Nursing Investigation Results -

Pennsylvania Department of Health
MILLCREEK MANOR
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MILLCREEK MANOR
Inspection Results For:

There are  13 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.
MILLCREEK 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 May 12, 2022, at Millcreek Manor, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


Initial comments:Name: MILLCREEK MANOR - Component: 02 - Tag: 0000


Facility ID # 131102
Component 02
Millcreek Manor

Based on a Medicare/Medicaid Recertification Survey completed on May 12, 2022, it was determined that Millcreek 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 five-story, Type II (222), fire resistive building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
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: MILLCREEK MANOR - Component: 02 - Tag: 0225

Based on observation and interview, it was determined that the facility failed to maintain stairways and smokeproof enclosure requirements for one of two stairways.

Findings include:

Observation on May 12, 2022, at 10:01 a.m., revealed the third floor west wing stairway had a hand sanitizer stand located in the egress path.

Interview with the director of maintenance on May 12, 2022, at 12:20 p.m., confirmed the west wing staircase had a hand sanitizer stand located in the egress path.



 Plan of Correction - To be completed: 06/02/2022

All objects have been removed from the facility stairwells blocking egress path. Maintenance staff will visually check the stairwells on their daily rounds throughout the facility.
NFPA 101 STANDARD Corridor - Doors: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.
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: MILLCREEK MANOR - Component: 02 - Tag: 0363

Based on observation and interview, it was determined that the facility failed to maintain corridor door requirements for one of over fifty rooms.

Findings include:

Observation on May 12, 2022, at 10:28 a.m., revealed the second floor, room 2104, had a magnet on the door latching mechanism, preventing it from latching.

Interview with the senior maintenance technician on May 12, 2022 at 10:28 a.m., confirmed the above door failed to positively latch due to a magnet, which was removed on-site.



 Plan of Correction - To be completed: 06/02/2022

1. Staff have been provided inservice education on not propping doors open that have automatic closers attached.
2. Maintenance will visually check corridor doors on daily rounds in the facility
3. Maintenance will check 2104 during monthly positive latch inspections.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MILLCREEK MANOR - Component: 02 - Tag: 0918

Based on document review and interview, the facility failed to maintain, inspect, and test the essential electric system for two of two emergency generators.

Findings include:

Document review on May 12, 2022, at 11:03 a.m., revealed the facility lacked documentation that an outside agency inspected and conducted the four-hour load test for both emergency generators within the last year.

Interview with the director of maintenance on May 12, 2022, at 11:03 a.m., confirmed the above documentation was not available at the time of the survey.





 Plan of Correction - To be completed: 06/02/2022

1. Director of Maintenance will follow up with outside agencies after all inspections have been completed so that proper documentation has been received by the facility for review and to keep on hand.
2. After proper documentation has been received and reviewed the inspection reports will be filed in the current years Life Safety Binder for Survey review (has been received)
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
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: MILLCREEK MANOR - Component: 02 - Tag: 0920

Based on observation and interview, it was determined that the facility failed to maintain electrical power cords for two of over fifty rooms.

Findings include:

Observation on May 12, 2022, between 9:55 a.m. and 11:03 a.m., revealed the following electrical power cord deficiencies:

A. (11:30 a.m.) Third floor, room 5104 , had two three-way multi-plug adapters plugged into the emergency power outlet;
B. (11:41 a.m.) Fourth floor, room 4104, had a three-way multi-plug adapter plugged into an outlet.

Interview with the senior maintenance technician on May 12, 2022, at 11:03 a.m., confirmed the above electrical power cord deficiencies, and the plug adapters were removed on-site.




 Plan of Correction - To be completed: 06/02/2022

1. Director of Maintenance has in-serviced the office staff on safety and fire protection. Staff were informed that multi-plug adaptors are not allowed at any location in the building.
2. Maintenance will visually check office on daily rounds in the facility.

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port