Nursing Investigation Results -

Pennsylvania Department of Health
MANATAWNY MANOR
Building Inspection Results

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MANATAWNY MANOR
Inspection Results For:

There are  34 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.
MANATAWNY MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: MAIN - Component: 01 - Tag: 0000


Facility ID #130802
Component 01
Main Building

Based on a Relicensure Survey completed on August 20, 2019, it was determined that Manatawny Manor was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a two-story, Type III (200), unprotected ordinary structure, with a partial basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other:State only Deficiency.
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 S-tags, but are deficient.
Observations:
Name: MAIN - Component: 01 - Tag: 0100

Findings include: 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 facility failed to install carbon monoxide alarms in close proximity to fossil fuel-burning devices, in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act, affecting the entire component.

Findings include:

1. Observation on August 20, 2019, at 12:00 PM revealed the facility did not install a carbon monoxide detector that could be heard by any location manned 24 hours per day.

Interview with the Director of Maintenance on August 20, 2019, at 12:00 PM confirmed the carbon monoxide detection did not alarm at a manned-station.



 Plan of Correction - To be completed: 10/11/2019

Maintenance Director/designee will install carbon monoxide detectors that can be heard by staff 24 hours per day.

NHA/designee will provide education to maintenance staff on the requirement that carbon monoxide detectors that could be heard by staff 24 hours per day.

Maintenance Director/designee will complete an initial test on installation to ensure the carbon monoxide detectors can be heard by staff 24 hours per day. Maintenance Director/designee will test the carbon monoxide detectors one time quarterly x 4.

DON/designee will report a summary of the audits at the monthly QAPI meeting x 3 months.

NFPA 101 STANDARD Multiple Occupancies - Construction Type:State only Deficiency.
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 - Component: 01 - Tag: 0133
Based on observation and interview, it was determined the facility failed to maintain common walls to non-confirming buildings, affecting one of three floors within the component.

Findings include:

1. Observation on August 20, 2019, at 11:42 AM revealed a penetration of the common wall separating the Adult Day Care Building from the Main Building, around a black wire, above the suspended ceiling within the Rehab Room, above the double doors.

Interview with the Maintenance Technician on August 20, 2019, at 11:42 AM confirmed there was a penetration.


2. Observation on August 20, 2019, at 12:50 PM revealed the door leaf closest to the Lounge of the double doors, located by 1st floor "C" Wing Resident Room 17, failed to close and positively latch.

Interview with the Maintenance Technician on August 20, 2019, at 12:50 PM confirmed the door did not positively latch.



 Plan of Correction - To be completed: 10/11/2019

Maintenance Director/designee will use an approved through penetration fire stop system to seal the penetration of the common wall separating the Adult Day Care Building from the Main Building, around a black wire, above the suspended ceiling within the Rehab Room, above the double doors.

Maintenance Director/designee will adjust the door leaf closest to the Lounge of the double doors, located by 1st floor "C" Wing Resident Room 17, to ensure they close and positively latch.

NHA/designee will educate maintenance department staff on the requirement to maintain the rating of fire walls. NHA/designee will educate maintenance department staff on the requirement to ensure fire doors close and positively latch.

Maintenance Director/designee will develop an audit tool to inspect the common wall separating the Adult Day Care Building from the Main Building. Maintenance Director/designee will complete the inspection semi-annually for one year. If necessary, any penetrations will be sealed using an approved through penetration fire stop system.

Maintenance Director/designee will develop an audit tool to ensure the fire doors within the component close and positively latch. Maintenance Director/designee will complete the audit one time weekly x 4 weeks and one time monthly x 2 months

Maintenance Director/designee will report a summary of the audits at the monthly QAPI meeting x 3 months.

NFPA 101 STANDARD Building Construction Type and Height:State only Deficiency.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: MAIN - Component: 01 - Tag: 0161
Based on observation and interview, it was determined the facility failed to maintain the building construction requirements, affecting three of three floors within the component.

Findings include:

1. Observation on August 20, 2019, between 11:00 AM and 1:30 PM revealed the building was a two-story, Type III (200), unprotected ordinary structure, which is fully sprinklered. This type of construction is limited to one story in height.

Interview with the Director of Maintenance on August 20, 2019, at 1:30 PM confirmed the construction type is not allowed in health care.



 Plan of Correction - To be completed: 10/11/2019

Facility wishes to utilize the FSES to comply with the regulatory requirement.
NFPA 101 STANDARD Means of Egress - General:State only Deficiency.
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 - Component: 01 - Tag: 0211
Based on observation and interview, it was determined the facility failed to maintain doors in the means of egress to be defeatable from the egress access side, affecting one of three floors within the component.

Findings include:

1. Observation on August 20, 2019, at 12:07 PM revealed a functional hasp-lock was installed on the outside of the Special Catering Supplies closet, located within the 1st floor Dry Storage Room.

Interview with the Maintenance Technician on August 20, 2019, at 12:07 PM confirmed the door could be locked against egress.



 Plan of Correction - To be completed: 10/11/2019

Maintenance Director/designee will remove the functional hasp-lock from the outside of the Special Catering Supplies closet located within the 1st floor Dry Storage Room.

NHA/designee will educate maintenance staff on the requirement to ensure doors are not locked against egress.

Maintenance Director/designee will develop an audit tool to ensure there is no door inappropriately locked against egress within the component. Maintenance Director/designee will complete the audit one time weekly x 4 weeks and then one time monthly x 2 months.

Maintenance Director/designee will report a summary of the audits at the monthly QAPI meeting x 3 months.

NFPA 101 STANDARD Hazardous Areas - Enclosure:State only Deficiency.
Hazardous Areas - Enclosure
2012 EXISTING
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. 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

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 - Component: 01 - Tag: 0321
Based on observation and interview, it was determined the facility failed to protect hazardous area doors to positively latch, affecting one of three floors within the component.

Findings include:

1. Observation on August 20, 2019, at 1:01 PM revealed the door to the basement Activities Storage Room failed to close and positively latch within the frame.

Interview with the Maintenance Technician on August 20, 2019, at 1:01 PM confirmed the door did not positively latch.


2. Observation on August 20, 2019, at 1:01 PM revealed the door, to the basement Medical Records Room across from the Furniture Storage Room, failed to close and positively latch within the frame.

Interview with the Maintenance Technician on August 20, 2019, at 1:01 PM confirmed the door did not positively latch.



 Plan of Correction - To be completed: 10/11/2019

Maintenance Director/designee will adjust the door to the basement Activities Storage Room and the door to the basement Medical Records Room across from the Furniture Storage Room to ensure they close and positively latch within the frame.

NHA/designee will educate maintenance department staff on the requirement to ensure doors to hazardous areas positively latch.

Maintenance Director/designee will develop an audit tool to ensure the doors to hazardous areas within the component positively latch within the frame. Maintenance Director/designee will complete the audit one time weekly x 4 weeks and one time monthly x 2 months.

Maintenance Director/designee will report a summary of the audits at the monthly QAPI meeting x 3 months.

NFPA 101 STANDARD Corridor - Doors:State only Deficiency.
Corridor - Doors
2012 EXISTING
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.
There is no impediment to the closing of the doors. Clearance between bottom of door and floor covering is not exceeding 1 inch. Roller latches are prohibited by CMS regulations on corridor doors and rooms containing flammable or combustible materials. Powered doors complying with 7.2.1.9 are permissible. 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 - Component: 01 - Tag: 0363

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

Findings include:

1. Observation on August 20, 2019, at 12:46 PM revealed the door to the "C" Wing Employee Restroom failed to close, and positively latch within the frame.

Interview with the Maintenance Technician on August 20, 2019, at 12:46 PM confirmed the door did not close and positively latch within the frame.


2. Observation on August 20, 2019, at 12:13 PM revealed the double doors to the Kitchen, across from the Employee Dining Room, did not close and positively latch within the frame.

Interview with the Maintenance Technician on August 20, 2019, at 12:13 PM confirmed the doors did not positively latch within the frame.






 Plan of Correction - To be completed: 10/11/2019

Maintenance Director/designee will adjust the door to the "C" Wing Employee Restroom and the double doors to the Kitchen, across from the Employee Dining Room to ensure they close and positively latch within the frame.

NHA/designee will educate maintenance department staff on the requirement to ensure doors protecting corridor openings close and positively latch.

Maintenance Director/designee will develop an audit tool to ensure doors within the component that protect corridor openings, close and positively latch within the frame. Maintenance Director/designee will complete the audit one time weekly x 4 weeks and one time monthly x 2 months.

Maintenance Director/designee will report a summary of the audits at the monthly QAPI meeting x 3 months.

NFPA 101 STANDARD Utilities - Gas and Electric:State only Deficiency.
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 - Component: 01 - Tag: 0511
Based on observation and interview, it was determined the facility failed to maintain electrical junction boxes to be covered, affecting one of three floors within the component.

Findings include:

1. Observation on August 20, 2019, at 11:46 AM revealed a junction box lacked a cover plate, above the suspended ceiling, above the 1st floor Adult Day Services sign.

Interview with the Maintenance Technician on August 20, 2019, at 11:46 AM confirmed the junction box lacked a cover plate.



 Plan of Correction - To be completed: 10/11/2019

Maintenance Director/designee will add a cover plate to the junction box, above the suspended ceiling, above the 1st floor Adult Day Services sign.

NHA/designee will educate maintenance staff to maintain electrical junction boxes to be covered.

Maintenance Director/designee will develop an audit tool to ensure there is a cover plate on the junction boxes above the ceiling within the component. Maintenance Director/designee will complete the audit one time weekly x 4 weeks and then one time monthly x 2 months.

Maintenance Director/designee will report a summary of the audits at the monthly QAPI meeting x 3 months.

NFPA 101 STANDARD Electrical Systems - Other:State only Deficiency.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided S-Tags, but are deficient.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain access to electrical panels, in one of five smoke barriers within the component.

Findings include:

1. Observation on August 20, 2019, at 12:39 PM revealed a cart was blocking access to the electrical panels, on the 1st floor Nursing Med Station Room.

Interview at the time of the exit conference with the Director and Maintenance Technician on August 20, 2019, at 12:39 PM confirmed the electrical panels were blocked.



 Plan of Correction - To be completed: 10/11/2019

The cart that was blocking access to the electrical panels, on the 1st floor Nursing Med Station Room has been moved to an appropriate location.

NHA/designee will provide education to nursing staff on the requirement to maintain access to electrical panels.

NHA/designee will develop an audit tool to conduct random observations of the electrical panels in the Nursing Med Station Rooms to ensure access is not blocked. NHA/designee will complete the audit one time weekly x 4 weeks and then one time monthly x 2 months.

NHA/designee will report a summary of the audits at the monthly QAPI meeting x 3 months.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:State only Deficiency.
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 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of electrical devices, affecting one of three floors within the component.

Findings include:

1. Observation on August 20, 2019, at 12:16 PM revealed the use of a power tap to supply power to a printer, and a cellular telephone charger, within the 1st floor Dietary Office.

Interview with the Maintenance Technician on August 20, 2019, at 12:16 PM confirmed the unauthorized use of a power tap.




 Plan of Correction - To be completed: 10/11/2019

The power tap to supply power to a printer, and a cellular telephone charger, within the 1st floor Dietary Office was removed.

NHA/designee will provide education to dietary staff on the requirement to monitor the use of electrical devices.

NHA/designee will develop an audit tool to ensure the there is no power tap being used to supply power to electrical devices within the component. NHA/designee will complete the audit one time weekly x 4 weeks and then one time monthly x 2 months.

NHA/designee will report a summary of the audits at the monthly QAPI meeting x 3 months.

Initial comments:Name: A-B - Component: 02 - Tag: 0000


Facility ID #130802
Component 02
A-B Addition

Based on a Relicensure Survey completed on August 20, 2019, at Manatawny Manor, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing health care occupancy.

This is a one-story, Type II (111), protected noncombustible structure, without a basement, which is fully sprinklered.




 Plan of Correction:


Initial comments:Name: B-C - Component: 03 - Tag: 0000


Facility ID #130802
Component 03
B-C Addition

Based on a Relicensure Survey completed on August 20, 2019, at Manatawny Manor, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing health care occupancy.

This is a two-story, Type II (111), protected noncombustible structure, without a basement, which is fully sprinklered.



 Plan of Correction:


Initial comments:Name: BUILDING 04 - Component: 04 - Tag: 0000


Facility ID #130802
Component 04
Adult Day Care Building

Based on a Relicensure Survey completed on August 20, 2019, it was determined that Manatawny Manor was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a one-story, Type III (211), protected ordinary structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:State only Deficiency.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: BUILDING 04 - Component: 04 - Tag: 0923
Based on observation and interview, it was determined the facility failed to maintain oxygen cylinders to be secured, affecting one of five rooms inspected within the component.

Findings include:

1. Observation on August 20, 2019, at 11:38 AM revealed an unsecured oxygen cylinder located within the Rehab Room.

Interview with the Maintenance Technician on August 20, 2019, at 11:38 AM confirmed the oxygen cylinder was not secured.



 Plan of Correction - To be completed: 10/11/2019

The unsecured oxygen cylinder located within the Rehab Room was properly secured.

Director of Rehab/designee will re-educate the therapy staff to ensure oxygen cylinders are properly secured.

NHA completed a whole house audit of the first floor and no other unsecured oxygen cylinder were identified.

Director of Rehab/designee will develop an audit tool for random observations in the Rehab Room to ensure oxygen cylinders are properly secured. Director of Rehab/designee will randomly observe the Rehab Room 5 times per week x 4 weeks and five times per month x 2 months.

Director of Rehab/designee will report a summary of the audits at the monthly QAPI meeting x 3 months.


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