Nursing Investigation Results -

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

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MANORCARE HEALTH SERVICES-POTTSVILLE
Inspection Results For:

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MANORCARE HEALTH SERVICES-POTTSVILLE - 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 21, 2019, at Manorcare Health Services-Pottsville, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


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


Facility ID #383802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 21, 2019, it was determined that Manorcare Health Services-Pottsville 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 structure, with a ground floor, and an unused, inaccessible basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
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 BUILDING - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain stairtower door gaps to be within the allowed margins, on two of four floors within the component.

Findings include:

1. Observation on May 21, 2019, between 1:05 PM and 1:30 PM, revealed stairtower doors had gaps that exceeded one eighth inch, at the following locations:

a. 1:05 PM, 1st floor, by Resident Room 146:
b. 1:15 PM, 1st floor, by Resident Room 113;
c. 1:30 PM, 3rd floor, by Resident Room 328.

Interview with the Director of Maintenance on May 21, 2019, at 1:30 PM confirmed the stairtower doors exceeded the allowed gap margins.





 Plan of Correction - To be completed: 06/24/2019

1)Stair tower door by room 146 has been fixed. Stair tower door by room 328 has been fixed. Stair tower door by room 113 will be fixed by 6/13/19.
2)Remaining stair tower doors have been checked and are smoke tight.
3) Maintenance director has been in serviced on proper gaps allowed to smoke doors
4) Maintenance director or designee will audit stair tower doors for gaps weekly for 4 weeks.
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 BUILDING - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors to positively latch, on one of four floors within the component.

Findings include:

1. Observation on May 21, 2019, at 2:00 PM revealed the corridor door to Resident Room 270 was hitting the frame, and failed to positively latch.

Interview with the Director of Maintenance on May 21, 2019, at 2:00 PM confirmed the door failed to close and positively latch.




 Plan of Correction - To be completed: 06/24/2019

1) Door for room 270 has been fixed and properly latches.
2) Building wide the doors were checked for any improperly closing.
3) Maintenance team was in serviced on making sure all room doors close properly.
4) Maintenance director or designee will audit the proper closing of resident room doors 8 per week for 4 weeks.
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: MAIN BUILDING - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the rating of smoke barrier walls, on two of four floors within the component.

Findings include:

1. Observation on May 21, 2019, between 12:30 PM and 2:00 PM, revealed penetrations above the smoke barrier doors, at the following locations:

a. 12:30 PM, 1st floor, by the Kitchen, around data wires, inside conduits, and two 4-inch PVC pipes, which lacked fire collars.
b. 1:10 PM, 1st floor, over the corridor double door by Resident Room 104, around blue data wires;
c: 2:00 PM, 2nd floor, over the corridor double door outside Resident Room 270, around blue data wires.

Interview with the Director of Maintenance on May 21, 2019, at 2:00 PM confirmed there were penetrations.





 Plan of Correction - To be completed: 06/24/2019

1)The penetrations around the data wires and inside conduits were caulked fire caulking. The penetrations around the PVC pipes had the proper collars applied.
2)Like areas in the facility were checked and any penetrations found were caulked.
3) Maintenance team was in serviced on proper repair of penetrations through smoke barrier walls.
4) Maintenance director or designee will audit smoke barrier walls weekly for 4 weeks.
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 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain the smoke barrier doors to meet the allowed gap margins, to self-close and be resistant to the passage of smoke, and to be tied into the fire alarm system, on two of four floors within the component.

Findings include:

1. Observation on May 21, 2019, between 12:40 PM and 1:10 PM, revealed smoke barrier doors exceeded one eighth of an inch gap, at the following locations:

a. 12:40 PM, by Resident Room 140, along the top, greater than 3/16 inch, and had a screw missing from the vision panel and hinges;
b. 1:10 PM, by Resident Room 104, had gaps along the top, greater than 3/16 inch.

Interview with the Director of Maintenance on May 21, 2019, at 1:10 PM confirmed the smoke barrier doors exceeded the allowed gap margins.

2. Observation on May 21, 2019, at 2:00 PM revealed the double smoke barrier door by Resident Room 207 was hitting the frame and failed to close to be smoke resistant.

Interview with the Director of Maintenance on May 21, 2019, at 2:00 PM confirmed the smoke barrier doors could not resist the passage of smoke.


3. Observation on May 21, 2019, at 2:18 PM revealed the smoke barrier door to the 1st floor Elevator Corridor, by the Dining/Activity Room, had hold-open closures installed and were not tied to fire alarm hold-open devices.

Interview with the Director of Maintenance on May 21, 2019, at 2:18 PM confirmed the smoke doors were not tied to the fire alarm system.



 Plan of Correction - To be completed: 06/24/2019

1) Smoke barrier door by 140 will have door adjusted to proper gap and have screw replaced by 6/13/19. Smoke barrier door at room 104 has been adjusted to proper gap.
2) all like doors (7) in facility have been checked and are withing proper gap level.
3) Maintenance team have been in serviced on allowable gap level.
4) Weekly maintenance director or designee will audit the gap size on the smoke barrier doors for 4 weeks.

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