Nursing Investigation Results -

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

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

There are  29 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-MONTGOMERYVILLE - 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 22, 2019, it was determined that ManorCare Health Services-Montgomeryville, had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.


 Plan of Correction:


483.73(b)(6) REQUIREMENT Policies/Procedures-Volunteers and Staffing: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.
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. At a minimum, the policies and procedures must address the following:]

(6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

*[For RNHCIs at 403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency.

*[For Hospice at 418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
Observations:
Name: - Component: -- - Tag: 0024

Based on document review and interview, it was determined the facility failed to address the use of volunteers in an emergency or other emergency staffing strategies.

Findings Include:

1. Document review on April 22, 2019, between 8:30 am and 10:30 am, revealed the facility failed to provide an emergency preparedness plan that identified policies and procedures to facilitate support from volunteers with varying levels of skills and training during an emergency.

Interview at the exit conference with the Administrator and the Director of Maintenance on April 22, 2019, at 2:45 pm, confirmed the lack of documentation.



 Plan of Correction - To be completed: 05/28/2019

The facility will create an emergency preparedness plan that address's policies and procedures to facilitate support from volunteers with varying levels of skilled and training during an emergency.
The emergency preparedness plan will be reviewed and updated annually. Changes will be submitted to QAA for review and recommendations.
Initial comments:Name: BUILDING 02 (ARCADIA UNIT AND MAIN BUILDING) - Component: 02 - Tag: 0000


Facility ID# 382402
Component 02
Building 02
Arcadia Unit and Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 22, 2019, it was determined that ManorCare Health Services-Montgomeryville 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 V (111), protected wood frame construction, with unused attic spaces, which is fully sprinklered.


 Plan of Correction:


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: BUILDING 02 (ARCADIA UNIT AND MAIN BUILDING) - Component: 02 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain the exit access to be accessible at all times affecting one of six smoke compartments.

Findings include:

Observation made on April 22, 2019, at 2:15 pm, revealed that the 1st floor emergency exit door between dietary and resident dinning room was blocked by two large serving charts on wheels.

Interview at the exit conference with the Administrator and the Director of Maintenance on April 22, 2019, at 2:45 pm, confirmed that this exit was blocked.










 Plan of Correction - To be completed: 05/28/2019

The carts were removed at time of survey-Completed on 4-22-19

The Maintenance Director or designee will conduct weekly rounds to ensure that items are not blocking the emergency exit doors. Obstructions will be removed if indicated. Findings will be reported to the QAA Committee for review and recommendation.

NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: BUILDING 02 (ARCADIA UNIT AND MAIN BUILDING) - Component: 02 - Tag: 0321

Based on observation and interview it was determined that the facility failed to ensure that hazardous areas doors are self-closing affecting one of six smoke zones within this facility.

Findings include:

Observation made on April 22, 2019 at 2:00 pm, revealed that 1st floor kitchen storage room corridor door failed to close completely and positively latch into the frame.

Interview at the exit conference with the Administrator and the Director of Maintenance on April 22, 2019, at 2:45 pm, confirmed the storage room door failed to close and positively latch.










 Plan of Correction - To be completed: 05/28/2019

The door will be adjusted to close and latch into frame-Maintenance completed on 4-23-19

The Maintenance Director or designee will conduct weekly rounds on doors to ensure they close completely and latch into the frame. Repairs will be made if indicated. Findings will be reported to the QAA Committee for review and recommendation.
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: BUILDING 02 (ARCADIA UNIT AND MAIN BUILDING) - Component: 02 - Tag: 0345

Based on documentation review and interview, it was determined the facility failed to maintain required components of the fire alarm system within two of two units within this facility.

Findings include:

Review of documents on April 22, 2019, between 8:30 am and 10:30 am, revealed fire alarm system inspection dated April 12, 2019, stated that (2) air handling units connected to the fire alarm system failed to shut down the system in the event of a smoke/or fire condition.

Interview at the exit conference with the Administrator and the Director of Maintenance on April 22, 2019, at 2:45 pm, confirmed that corrected documentation was unavailable.















 Plan of Correction - To be completed: 05/28/2019

Contractor called to correct this issue-To be completed by 5-15-19

The Maintenance Director or designee will continue to monitor fire alarm inspections to ensure identified areas on inspection are corrected and supporting documentation is obtained. Findings will be reported to the QAA Committee for review and recommendation.
NFPA 101 STANDARD Smoke Detection: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.
Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2
Observations:
Name: BUILDING 02 (ARCADIA UNIT AND MAIN BUILDING) - Component: 02 - Tag: 0347

Based on documentation review and interview, it was determined the required smoke detectors are not maintained, inspected and/or tested in accordance with manufacturer's specifications affecting the entire facility.

Findings include:

1. Review of documents on April 22, 2019, between 8:30 am and 10:30 am, revealed facility failed to provide two year sensitivity testing documentation.

Interview at the exit conference with the Administrator and the Director of Maintenance on April 22, 2019, at 2:45 pm, confirmed the documentation was not available.









 Plan of Correction - To be completed: 05/28/2019

Two year sensitivity testing is scheduled for 5-10-19

The Maintenance Director or designee will continue to monitor smoke detectors to ensure manufacturer's specifications are followed and supporting documentation is obtained. Findings will be reported to the QAA Committee for review and recommendation.

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: BUILDING 02 (ARCADIA UNIT AND MAIN BUILDING) - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain that the doors protecting corridor openings, which are positive latching and resistive to the passage of smoke affecting one of six smoke compartments within this facility.

Findings:

Observation made on April 22, 2019, at 1:15 pm, 2nd floor C wing room 226 corridor door would not resist the passage of smoke due to a gap greater than a one half 1/2" inch between the door and door frame.

Interview at the exit conference with the Administrator and the Director of Maintenance on April 22, 2019, at 2:45 pm, confirmed door was not resistive to the passage of smoke.




 Plan of Correction - To be completed: 05/28/2019

The door will be adjusted and made to be smoke tight-Maintenance completed on 4-23-19

The Maintenance Director or Designee will conduct quarterly rounds to ensure corridor door gaps are not greater than one half inch between the door and frame repairs will be made if indicated. Findings will be reported to the QAA Committee for review and recommendation.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar: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.
Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.
Observations:
Name: BUILDING 02 (ARCADIA UNIT AND MAIN BUILDING) - Component: 02 - Tag: 0371

Based on document review, observation and interview, it was determined that the facility failed to provide at least two smoke compartments on each floor with more than 30 patients, affecting one of two floors of the building.

Findings include:

1. Observation and document review on April 22, 2019, at 8:45 am, revealed the second floor of the facility lacked complete smoke barrier walls. The walls did not extend above the second floor attic spaces.

Interview at the exit conference with the Administrator and the Director of Maintenance on April 22, 2019, at 2:45 pm, confirmed the smoke barriers on the 2nd floor did not extend to the deck above the attic.







 Plan of Correction - To be completed: 05/28/2019

The facility had an engineer survey the facility for the (FSES) and all information, the report was sent to Life Safety
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 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: BUILDING 02 (ARCADIA UNIT AND MAIN BUILDING) - Component: 02 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of the smoke barrier walls affecting one of six smoke compartments within this facility.

Findings include:

Observation made on April 22, 2019, at 1:35 pm, revealed above the 1st floor B wing smoke barrier doors by storage room had a unsealed penetration around 2" inch EMT conduit sleeve.

Interview at the exit conference with the Administrator and the Director of Maintenance on April 22, 2019, at 2:45 pm, confirmed the unsealed penetration.




 Plan of Correction - To be completed: 05/28/2019

The penetration will be sealed with an UL approved fire stop system and made to be smoke tight-Maintenance to complete by 5-15-19

The Maintenance Director or Designee will conduct quarterly rounds to ensure smoke penetrations are sealed. Repairs will be made if indicated. Findings will be reported to the QAA Committee for review and recommendation.


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