Pennsylvania Department of Health
MANOR AT PENN VILLAGE, THE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MANOR AT PENN VILLAGE, THE - 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 February 1, 2024, at The Manor at Penn Village, 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 #040302
Component 01
Main Building 01

Based on a Medicare/Medicaid Recertification Survey completed on February 1, 2024, it was determined that The Manor at Penn Village 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 483.70(a).

This is a one story, Type V (111), protected, wood-frame, fully sprinklered structure with partial basement.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain means of egress, affecting one of six smoke compartments.

Findings include:

1. Observation on February 1, 2024, at 12:00 pm, revealed the 1st floor exit door located in West Hall wing needed excessive force to be opened.

Interview at the time of the exit conference with the administrator and maintenance supervisor on February 1, 2024, at 12:30 pm, confirmed the exit door needed excessive force to be opened.

Plan of Correction - To be completed: 03/18/2024

1. The 1st Floor exit door located in West Hall wing, noted to need additional force to open when tested, will be repaired to proper function.

2. Additional exit doors will be reviewed for proper function.

3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Means of Egress- General specific to maintaining exit doors to proper function, and will continue to monitor in accordance with NFPA standards.

4. Any findings will be reported to the monthly QAPI Committee for further review.

NFPA 101 STANDARD Corridor - Doors:

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 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors on one of six smoke compartments.

Findings include;

1. Observation on February 1, 2024, at 12:05 pm, revealed the door to room 114 failed to latch in the frame when tested.

Interview at the time of the exit conference with the administrator and maintenance supervisor on February 1, 2024, at 12:30 pm, confirmed the door lacked positive latching.

Plan of Correction - To be completed: 03/18/2024

1. The door to resident room 114 will be repaired to properly latch when closed.

2. Additional resident room doors will be reviewed for proper latching.

3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Corridor- Doors specific to maintaining resident room doors to properly latch when closed, and will continue to monitor in accordance with NFPA standards.

4. Any findings will be reported to the monthly QAPI Committee for further review.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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, affecting four of six smoke compartments.

Findings include;

1. Observation on Febraury 1, 2024, between 11:40 am, and 12:08 pm, revealed the following smoke barrier doors failed to completely close when released from the hold open devices.

a. At 11:40 am, Smoke barrier doors at the top of the ramp (wood), near the exit.
b. At 12:08 pm, South hall smoke barrier doors, near room 105.

Interview at the time of the exit conference with the administrator and maintenance supervisor on February 1, 2024, at 12:30 pm, confirmed the smoke barrier doors did not close smoke tight.

Plan of Correction - To be completed: 03/18/2024

1. The cross-corridor smoke barrier doors that did not completely close when released from their hold-open devices, noted at the top of the ramp (wood) near the exit and South Hall near room 105, will be repaired to close smoke tight.

2. Additional cross-corridor smoke barrier doors will be reviewed for closing smoke tight when released from their hold-open devices.

3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Subdivision of Building Spaces- Smoke Barrier Doors specific to maintaining cross-corridor smoke barrier doors to close smoke tight when released form their hold-open devices, and will continue to monitor in accordance with NFPA standards.

4. Any findings will be reported to the monthly QAPI Committee for further review.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

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 monitor for the unauthorized use of power taps and extension cords.

Findings include:

1. Observation on February 1, 2024, at 12:02 pm, revealed several extension cords plugged into one another and being powered by a power tap.

Interview at the time of the exit conference with the administrator and maintenance supervisor on February 1, 2024, at 12:30 pm, confirmed the cords were plugged one to another and in use.

Plan of Correction - To be completed: 03/18/2024

1. The extension cords and power tap, noted to be in improper use, were removed.

2. Additional resident care areas will be reviewed for the improper use of extension cords and power taps.

3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Electronic Equipment- Power Cords and Extension Cords specific to the improper use of extension cords and power taps in resident care areas, and will continue to monitor in accordance with NFPA standards.

4. Any findings will be reported to the monthly QAPI Committee for further review.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID #040302
Component 02
Building 02

Based on a Medicare/Medicaid Recertification Survey completed on February 1, 2024, it was determined that The Manor at Penn Village 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 483.70(a).

This is a three story, Type II (222) fire resistive, fully sprinklered structure.

Plan of Correction:

NFPA 101 STANDARD Doors with Self-Closing Devices:

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain required self closing devices on doors on one of three floors.

Findings include;

1. Observation on February 1, 2024, at 10:50 am, revealed the self closing device to the activites storage room was removed.

Interview at the time of the exit conference with the administrator and maintenance supervisor on February 1, 2024, at 12:30 pm, confirmed the storage room door was not self closing.

Plan of Correction - To be completed: 03/18/2024

1. The self-closing device noted to be missing on the activities storage room door will be replaced.

2. Additional hazardous enclosure area doors will be reviewed for missing self-closing devices.

3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Doors with Self-Closing Devices specific to properly maintaining self-closing devices on hazardous area enclosure doors where required, and will continue to monitor in accordance with NFPA standards.

4. Any findings will be reported to the monthly QAPI Committee for further review.

NFPA 101 STANDARD Corridor - Doors:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors on one of three floors.

Findings include;

1. Observation on February 1, 2024, at 11:15 am, revealed the door to room 307 failed to latch in the frame when tested.

Interview at the time of the exit conference with the administrator and maintenance supervisor on February 1, 2024, at 12:30 pm, confirmed the door lacked positive latching.

Plan of Correction - To be completed: 03/18/2024

1. The door to resident room 307 will be repaired to properly latch when closed.

2. Additional corridor doors will be reviewed for proper latching.

3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Corridor- Doors specific to maintaining doors to properly latch when closed, and will continue to monitor in accordance with NFPA standards.

4. Any findings will be reported to the monthly QAPI Committee for further review.

NFPA 101 STANDARD Electrical Systems - Other:

Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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.
Chapter 6 (NFPA 99)

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain the electrical system on one of three floors.

Findings include;

1. Observation on February 1, 2024, at 11:10 am, revealed a broken outlet between the beds in room 322, on the 3rd floor.

Interview at the time of the exit conference with the administrator and maintenance supervisor on February 1, 2024, at 12:30 pm, confirmed the outlet was broken.

Plan of Correction - To be completed: 03/18/2024

1. The broken outlet noted between the beds in resident room 322 was replaced.

2. Additional resident room outlets will be reviewed for being broken.

3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Systems- Other specific to properly maintaining outlets in resident rooms, and will continue to monitor in accordance with NFPA standards.

4. Any findings will be reported to the monthly QAPI Committee for further review.

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