Nursing Investigation Results -

Pennsylvania Department of Health
MANATAWNY MANOR
Building Inspection Results

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

There are  36 surveys for this facility. Please select a date to view the survey results.

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MANATAWNY 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 November 19, 2019, at Manatawny Manor, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: MAIN - Component: 01 - Tag: 0000


Facility ID #130802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on November 19, 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. 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 III (200), unprotected ordinary structure, with a partial basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type: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.
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 wall doors to be within the allowed gap margin, to be in good repair, and to positively latch, affecting three of five openings within the component.

Findings include:

1. Observation on November 19, 2019, at 12:30 PM revealed the common wall doors separating Component 01 and 04, at Rehab, had a gap greater than 1/8 inch between the door and frame, and between the doors.

Interview with the Director of Maintenance on November 19, 2019, at 12:30 PM confirmed the doors exceeded the allowed gap margins.


2. Observation on November 19, 2019, at 1:00 PM revealed the common wall doors separating Component 01 and 03, at Resident Room B11, had holes from old hardware in both the doors and frame.

Interview with the Director of Maintenance on November 19, 2019, at 1:00 PM confirmed the doors had holes where old hardware had been removed.


3. Observation on November 19, 2019, at 1:20 PM revealed the common wall doors separating Component 01 and 02, at Resident Room A17, had a gap greater than 1/8 inch between the door and frame, and between the doors; and was missing latching hardware

Interview with the Director of Maintenance on November 19, 2019, at 1:20 PM confirmed the doors exceeded the allowed gap margins, and did not positively latch.



 Plan of Correction - To be completed: 01/18/2020

Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceeding.

Facility wishes to utilize a six month time limited waiver in order to resolve the deficiency.

Maintenance Director/designee will evaluate, order and install approved through fire stop hardware to the common wall doors and/or door frame separating Component 01 and 04, at Rehab, to ensure there is not a gap greater than 1/8 inch between the door and frame and between the doors.

Maintenance Director/designee will evaluate, order and install approved through fire stop hardware to fill the holes in the hardware of both doors and frame of the common wall separating Component 01 and 03 at Resident Room B11.

Maintenance Director/designee will evaluate, order and install approved through fire stop hardware to the common wall doors and/or door frame separating Component 01 and 02, at Resident Room A17, to ensure there is not a gap greater than 1/8 inch between the door and frame and between the doors. Maintenance Director/designee will add latching hardware to the door.

NHA/designee will educate maintenance department staff on the requirement to maintain the rating of fire doors. NHA/designee will educate maintenance department staff on the requirement to ensure fire wall doors have appropriate latching hardware.

Maintenance Director/designee will develop an audit tool to inspect the fire doors separating Component 01 and 02, at Resident Room A17, Component 01 and 03, at Resident Room B11, and Component 01 and 04, at Rehab to ensure the rating of the fire doors is maintained and appropriate latching hardware is installed. Maintenance Director/designee will complete the inspection semi-annually for one year. If necessary, any additional hardware will be ordered and installed to the doors and/or door frame to ensure the rating of the fire doors are maintained.

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:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
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 two of two floors within the component.

Findings include:

1. Observation on November 19, 2019, between 11:00 AM and 2:30 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 November 19, 2019, at 2:30 PM confirmed the construction type is not allowed in Health Care.




 Plan of Correction - To be completed: 01/18/2020

Facility wishes for DSI to conduct the FSES to comply with the regulatory requirement.
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 - Component: 01 - Tag: 0225
Based on observation and interview, it was determined the facility failed to maintain the stairtower doors to be within the allowed gap margins, affecting one of five smoke compartments within the component.

Findings include:

1. Observation on November 19, 2019, at 12:45 PM revealed the door to the exit passageway by the Main Dining Room had gaps greater than 1/8 inch.

Interview with the Director of Maintenance on November 19, 2019, at 12:45 PM confirmed the stairtower door exceeded the allowed gap margin.


 Plan of Correction - To be completed: 01/18/2020

Facility wishes to utilize a six month time limited waiver in order to resolve the deficiency.

Maintenance Director/designee will evaluate, order and install approved through fire stop hardware to the door and/or door frame to the exit passageway by the Main Dining Room to ensure there is not a gap greater than 1/8 inch.

NHA/designee will educate maintenance department staff on the requirement to maintain the rating of fire doors.

Maintenance Director/designee will develop an audit tool to inspect the door to the exit passageway by the Main Dining Room to ensure the rating is maintained. Maintenance Director/designee will complete the inspection semi-annually for one year. If necessary, any additional hardware will be ordered and installed to the fire door and/or door frame to ensure the rating of the fire door is maintained.

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

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 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors to be within the allowed gap margins, and were not capable of self-closing, in one of five smoke compartments within the component.

Findings include:

1. Observation on November 19, 2019, at 12:20 PM revealed the rated door to Therapy Storage had a gaps greater than 1/8 inch, and the closure was disconnected.

Interview with the Director of Maintenance on November 19, 2019, at 12:20 PM confirmed the hazardous area door exceeded the allowed gap margins, and could not self-close.







 Plan of Correction - To be completed: 01/18/2020

Facility wishes to utilize a six month time limited waiver in order to resolve the deficiency.

Maintenance Director/designee will remove the rating tag from the door to Therapy Storage. Maintenance Director/designee will evaluate, order and install approved through fire stop hardware to resolve the deficiency.

NHA/designee will educate maintenance department staff on the requirement to ensure doors to hazardous areas have positive latching hardware connected. NHA/designee will also educate maintenance department staff on the requirement to ensure doors to hazardous areas do not have gaps greater than 1/8 inch.

Maintenance Director/designee will develop an audit tool to ensure the door to Therapy Storage remains in compliance. 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: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.
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 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors to positively latch, and to be smoke tight, affecting two of five smoke compartments within the component.

Findings include:

1. Observation on November 19, 2019, at 12:00 PM revealed the double doors to the kitchen at the exit end, failed to close and positively latch.

Interview with the Director of Maintenance on November 19, 2019, at 12:00 PM confirmed the doors did not positively latch.


2. Observation on November 19, 2019, between 12:42 PM and 12:50 PM revealed rated corridor doors exceeded one eighth of an inch gaps, and were impeded from closing by the door coordinators, at the following locations:

a. 12:40 PM, the rated door between the Dining Room and Kitchen;
b. 12:42 PM, doors to the Dining Room, at the Kitchen end;
b. 12:50 PM, doors to the Dining Room, at the Lobby end.

Interview with the Director of Maintenance on November 19, 2019, at 12:50 PM confirmed the corridor doors could not resist the passage of smoke, and were impeded from closing.






 Plan of Correction - To be completed: 01/18/2020

Facility wishes to utilize a six month time limited waiver in order to resolve the deficiency.

Maintenance Director/designee will evaluate, order and install approved through fire stop hardware to the double doors and/or door frame to the kitchen at the exit end to ensure they close and positively latch.

Maintenance Director/designee will remove the rating tags from the door between the Dining Room and Kitchen, the doors to the dining at the kitchen end, and the doors to the dining room at the lobby end. Maintenance Director/designee will evaluate, order and install approved through fire stop hardware to resolve the deficiency.

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 the double doors to the kitchen at the exit end and each of the dining rooms doors remain in compliance. 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.

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


Facility ID #130802
Component 02
A-B Addition

Based on a Medicare/Medicaid Recertification Survey completed on November 19, 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. 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 II (111), protected noncombustible structure, without a basement, which 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: A-B - Component: 02 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain stairtower doors to be wtihin the allowed gap margins, affecting one of two smoke compartment within the component.

Findings include:

1. Observation on November 19, 2019, at 1:30 PM revealed the stairtower door by Resident Room B18 had a gaps greater than 1/8 inch.

Interview with the Director of Maintenance on November 19, 2019, at 1:30 PM confirmed the stairtower door exceeded the allowed gap margins.




 Plan of Correction - To be completed: 01/18/2020

Facility wishes to utilize a six month time limited waiver in order to resolve the deficiency.

Maintenance Director/designee will evaluate, order and install approved through fire stop hardware to the stairtower door and/or door frame by Resident Room B18 to ensure there is not a gap greater than 1/8 inch.

NHA/designee will educate maintenance department staff on the requirement to maintain the rating of fire doors.

Maintenance Director/designee will develop an audit tool to inspect the stairtower door by Resident Room B18 to ensure the rating is maintained. Maintenance Director/designee will complete the inspection semi-annually for one year. If necessary, any additional hardware will be ordered and installed to ensure the rating of the fire door is maintained.

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

NFPA 101 STANDARD Soiled Linen and Trash Containers: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.
Soiled Linen and Trash Containers
Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended.
Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent.
18.7.5.7, 19.7.5.7
Observations:
Name: A-B - Component: 02 - Tag: 0754

Based on observation and interview, it was determined the facility failed to store soiled linen and trash receptacles with a combined or single capacity exceeding 32 gallons in a protected room, affecting one of two smoke compartments within the component.

Findings include:

1. Observation on November 19, 2019, at 1:32 PM revealed a soiled, a clean linen, and trash container were being stored in the corridor outside Resident Room B22.

Interview with the Director of Maintenance on November 19, 2019, at 1:32 PM confirmed the containers were stored outside of a protected hazardous storage area.




 Plan of Correction - To be completed: 01/18/2020

NHA removed the identified soiled, clean linen, and trash containers that were being stored in the corridor outside Resident Room B22.

NHA/designee will educate nursing care staff on the requirement to properly store soiled linen and trash receptacles with a combined or single capacity exceeding 32 gallons in a protected room.

NHA/designee will develop an audit tool to track random observations of the corridor outside Resident Room B22. Random observations of the corridor outside Resident Room B22 will be completed one time weekly x 4 weeks and 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: B-C - Component: 03 - Tag: 0000


Facility ID #130802
Component 03
B-C Addition

Based on a Medicare/Medicaid Recertification Survey completed on November 19, 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. 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, 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 Medicare/Medicaid Recertification Survey completed on November 19, 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. 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 (211), protected ordinary structure, without a basement, which is fully sprinklered.



 Plan of Correction:



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