Nursing Investigation Results -

Pennsylvania Department of Health
UNITED ZION RETIREMENT COMMUNITY
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
UNITED ZION RETIREMENT COMMUNITY
Inspection Results For:

There are  45 surveys for this facility. Please select a date to view the survey results.

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UNITED ZION RETIREMENT COMMUNITY - 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 Janaury 31, 2019, at United Zion Retirement Community, 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 #470402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 31, 2019, it was determined that United Zion Retirement Community 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 II (111), protected noncombustible structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
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 - Component: 01 - Tag: 0100

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.
35 P.S. 448.808. Issuance of license.
(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:
(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.
Based on observation and interview, it was determined the following item did not meet the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component.
Findings include:

1. Observation on January 31, 2019, between 11:00 AM and 3:00 PM, revealed the facility failed to supply the required accurate floor plans, showing all the required information for the Life Safety Survey.

Interview with the Director of Maintenance on January 31, 2019, at 3:00 PM confirmed accurate floor plans were not supplied.




 Plan of Correction - To be completed: 03/15/2019

K100- The building floor plan will be updated by 3/15/2019 and the updated floorplan will reflect building construction that occurs in the future by Environmental Services staff. This Life Safety Inspection will be reviewed at the QAPI Committee.
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 BUILDING - 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 margins, and to maintain door hardware to be complete, on one of two floors within the component.

Findings include:

1. Observation on January 31, 2019, at 1:40 PM revealed the common wall doors separating the Nursing Care from Personal Care, on the lower level, had a gap greater than 1/4 inch on the top, and was missing parts on the panic hardware.

Interview with the Director of Maintenance on January 31, 2019, at 1:40 PM confirmed the common wall doors exceeded the allowed gap margin.




 Plan of Correction - To be completed: 04/01/2019

K-133 the lower level common wall doors will be replaced to be within the allowed margins and to have functioning panic hardware. It will take twenty weeks/July 05, 2019, to obtain the newly ordered replacement door and a Time waiver will be requested. Environmental Services staff will monitor doors monthly and results reported to the QAPI 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 BUILDING - Component: 01 - Tag: 0225

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

Findings include:

1. Observation on January 31, 2019, between 12:45 PM and 2:15 PM revealed stairtower doors exceeded one eighth inch gap, at the following locations:

a. 12:45 PM, lower level, stairtower at the back of Kitchen;
b. 1:20 PM, lower level, stairtower door, by Central Supply;
c. 1:25 PM, lower level, stairtower to the Lobby door;
d. 1:55 PM, 1st floor, Farm House Stairtower;
e. 2:05 PM, 1st floor, stairtower by Resident Room 23C;
f. 2:15 PM, 1st floor, stairtower door by Resident Room 12C.

Interview with the Director of Maintenance on January 31, 2019, at 2:15 PM confirmed the stairtower doors exceeded the allowed gap margin.




 Plan of Correction - To be completed: 04/01/2019

K- 225 two stair tower doors, on two of the two floors, will be repaired by 03/15/2019 and four will be replaced in twenty weeks/July 5, 2019 to be within the allowed margins and a Time waiver will be requested. Environmental Services staff will monitor doors monthly and results reported to the QAPI Committee.
NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
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: MAIN BUILDING - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors to be within the allowed gap margins, and to be in good repair, on two of two floors within the component.

Findings include:

1. Observation on January 31, 2019, between 12:30 PM and 2:45 PM, revealed hazardous area doors exceeded one eighth inch gap, at the following locations:

a. 12:30 PM, lower level, Mechanical/Vending Machine Room;
b. 1:22 PM, lower level, Central Supply;
c. 1:30 PM, lower level, Tank Room;
d. 2:10 PM, 1st floor, Soiled Linen, by Resident Room 10;
e. 2:45 PM, 1st floor, Soiled Linen, by Resident Room 33.

Interview with the Director of Maintenance on January 31, 2019, at 2:45 PM confirmed the hazardous area doors exceeded the allowed gap margins.


2. Observation on January 31, 2019, between 12:30 PM and 2:45 PM, revealed hazardous area doors had penetrations through the doors, at the following locations:

a. 12:30 PM, lower level, Mechanical/Vending Machine Room;
b. 12:35 PM, lower level, Laundry (washer side) door.

Interview with the Director of Maintenance on January 31, 2019, at 2:45 PM confirmed there were penetrations through the doors.



 Plan of Correction - To be completed: 04/01/2019

K-321
a.) The Hazardous area doors, four will be replaced in twenty weeks/July 5, 2019, to obtain the newly ordered replacement doors and a Time waiver will be requested. One door will be repaired by 03/15/2019 to be within the allowed margins.
b.) The Hazardous area doors in lower mechanical/ vending machine room and the lower level laundry door penetration will be fixed by 03/15/2019. Environmental Services staff will monitor doors monthly and results reported to the QAPI Committee.

NFPA 101 STANDARD Corridor - Doors: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.
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 two of two floors within the component.

Findings include:

1. Observation on January 31, 2019, between 1:10 PM and 2:00 PM, revealed corridor doors failed to positively latch, at the following locations:

a. 1:10 PM, lower level Conference Room;
b. 2:00 PM, 1st floor Resident Room 32.

Interview with the Director of Maintenance on January 31, 2019, at 2:00 PM confirmed the doors did not positively latch.




 Plan of Correction - To be completed: 04/01/2019

K-363
The lower level conference room corridor door will be replaced in twenty weeks/July 5, 2019, to obtain the new door and a Time waiver will be requested. The first floor resident room 32 door was fixed 02/14/2019 to ensure closure. Weekly checks of this double door closure will be conducted by Environmental Services staff for 3 months and results reported to the QAPI 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 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 one of two floors within the component.

Findings include:

1. Observation on January 31, 2019, at 2:40 PM revealed a penetration inside a 2-inch conduit over the smoke barrier doors outside Resident Room 33, on the 1st floor.

Interview with the Director of Maintenance on January 31, 2019, at 2:40 PM confirmed there was a penetration.


 Plan of Correction - To be completed: 03/15/2019

K-372 the unsealed penetration inside a 2-inch conduit over the smoke barrier doors outside residents' room 33 on first floor will be fixed 03/15/2019 with fire-rated caulking seal the 2-inch penetration. Penetrations will be sealed by vendors or maintenance. A reminder letter will be sent by 03/15/2019 to our mechanical support vendors to remind them that each and every time there are penetrations in smoke barriers created, they are required to seal those penetrations with red fire caulk. Environmental Services staff will check the fire rated wall at least quarterly to ensure penetrations are sealed and results reported to the QAPI 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 BUILDING - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors to be smoke tight, on one of two floors within the component.

Findings include:

1. Observation on January 31, 2019, at 1:50 PM revealed the double smoke barrier doors, by the Ambulance Entrance, were equipped with latching hardware, which during the survey, did not close and latch.

Interview with the Director of Maintenance on January 31, 2019, at 1:50 PM confirmed the doors were not smoke tight due to hardware malfunction.


 Plan of Correction - To be completed: 02/14/2019

K-374 the double smoke barrier door by the ambulance entrance was adjusted to ensure closure on 02/14/2019 to latch when closed. Weekly checks of this double door closure will be conducted by Environmental Services staff for 3 months and results reported to the QAPI Committee.
Initial comments:Name: SUNROOM - Component: 03 - Tag: 0000


Facility ID #470402
Component 03
Sunroom Building

Based on a Medicare/Medicaid Recertification Survey completed on January 31, 2019, at United Zion Retirement Community, it was determined there were no deficiencies identified under the 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 V (111), protected wood frame structure, without a basement, which is fully sprinklered.



 Plan of Correction:



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