Pennsylvania Department of Health
MIFFLIN CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 43 surveys for this facility. Please select a date to view the survey results.

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MIFFLIN CENTER - 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 November 25, 2024, at Mifflin Center, 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 #081002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on November 25, 2024, it was determined that Mifflin Center 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 one-story, Type III (200), unprotected ordinary structure, with a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Egress 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.

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0222

Based on observation and interview, it was determined the facility failed to maintain doors in the means of egress to be free from locking arrangements requiring a tool or key to operate from the egress side and to maintain special locking arrangement signage, affecting two of four smoke compartments within the component.

Findings include:

1. Observation on November 25, 2024, at 11:27 AM, revealed the emergency release knob of the door to the Main Walk-In Cooler, within the Kitchen, was missing, rendering the door able to be locked without a means of egress from within.

Interview with the Maintenance Director on November 25, 2024, at 11:27 AM, confirmed the Cooler could be locked against egress.

2. Observation on November 25, 2024, at 11:31 AM, revealed the exterior exit door, from the Activities Room, was equipped with a special locking arrangement, but lacked signage reading, "Push until alarm sounds. Door can be opened in 15 seconds."

Interview with the Maintenance Director on November 25, 2024, at 11:31 AM, confirmed the lack of special locking arrangement signage.

3. Observation on November 25, 2024, at 12:01 PM, revealed the Zone 3 double exterior exit doors were equipped with a special locking arrangement, but lacked signage reading, "Push until alarm sounds. Door can be opened in 15 seconds."

Interview with the Maintenance Director on November 25, 2024, at 12:01 PM, confirmed the lack of special locking arrangement signage.

Plan of Correction - To be completed: 01/07/2025

1) The emergency release knob of the door to the Main Walk-In cooler, within the kitchen, was replaced now allowing the door to be unlocked having a means of egress from within. New signage with the correct wording "push until alarm sounds" "door can be opened in 15 seconds".
2.3) The exterior exit door, from the Activities Room and the Zone 3 double exterior doors has the correct special locking arrangement signage posted.
Egress doors in four smoke compartments were checked and have the correct special locking arrangement signage in place.
Maintenance Director or designee will complete quarterly audits for correct egress door signage in place and report findings at quarterly QAPI meetings.

NFPA 101 STANDARD Exit Signage:

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 - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed to maintain exit signage, affecting one of four smoke compartments within the component.

Findings include:

1. Observation on November 25, 2024, at 11:36 AM, revealed the exterior door across from Resident Room 418, leading to an enclosed courtyard, which was equipped with a window and could be mistaken for an exit, lacked "NO EXIT" signage.

Interview with the Maintenance Director on November 25, 2024, at 11:36 AM, confirmed the lack of "NO EXIT" signage.

Plan of Correction - To be completed: 01/07/2025

1) The exterior door across from Resident Room 418, leading to an enclosed courtyard, has a "NO EXIT" sign placed on the door.
Exit signage for doors in all four smoke compartments was checked and all in place where needed.
Maintenance Director or designee will complete quarterly checks for exterior doors having "NO EXIT" signage in place and report findings at monthly QAPI meetings

NFPA 101 STANDARD Cooking Facilities:

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0324

Based on document review and interview, it was determined the facility failed to maintain kitchen exhaust systems, affecting one of four smoke compartments within the component.

Findings include:

1. Review of documentation on November 25, 2024, at 10:55 AM, revealed the following deficiencies noted on the previous two kitchen exhaust cleaning reports, dated 11/15/23 and 5/16/23:

a) "Unable to remove/tip fan." "This system was not completely cleaned to NFPA 96 standards."

Interview with the Maintenance Director on November 25, 2024, at 10:55 AM, confirmed the facility lacked documentation verifying the kitchen exhaust system had been cleaned to minimum standards.

Plan of Correction - To be completed: 01/07/2025

1)Kitchen exhaust cleaning report will have documentation verifying the kitchen exhaust system has been cleaned to be compliant with NFPA 96 standards by Cintas, provider installing a hinge kit to the two vents on the roof allowing the fan to be tipped and cleaned well.
Center maintenance staff will look at the deficiency section of the provider reports to confirm that the vendor has completed the job and found no deficiences that need to be addressed. Any deficiency found by the vendor will be addressed and the documentation kept on file in the Life Safety Binder.
Maintenance Director or designee will review kitchen exhaust cleaning reports have been cleaned to meet minimum standards semi-annually including confirming that all relevant documentation is filed in the Life Safety Binder and share findings at QAPI meetings.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 hardware components of the automatic sprinkler protection system, affecting one of four smoke compartments within the component.

Findings include:

1. Observation on November 25, 2024, at 11:40 AM, revealed the Zone 3 sprinkler head, located within the corridor, between the Nurses' Station and the smoke barrier doors, lacked an escutcheon.

Interview with the Maintenance Director on November 25, 2024, at 11:40 AM, confirmed the missing escutcheon.

Plan of Correction - To be completed: 01/07/2025

1)A new escutcheon was installed on the Zone 3 sprinkler head, located within the corridor, between the nurses station and the smoke barrier doors.
The hardware components of the automatic sprinkler protection system, for all four smoke compartments were checked and escutcheons are in place.
Quarterly, visual audits will be conducted throughout the year by Maintenance Director or designee to confirm all elements of the sprinkler heads are present and share findings at QAPI meetings.

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 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain the positive latching of corridor doors, affecting one of four smoke compartments within the component.

Findings include:

1. Observation on November 25, 2024, at 11:44 AM, revealed the door to the Clean Linen Room, by the Zone 3 Nurses' Station, lacked positive latching hardware.

Interview with the Maintenance Director on November 25, 2024, at 11:44 AM, confirmed the corridor door did not positively latch within the door frame.

Plan of Correction - To be completed: 01/07/2025

1)The corridor door to the clean linen room, by the Zone 3 nurses station, was repaired and positive latches within the door frame.
Corridor doors in all four smoke compartment zones were checked and positive latch.
Maintenance Director or designee will complete monthly, random audits of corridor doors for hardware and positive latching and share findings at QAPI monthly meetings.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0371

Based on observation and interview, it was determined the facility failed to provide smoke compartments which did not exceed 22,500 square feet, affecting two of four smoke compartments within the component.

Findings include:

1. Observation on November 25, 2024, at 11:55 AM, revealed smoke compartments exceeded the maximum size allowed, at the following locations:

a. A and B Wings;
b. C Wing and Admin Wing.

Interview with the Maintenance Director on November 25, 2024, at 11:55 AM, confirmed the smoke compartments exceeded the maximum square footage.

Plan of Correction - To be completed: 01/07/2025

Center would like to request DSI conduct the FSES survey.

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 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of extension cords and surge suppressors, affecting one of four smoke compartments within the component.

Findings include:

1. Observation on November 25, 2024, at 11:06 AM, revealed an extension cord supplying electrical power to a surge suppressor, within the basement Internet Room.

Interview with the Maintenance Director on November 25, 2024, at 11:06 AM, confirmed a surge suppressor was supplied with electrical power by an extension cord.

Plan of Correction - To be completed: 01/07/2025

1) An electrician eliminated the extension cord that was supplying power to a surge protector, within the internet room, in the basement to allow a permanent correction to the problem. Both the extension cord and the surge protector were eliminated.
Maintenance reviewed all four smoke compartments which were clear from extension cords and surge suppressors and none were used as a substitute for fixed wiring of a structure.
Maintenance Director or designee will inservice center staff on power cords and extension cords.
Maintenance Director or designee will perform checks of smoke compartments for any extension cords periodically throughout the year and more frequently with seasonal decorating along with monitoring vendors if new equipment is installed, share findings at QAPI meetings.

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