Nursing Investigation Results -

Pennsylvania Department of Health
EPHRATA MANOR
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
EPHRATA MANOR
Inspection Results For:

There are  35 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.
EPHRATA 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 February 11, 2020, at Ephrata 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 - Component: 01 - Tag: 0000


Facility ID #053502
Component 01
Main Building (Long Term Care and Core Building)

Based on a Medicare/Medicaid Recertification Survey completed on February 11, 2020, it was determined that Ephrata Manor 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, with a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Vertical Openings - 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.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain the rating of vertical shafts, affecting one of three floors within the component.

Findings include:

1. Observation on February 11, 2020, at 10:28 AM revealed the 2nd floor access panel to the shaft containing the linen chute did not automatically close and latch within the frame.

Interview with the Director of Environmental Services on February 11, 2020, at 10:28 AM confirmed the panel did not self-close and positively latch.



 Plan of Correction - To be completed: 04/02/2020

A new access panel was ordered and will be installed on 4-2-20. Monthly audits will be completed to ensure compliance. This will be accomplished for a minimum of six months or until a pattern of compliance has been established and approved by QAPI committee.
Date of competition 4-2-2020

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the sprinkler heads to be free of obstructions, affecting two of three floors within the component.

Findings include:

1. Observation on February 11, 2020, at 11:45 AM revealed the track of an overhead door located within the Loading Dock was installed beneath a sprinkler head, obstructing the flow of water from the head, when the door is open.

Interview with the Director of Environmental Services on February 11, 2020, at 11:45 AM confirmed the obstructed sprinkler head.


2. Observation on February 11, 2020, at 12:23 PM revealed the track of an overhead door located within the Trash Compactor Room was installed beneath a sprinkler head, obstructing the flow of water from the head, when the door is open.

Interview with the Director of Environmental Services on February 11, 2020, at 12:23 PM confirmed the obstructed sprinkler head.




 Plan of Correction - To be completed: 03/05/2020

Will install a sidewall sprinkler head under garage door in loading dock area and in trash compactor room.

Date of Completion March 5, 2020.

NFPA 101 STANDARD Portable Fire Extinguishers:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain unobstructed access to fire extinguishers, affecting one of over ten extinguishers inspected within the component.

Findings include:

1. Observation on February 11, 2020, at 12:35 PM revealed the fire extinguisher located within the Boiler Room was obstructed by multiple trash cans, and a skid of light bulbs.

Interview with the Director of Environmental Services on February 11, 2020, at 12:35 PM confirmed the obstructed fire extinguisher.




 Plan of Correction - To be completed: 03/05/2020

The trash cans and skid of recycling light bulbs were relocated on 2-11-20. The floor area in front of the fire extinguisher was marked off with yellow and black caution tape, on 2-12-20. Monthly audits will be completed for a minimum of six months or until a pattern of compliance has been established and approved by QAPI committee.
Date of competition March 5, 2020.


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