Pennsylvania Department of Health
MORAVIAN MANOR
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 52 surveys for this facility. Please select a date to view the survey results.

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MORAVIAN 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 July 22, 2024, at Moravian 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 #135202
Component 01
Building 01

Based on a Medicare/Medicaid Recertification Survey completed on July 22, 2024, it was determined that Moravian 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 (222), fire resistive structure, with 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 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.

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 BUILDING - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of exit stairtower enclosures, affecting one of twelve smoke compartments within the component.

Findings include:

1. Observation on July 22, 2024, at 12:02 PM, revealed the vision panel within the 1st floor door to Stair 14 exhibited a fire resistance rating of 45 minutes.

Interview with the Director of Building and Grounds on July 22, 2024, at 12:02 PM, confirmed the vision panel did not exhibit a fire resistance rating of at least 60 minutes.

Plan of Correction - To be completed: 08/08/2024

K 0225 – Complete Door & Access ordered (1) 3"x33" Fire Lite window and Frame with a 60 minute fire rating and will install. An audit conducted by trained Maintenance staff of all fire doors will be performed quarterly to ensure that all doors and frames meet NFPA101 standards. Audits will be recorded in the Quality Assurance Performance Improvement (QAPI) program and reviewed by the QA committee quarterly. A time limited waiver has been submitted as the correction will take no longer than 90 days.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu:

Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of soiled linen chutes, affecting one of twelve smoke compartments within the component.

Findings include:

1. Observation on July 22, 2024, at 11:11 AM, revealed the second floor access panel to the soiled linen chute, within the Health Center North Soiled Utility Room, failed to automatically close and positively latch within the frame.

Interview with the Director of Building and Grounds on July 22, 2024, at 11:11 AM, confirmed the access panel did not automatically close and positively latch within the frame.

Plan of Correction - To be completed: 08/08/2024

K 0541 – The chute door in Health Center North Soiled Utility Room was fixed by a trained Maintenance staff and confirmed that door now latches within the frame. An audit conducted by trained maintenance staff of all chute doors will be performed semiannually to ensure that all doors meet NFPA101 standards. Audits will be recorded in the Quality Assurance Performance Improvements (QAPI) program and reviewed by the QA committee annually.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

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: MAIN BUILDING - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain oxygen storage rooms as capable of being secured, affecting one of twelve smoke compartments within the component.

Findings include:

1. Observation on July 22, 2024, at 12:45 PM, revealed the basement Oxygen Storage Room lacked a means of securing and restricting access.

Interview with the Director of Building and Grounds on July 22, 2024, at 12:45 PM, confirmed the Oxygen Storage Room could not be secured against unauthorized access.

Plan of Correction - To be completed: 08/08/2024

K 0923 – Basement Oxygen Storage Room Door. Trained Maintenance staff has ordered a heavy duty commercial door lever lock and will install. An audit conducted by trained Maintenance staff of all doors will be performed weekly for one month to ensure that all doors and frames meet NFPA101 standards. Then will be completed monthly for total of three months. Audits will be recorded in the quarterly Quality Assurance Performance Improvement (QAPI) program and reviewed by the QA committee quarterly. All work and audits to be completed by 11/8/2024

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