deficiency.

Plan of Correction - To be completed: 03/01/2024

On 1-30-2024 the Maintenance Supervisor ordered a gate for the main entrance stairwell. The gate will be installed once it arrives. The Director of Maintenance will inspect all other exit stairs to ensure no other gate is needed and report his findings at the next quality assurance committee meeting.

NFPA 101 STANDARD Vertical Openings - Enclosure:

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 vertical opening enclosures in three instances, affecting eight of twelve smoke compartments.

Findings include:

1. Observation on January 16, 2024, revealed the following vertical opening enclosure deficiencies:

a) 1:04 p.m., in the nursing supply storage room located in the basement there were multiple unsealed conduit penetrations in the concrete deck above:
b) 1:14 p.m., there were multiple unsealed penetrations in the mechanical chase located behind the dryers in the laundry room:
c) 1:17 p.m., the fire-rated door protecting the laundry chute room was separating and an unapproved method of repair was in place (the door was being held together with drywall screws).

Interview with the Facility CEO, Maintenance Director, and Facility Staff on January 17, 2024, at 1:30 p.m., confirmed the listed vertical opening enclosure deficiencies.

Plan of Correction - To be completed: 03/01/2024

The Maintenance department sealed the nursing supply storage room conduits with approved fire sealant on 1-25-24 and the mechanical chase behind the dryers on 1-31-24. Director of Maintenance ordered a new door for the laundry chute room on 1-24-24. When the door arrives it will be installed. The Maintenance director will inspect the rest of the nursing supply storage room, the area behind the dryers and the rest of the doors in the laundry area and report his findings at the next quality assurance committee meeting.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Plan of Correction - To be completed: 03/01/2024

a) Director of Maintenance contacted the sprinkler contractor on 2-1-24 to adjust the sprinkler head in the 3rd floor nurses lounge closet. Maintenance director will inspect the surrounding area for other sprinkler head deficiencies and report his findings at the next quality assurance committee meeting. b,c,d,e) the ceiling penetrations in the PT office closet, housekeeping closet by Therapy, Medical records office, and Activities storage room were sealed on 1-29-24. The director of Maintenance will inspect the remainder of those areas and report his findings at the next quality assurance committee meeting, f) the Activities Director removed the storage above the 18" horizontal sprinkler plane. All staff will be educated by 2-2-24 in regards to storage height restrictions. The Maintenance director will install signage and inspect the activities storage room and report his findings at the next quality assurance committee meeting.

NFPA 101 STANDARD Corridor - Doors:

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 BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors in one instance, affecting one of twelve smoke compartments.

Findings include:

1. Observation on January 16, 2023, at 10:14 a.m., revealed the door to resident room 205 would not close and latch in its frame when tested.

Interview with the Facility CEO, Maintenance Director, and Facility Staff on January 17, 2024, at 1:30 p.m., confirmed the listed corridor door deficiency.

Plan of Correction - To be completed: 03/01/2024

The Maintenance department repaired the door latch strike plate on resident room 205 on 1-25-24. The Director of Maintenance will inspect the remainder of the 2nd floor resident room doors and report his findings at the next quality assurance committee meeting.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls in two instances, affecting four of three smoke compartments.

Findings include:

1. Observation on January 16, 2024, revealed the following smoke barrier wall deficiencies:

a) 11:00 a.m., there were multiple unsealed wire penetrations above the ceiling at the smoke barrier doors by the PT office;
b) 11:18 a.m., there were multiple unsealed data wires above the ceiling at the south unit entrance doors.

Interview with the Facility CEO, Maintenance Director, and Facility Staff on January 17, 2024, at 1:30 p.m., confirmed the listed smoke barrier wall deficiencies.

Plan of Correction - To be completed: 03/01/2024

The Maintenance director sealed the penetrations with approved fire sealant above the smoke barrier doors by Therapy on 1-25-24. He also sealed the penetrations above the South wing entrance door on 1-31-24. Maintenance Director will inspect those areas and report his findings at the next quality assurance committee meeting.

NFPA 101 STANDARD Electrical Systems - Receptacles:

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on observation and interview, it was determined the facility failed to maintain electrical receptacles in two instances, for two of over 50 receptacles inspected.

Findings include:

1. Observation on January 16, 2024, revealed the following electrical receptacle deficiencies:

a) 10:20 a.m., there was an electrical receptacle within six feet of a sink in the second-floor nurse station B clean utility room that was not GFCI protected;
b) 10:40 a.m., there was a broken electrical receptacle in the BD hallway by room 105.

Interview with the Facility CEO, Maintenance Director, and Facility Staff on January 17, 2024, at 1:30 p.m., confirmed the listed electrical receptacle deficiencies.

Plan of Correction - To be completed: 03/01/2024

The Maintenance Director replaced the outlet in the 2nd floor clean utility with a GFCI receptacle on 1-25-24. The Maintenance Director will inspect the rest of 2nd floor for outlets within 6 feet of a sink and report his findings at the next quality assurance committee meeting.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID# 133702
Component 02
Dietary Addition

Based on a Medicare/Medicaid Recertification Survey completed on January 16 and 17, 2024, it was determined that Morrisons Cove Home 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 II (111), protected non-combustible building, without a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Doors with Self-Closing Devices:

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.

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain self-closing doors in one instance, affecting one of one smoke compartments.

Findings include:

1. Observation on January 16, 2024, at 11:55 a.m., revealed the self-closing door to the kitchen dry storage room was being held open with an unapproved hold-open device (there was a ladder being used to hold the door open).

Interview with the Facility CEO, Maintenance Director, and Facility Staff on January 17, 2024, at 1:30 p.m., confirmed the listed self-closing door deficiency.

Plan of Correction - To be completed: 03/01/2024

The Director of Dietary removed the ladder immediately upon being found. All staff will be educated by 2-2-24 on the regulations regarding storage room doors with self-closing devices. The Director of Maintenance will inspect the dry goods storage door and all other Dietary storage doors and report his findings at the next quality assurance committee meeting.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting one of one smoke compartments.

Findings include:

1. Observation on January 16, 2024, at 11:57 a.m., revealed the facility failed to maintain a heat/smoke resistive ceiling for the proper activation/operation of the automatic sprinkler system. There were multiple unsealed penetrations in the ceiling of the kitchen hallway.

Interview with the Facility CEO, Maintenance Director, and Facility Staff on January 17, 2024, at 1:30 p.m., confirmed the listed automatic sprinkler system deficiency.

Plan of Correction - To be completed: 03/01/2024

The Director of Maintenance sealed the penetrations in the kitchen hallway on 1-25-24. The Maintenance Director will inspect the rest of the Dietary hallway and report his findings at the next quality assurance committee meeting

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