Pennsylvania Department of Health
CHAPEL MANOR
Building Inspection Results

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CHAPEL MANOR
Inspection Results For:

There are  49 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.
CHAPEL MANOR - 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 March 27, 2024, at Chapel Manor, 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# 031602
Component 01

Based on a Medicare/Medicaid Recertification Survey completed on March 27, 2024, it was determined Chapel Manor was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 (222), fire resistive building, with a basement, that 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 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined that the facility failed to maintain the fire-resistance rating of stair towers, affecting one of three levels.

Findings include:

Observation on March 27, 2024, at 10:50 a.m., revealed D-wing back hall stair tower door had open holes where the astragal was removed.

Exit Interview with the Administrator and Maintenance Director on March 27, 2024, at 12:15 p.m., confirmed the stair tower door deficiency.




 Plan of Correction - To be completed: 05/20/2024

Back hall stairways door was repaired,the opening have been sealed.
Maintenance staff will be educated on proper servicing of fire doors.
Audit will be performed on all fire doors to ensure doors are in good condition.
Maintenance will complete weekly audits of random doors for 4 weeks.

NFPA 101 STANDARD Emergency Lighting: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.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to maintain its emergency lighting, affecting one of three levels.

Findings include:

Document review on March 27, 2024, at 9:00 a.m., revealed the facility lacked documentation of the following required tests of the battery back-up lighting:

a. monthly 30-second testing.
b. annual 90-minute test.

Exit Interview with the Administrator and Maintenance Director on March 27, 2024, at 12:15 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 05/20/2024

All backup lights test documents are available in the life safety book and are up to date.
The Maintenance Director will ensure documentation is filed timely.

NFPA 101 STANDARD Exit Signage: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.
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed to ensure that exit signs were maintained, affecting one of three levels.

Findings include:

Observation on March 27, 2024, at 10:15 a.m., revealed, ground floor electrical room exit sign was not illuminated.

Exit Interview with the Administrator and Maintenance Director on March 27, 2024, at 12:15 p.m., confirmed the exit sign deficiency.




 Plan of Correction - To be completed: 05/20/2024

Exit sign was replaced
Maintenance staff have been educated on inspecting exit signs for proper lighting All exit signs will be inspected for proper lighting
Maintenance will complete weekly audits for 6 weeks and then monthly

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: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous areas in sprinklered locations, affecting one of three levels.

Findings Include:

Observation on March 27, 2024, at 10:55 a.m., revealed, on the second floor, D-wing Soiled room door had an open hole where hardware was removed.

Exit Interview with the Administrator and Maintenance Director on March 27, 2024, at 12:15 p.m., confirmed the door deficiency.




 Plan of Correction - To be completed: 05/20/2024

Door knob has been replaced
Maintenance staff will be educated on ordering and completing maintenance tasks
timely
Audit of all soiled linen rooms doors weekly for 6 weeks

NFPA 101 STANDARD Portable Fire Extinguishers: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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based upon observation and interview, it was determined the facility failed to ensure that portable fire extinguishers were maintained, affecting two of three levels.

Observations on March 27, 2024, revealed cabinet fire extinguisher indicator lights were not illuminated in the following locations:

a. 10:25 a.m., ground floor kitchen hall.
b. 11:50 a.m., on the first floor, A-wing.

Exit Interview with the Administrator and Maintenance Director on March 27, 2024, at 12:15 p.m., confirmed the burned-out bulbs.




 Plan of Correction - To be completed: 05/20/2024

Fire extinguisher lights were replaced
Maintenance staff will be educated on
inspecting fire extinguisher lights
Initial audit of all lights over fire extinguishers was completed.
Random audits will be completed for 6 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 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to ensure smoke barrier doors resist the passage of smoke, affecting two of three levels.

Observations on March 27, 2024, revealed the following smoke barrier doors failed to fully close smoke tight when tested:

a. 10:30 a.m., on the ground floor- coordinator not functioning.
b. 11:00 a.m., on the second floor, D-wing- catching on astragal.

Exit Interview with the Administrator and Maintenance Director on March 27, 2024, at 12:15 p.m., confirmed the doors failed too fully close.




 Plan of Correction - To be completed: 05/20/2024

D-wing doors were repaired so it can close properly and fully.
Ground floor coordinator has been replaced.
Maintenance staff will be educated on all fire doors for properly opening and closing
Maintenance supervisor will audited doors for 6 weeks

NFPA 101 STANDARD Utilities - Gas and Electric: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.
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting one of three levels.

Findings include:

Observation on March 27, 2024, at 11:20 a.m., revealed a non-GFCI outlet within six feet of a sink, on the first Floor, B-wing Med Room. Per NFPA 70 210.8(B)5, a GFCI outlet is required where receptacles are installed within six ft of the outside edge of the sink.

Exit Interview with the Administrator and Maintenance Director on March 27, 2024, at 12:15 p.m., confirmed a GFCI outlet was not installed within six ft of the sink.




 Plan of Correction - To be completed: 05/20/2024

GFCI outlet has been replaced
Outlets will be audited to ensure they meet the NFPA standard.
Maintenance staff will be educated on appropriate outlets
Weekly audit will be completed for 6 weeks

NFPA 101 STANDARD Smoking Regulations: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.
Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain smoking areas, affecting one of three levels.

Findings include:

1. Observation on March 27, 2024, at 8:15 a.m., revealed a 2- staff employees smoking outside the stairwell door next to the building. This is not the designated smoking area.

Exit Interview with the Administrator and Maintenance Director on March 27, 2024, at 12:15 p.m., confirmed the employees smoking.

2. Observation on March 27, 2024, at 11:45 a.m., revealed the designated smoking area trashcan had combustible debris mixed in with discarded cigarette butts.

Exit Interview with the Administrator and Maintenance Director on March 27, 2024, at 12:15 p.m., confirmed the deficiency.




 Plan of Correction - To be completed: 05/20/2024

Smoking area has been cleaned and all buds were removed
All employees have been educated on designated smoking area
All resident have been educated in resident council meeting on where to put all trash and
where to put cigarettes buds in (smoking area)
Audits will be completed weekly for 6 weeks to ensure the smoking area is well
maintained

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain required testing of emergency generator components, affecting the entire facility.

Findings Include:

Document review on March 27, 2024, at 9:00 a.m., revealed the facility lacked verifying documentation of the following emergency generator maintenance items:

a. annual 90-minute load bank.

Exit Interview with the Administrator and Maintenance Director on March 27, 2024, at 12:15 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 05/20/2024

The 90 minute annual load test was performed on 4/5/2024
Audit will be conducted to ensure all service inspections are logged/file
Maintenance staff will be educated on timely filing of inspection/service maintenance Records.
Audits will be conducted weekly for 6 weeks

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of electrical devices affecting one of three levels.

Findings include:

Observation on March 27, 2024, at 10:40 a.m., revealed, on the ground floor, Nurse Practitioners ' Office, a microwave and a fridge were plugged into a surge protector.

Exit Interview with the Administrator and Maintenance Director on March 27, 2024, at 12:15 p.m., confirmed the unauthorized electrical device.




 Plan of Correction - To be completed: 05/20/2024

Power strip was removed from Nurse Practitioners' office
Staff will be re-educated on the restriction of surge protector usage.
Office will be audited to ensure no surge protector is in use
Maintenance will complete weekly audits of surge protectors for 6 weeks


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