Nursing Investigation Results -

Pennsylvania Department of Health
PENNSBURG MANOR
Building Inspection Results

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

There are  38 surveys for this facility. Please select a date to view the survey results.

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PENNSBURG 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 June 15, 2022, at Pennsburg 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 01 - Component: 01 - Tag: 0000


Facility ID# 162402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 15, 2022, it was determined Pennsburg Manor was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 three story, Type II (000), unprotected non-combustible structure, which is fully sprinklered.




 Plan of Correction:


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 BUILDING 01 - Component: 01 - Tag: 0161

Based on observation, document review, and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire facility.

Findings include:

1. Observation and documents reviewed on June 15,2022, between 10:00 am, and 1:00 pm, revealed the building had been classified as a three story, Type II (000), unprotected non-combustible construction. The maximum allowable story height for this construction type is two stories.

Interview at the time of the exit conference with the administrator and facility maintenance representative on June 15, 2022, at 1:30 pm, confirmed the story height exceeded the maximum allowance for the above listed construction type.






 Plan of Correction - To be completed: 08/17/2022

The facility will request an FSES inspection to be completed in order to be in compliance.


Facility is asking for the waiver to be extended until November 01, 2023.

The facility hired an outside architect to complete the inspection in order to identify possible solutions to remove the FSES.

The Maintenance Director/Designee will report any identified concerns at the monthly QAPI Committee.

NFPA 101 STANDARD Means of Egress - General: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.
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 BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to ensure exit access corridors were maintained clear and unobstructed, affecting one of three floors.

Findings Include:

1. Observation on June 15, 2022, at 12:10 pm, revealed the storage of several stationary chairs in the 1st floor south corridor.

Interview at the time of the exit conference with the administrator and facility maintenance representative on June 15, 2022, at 1:30 pm, confirmed the chairs were being stored in the corridor.





 Plan of Correction - To be completed: 08/10/2022

The Maintenance Director removed all stationary chairs from the 1st floor south corridor to ensure exit access corridors were maintained clear and unobstructed.
The Maintenance Director/ Designee will conduct weekly random audits of corridors to ensure exit access corridors are clear and unobstructed.

The Maintenance Director/ Designee will in-service all staff to ensure they are aware that all corridors must remain clear and unobstructed.
The audit results will be reviewed monthly x3 by the facility QAPI Committee.

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 BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of stair tower enclosures, affecting two of three stairtowers.

Findings include:

1. Observation on June 15, 2022, between 12:00 pm and 12:20 pm, revealed the following deficiencies of the stair tower enclosures:

a. At 12:00 pm, the stair tower door at the elevator on the 2nd floor failed to latch in the frame when tested.
b. At 12:20 pm, the north stair tower door on the 1st floor had a gap in excess of 3/16 of an inch at the header on the latch side.

Interview at the time of the exit conference with the administrator and facility maintenance representative on June 15, 2022, at 1:30 pm, confirmed the door deficiences.





 Plan of Correction - To be completed: 08/10/2022

The Maintenance Director installed a new push bar and latch to the stair tower door at the elevator on the 2nd floor to ensure positive latching to maintain the proper fire resistance rating of the stair tower enclosure. The Maintenance Director contacted Liberty Doors to set up a time for them to visit the facility in order to fix the gap that exceeds 3/16 of an inch at the header on the latch side to maintain the proper fire resistance rating of the stair tower enclosure.

The Maintenance Director/ Designee will audit all the doors on the stair towers to ensure positive latching and less than 3/16 of an inch at the header of doors.


The Maintenance Director/ Designee will in-service all staff to ensure they are aware that if a door does not properly latch in a stair tower enclosure they are to report to the TELS maintenance system.
The Maintenance Director/ Designee will complete random audits in stair tower enclosures to ensure doors for positive latching.
The audit results will be reviewed monthly x3 by the facility QAPI Committee.

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 BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain doors to hazardous areas, on one of three floors.

Findings include;

1. Observation between 12:30 pm and 12:38 pm, revealed the following hazardous area doors failed to latch in the corresponding frame.

a. At 12:30 pm, the door to soiled linen, main laundry ground floor.
b. At 12:38 pm, the door to the housekeeping office, which is also used for combustible storage. On the ground floor.

Interview at the time of the exit conference with the administrator and facility maintenance representative on June 15, 2022, at 1:30 pm, confirmed the doors lacked positive latching.





 Plan of Correction - To be completed: 08/10/2022

The Maintenance Director fixed the door knob to the solid linen, main laundry ground floor and to the housekeeping office on the ground floor, which is used for combustible storage in order to ensure positive latching.

The Maintenance Director/ Designee will audit all the doors of hazardous areas in the facility to ensure positive latching.

The Maintenance Director/ Designee will in-service all staff to ensure they are aware that if a door does not properly latch in a hazardous area they are to report in the TELS maintenance system.

The Maintenance Director/ Designee will complete random weekly audits in hazardous locations to ensure doors for positive latching.

The audit results will be reviewed monthly x3 by the facility QAPI Committee.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the fire protection sprinkler system on two of three floors.

Findings include:

1. Observation on June 15, 2022, between 12:12 pm, and 12:35 pm, revealed the following;

a. At 12:12 pm, ceiling tile missing in the soiled utility room, North corridor on the 1st floor.
b. At 12:35 pm, a sprinkler in the clean side of the laundry room was obstructed by duct work, near the dryer access door.

Interview at the time of the exit conference with the administrator and facility maintenance representative on June 15, 2022, at 1:30 pm, confirmed the sprinkler deficiencies.




 Plan of Correction - To be completed: 08/10/2022

The Maintenance Director installed the missing ceiling tile in the soiled utility room, north corridor on the 1st floor. The Maintenance Director contacted Cintas Fire Protection Company to set up a time for them to visit the facility in order to move the sprinkler to the clean side of the laundry room that was obstructed by duct work near the dryer access door in order to maintain the fire protection sprinkler system.

The Maintenance Director/ Designee will audit all ceiling tiles in the facility to ensure they are not missing. The Maintenance Director/ Designee will audit all sprinklers in the facility to ensure they are not obstructed.

The Maintenance Director/ Designee will complete random weekly facility location audits to ensure there are no missing ceiling tiles.

The Maintenance Director/ Designee will complete random facility location audits to ensure there are no obstructions to sprinkler heads.

The audit results will be reviewed monthly x3 by the facility QAPI Committee.

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

Based on observation and interview, it was determined the facility failed to monitor and restrict the use of power taps in one of nine smoke compartments.

Findings include:

1. Observation on June 15, 2022, at 11:40 am, revealed a microwave was being powered by a power tap in the activities office on the 2nd floor.

Interview at the time of the exit conference with the administrator and facility maintenance representative on June 15, 2022, at 1:30 pm, confirmed the power tap was in use.





 Plan of Correction - To be completed: 08/10/2022

The Maintenance Director immediately unplugged and removed the microwave from the power strip.

The Maintenance Director drilled hole in the countertop to allow the cord to properly reach the outlet.

The Maintenance Director/ Designee will audit all microwave connections in the facility to ensure they are not plugged into a power strip or extension cord.

The Maintenance Director/ Designee will in-service all staff to ensure they are aware that microwaves are not to be plugged into a power strip or extension cord.

The Maintenance Director/ Designee will randomly audit all microwave connections in the facility on a monthly basis to ensure they are not plugged into a power strip or extension cord.

The audit results will be reviewed monthly x3 by the facility QAPI Committee.


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