Nursing Investigation Results -

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

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MANORCARE HEALTH SERVICES-PITTSBURGH
Inspection Results For:

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MANORCARE HEALTH SERVICES-PITTSBURGH - 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 6, 2019, at Manorcare Health Services-Pittsburgh, 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# 140102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 6, 2019, it was determined that Manorcare Health Services-Pittsburgh 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 (000), unprotected noncombustible building, with a basement, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain the building construction requirements for the entire building.

Findings include:

1. Observation and interview on May 6, 2019, at 8:30 a.m., revealed the building is a three-story, unprotected noncombustible structure, that is fully sprinklered. This type of construction is not permitted to be greater than two stories in height.

Interview with the Administrator, Assistant Administrator and Maintenance Director on May 6, 2019, at 8:30 a.m., confirmed the construction type did not meet the requirements for an existing building.







 Plan of Correction - To be completed: 06/13/2019

Facility has secured contracted services through ACC Fire Pro were secured and a new FSES was completed on June 8th 2017. Facility will utilize most recent FSES on file.
Nursing Home Administrator/designee will re-educate maintenance staff of K0161, building construction type and height.


NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on documentation review and interview, it was determined the facility failed to maintain the cooking equipment in two instances, affecting the entire facility.

Findings include:

1. Documentation review and interview on May 6, 2019, at 8:30 a.m., revealed the following:

a) The facility failed to have the two required semi-annual kitchen suppression inspections performed since the previous Life Safety Survey on April 16, 2018;
b) The hood cleaning report dated December 26, 2018, revealed portions of the ductwork were inaccessible and were not able to be cleaned.

Interview with the Administrator, Assistant Administrator and Maintenance Director on May 6, 2019, at 2:00 p.m., confirmed the cooking equipment deficiencies.





 Plan of Correction - To be completed: 06/13/2019

Facility completed Spring 2019 Kitchen Suppression inspection on May 8th, 2019.
Duct work cleaning has been scheduled to be done through Kool Kleen on May 21st 2019.
Audits of the Kitchen Suppression test, duct work cleanings, and whole kitchen safety readiness are to be done once a week for four weeks by Maintenance Director/designee.
Nursing Home Administrator/designee will re-educate maintenance staff of K0324, cooking facilities and the results of kitchen audits will be reviewed in facility quality assurance and assessment committee.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345


Based on observation and interview, it was determined the facility failed to maintain the fire alarm system in one instance affecting the entire facility.

Findings include:

1. Observation on May 6, 2019, revealed the main fire alarm control panel was showing a trouble code.

Interview with the Administrator, Assistant Administrator and Maintenance Director on May 6, 2019, at 2:00 p.m., confirmed the fire alarm deficiency.






 Plan of Correction - To be completed: 06/13/2019

According to NFPA 101 Fire Alarm system and Maintenance:
Part ordered for Fire Alarm system in order to discontinue trouble signal on system as well as a new smoke detector was ordered and will be installed May 23rd.
Nursing Home Administrator/designee will monitor system once a week for four weeks making sure system does not display a trouble signal as well as re-educate maintenance staff on how to properly monitor system.
Results of this audit will be reviewed in facility quality assurance and assessment committee.


NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, for one of four quarterly sprinkler inspections.

Findings include:

1. Documentation review and interview on May 6, 2019, at 8:30 a.m., revealed the facility failed to have the third quarter automatic sprinkler system inspection performed.

Interview with the Administrator, Assistant Administrator and Maintenance Director on May 6, 2019, at 2:00 p.m., confirmed the automatic sprinkler inspection deficiency.





 Plan of Correction - To be completed: 06/13/2019

Sprinkler system inspections, since 3rd quarter inspection was missed are to be completed every quarter according to regulation.
Administrator/designee will re-educate Maintenance director to do sprinkler inspections every quarter with no gaps in the schedule for 2019.
Audits will be performed once a week for four weeks to ensure sprinkler inspections are being completed by the Nursing Home Administrator.

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 BUILDING 01 - Component: 01 - Tag: 0374


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

Findings include:

1. Observation on May 6, 2019, at 9:32 a.m., revealed the smoke barrier doors in the basement, near the storage room, had a gap > 1/8", where the two door leaves meet, which would prevent the doors from resisting the passage of smoke.

Interview with the Administrator, Assistant Administrator and Maintenance Director on May 6, 2019, at 2:00 p.m., confirmed the smoke barrier door deficiency.








 Plan of Correction - To be completed: 06/13/2019

Door in smoke compartment was fixed to the 1/8th regulation gap for smoke doors on May 10th, 2019.
Nursing Home Administrator/designee will re-educate maintenance staff on proper gap allowed according to regulation for all fire doors.
Audits of the smoke door will be done once a week for four weeks to ensure smoke doors remains in compliance with gap regulation by the Nursing Home Administrator.
Results of this audit will be reviewed in quality assurance and assessment committee.

NFPA 101 STANDARD Electrical Systems - Receptacles: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.
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 one instance, in one of more than 50 receptacles inspected.

Findings include:

1. Observation on May 6, 2019, at 9:45 a.m., revealed a damaged electrical outlet in the basement South Corridor across from the storage room.

Interview with the Administrator, Assistant Administrator and Maintenance Director on May 6, 2019, at 2:00 p.m., confirmed the electrical outlet deficiency.





 Plan of Correction - To be completed: 06/13/2019

Electrical receptacle in south corridor basement was fixed on May 7th to be in compliance with regulation.
Nursing Home Administrator/designee will re-educate Maintenance director on how to properly maintain electrical receptacles.
Audits of properly maintained receptacles will be done once a week for 4 weeks by the Maintenance director.
Results of audits will reviewed in facility quality assurance assessment committee.



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