Pennsylvania Department of Health
PENNSBURG MANOR
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 43 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.


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 April 25, 2024, 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 April 25, 2024, it was determined that 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 -tory, Type II (111), protected, non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

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 K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on observation and interview, the facility failed to maintain portable, accurate floor plans, affecting the entire facility.

Findings include:

Document review on April 25, 2024, at 10:00 a.m., revealed the facility failed to provide portable Life Safety Code Floor Plans that included the following information:

a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls;
c. Horizontal exits;
d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shafts walls.

Exit interview with the administrator and maintenance director on April 25, 2024, at 12:30 p.m., confirmed portable floor plans were unavailable at time of survey.

Plan of Correction - To be completed: 06/24/2024

The Maintenance Director has obtained accurate and up-to-date life safety floor plans for the facility. Floor Plans will be placed in the Life Safety binder and will be audited once per year to ensure drawings are present and up-to-date.

NFPA 101 STANDARD Building Construction Type and Height:

This is a less serious (but not lowest level) 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 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.

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 and interview, the facility failed to maintain building construction requirements in approximately seven locations, affecting three of three floors.

Findings include:

1. Observation on April 25, 2024, between 11:00 a.m. and 11:45 a.m., revealed steel beams, appearing to be load bearing, lacked fire proofing in the following locations:
a. 11:00 a.m., One beam at angled smoke barrier doors on the ground floor;
b. 11:30 a.m., One beam at angled smoke barrier doors on the second floor;
c. 11:45 a.m., One beam at angled smoke barrier doors on the third floor.

This is a repeat citation from May 31, 2023.

Exit interview with the administrator and maintenance representative on April 25, 2024, at 12:30 p.m., confirmed the unprotected steel.

2. Observation on April 25, 2024, at 11:05 a.m., revealed an approximately eight-inch open hole behind a grill in the laundry room wall on the ground floor.

Exit interview with the administrator and maintenance representative on April 25, 2024, at 12:30 p.m., confirmed the wall penetration.

3. Observation on April 25, 2024, at 11:15 a.m., revealed, on the ground floor by the north hall stair, an unknown expanding foam product use to fill void penetrations.

Exit interview with the administrator and maintenance director on April 25, 2024, at 12:30 p.m., confirmed the unknown foam substance.

Plan of Correction - To be completed: 06/24/2024

For the first observation, the facility continues to recruit outside contractors to provide estimates for the different facets this job requires. Once approved, work will be completed. The facility has verified that no further beams within the building require fireproofing, preventing this issue from reoccurrence.
For the second observation, the Maintenance Director has installed 3M Fire Barrier Self-Locking Pillows, 2"x4"x9" 90G9 ULC Listed, and sealed with Metacaulk FRP fire rated putty, 12Y3 UL Listed in order to maintain the fire barrier's fire rating. Facility will ensure that through-wall penetrations exposed during future building changes will be properly repaired to fire rating standards.
For the third observation, the Maintenance Director will remove all firestop foam from the penetration and seal it with 3M Fire Barrier Sealant FD-150+, 90G9 UL Listed. Additionally, the facility will ensure that through-wall penetrations made during future building changes will be properly sealed to fire rating standards.

Facility will be requesting an extension/waiver as we are uncertain as a confirmed date contractors will be out to complete project.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on observation review and interview, the facility failed to maintain the fire alarm system, affecting one fire alarm panel.

Findings Include:

Observation on April 25, 2024, at 12:00 p.m., revealed the facility's fire alarm panel was in a trouble mode at the time of the survey.

Exit interview with the administrator and maintenance director on April 25, 2024, at 12:30 p.m., confirmed the fire alarm panel trouble status.

Plan of Correction - To be completed: 06/24/2024

The facility's Fire Alarm System equipment is contracted to CINTAS, who has provided the facility with an estimate to repair the system's Ground Fault Trouble. The facility will escalate the urgency of getting this issue resolved.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 document review and interview, the facility failed to maintain automatic sprinkler system components, affecting the entire facility.

Findings include:

1. Document review on April 25, 2024, at 9:30 a.m., revealed the facility failed to provide documentation for the following sprinkler system inspections:

a. Fourth quarter inspection, 2023;
b. First quarter inspection, 2024.

Exit interview with the administrator and maintenance director on April 25, 2024, at 12:30 p.m., confirmed the missing documentation.

2. Document review on April 19, 2023, at 9:35 a.m., revealed the September 5, 2023, annual sprinkler inspection report listed the following deficiency, which remained uncorrected at time of survey:

a. Failed to inspect anti-freeze system due to equipment inavailability.

Exit interview with the administrator and maintenance director on April 25, 2024, at 12:30 p.m., confirmed the sprinkler system deficiency.

3. Observation on April 25, 2024, at 11:45 a.m., revealed two sprinklers were missing their escutcheons on the ground floor, in the main entrance canopy.

Exit interview with the administrator and maintenance director on April 25, 2024, at 12:30 p.m., confirmed the missing escutcheons.

Plan of Correction - To be completed: 06/24/2024

For the first observation, the Maintenance Director has obtained both the 4th Quarter 2023 and the 1st Quarter 2024 Quarterly Sprinkler System Inspections and placed them in the Life Safety book. The Maintenance Director will audit the Life Safety book once per week to ensure proper paperwork is present.
For the second observation, an estimate from CINTAS has been received to complete the inception of the antifreeze system. Proper urgency will be applied to the proper channels to complete this annual requirement.
For the third observation, the Maintenance Director will purchase suitable escutcheons to install at the two sprinkler heads. A full facility audit will be conducted to ensure no further sprinkler heads are missing their escutcheons.

NFPA 101 STANDARD Portable Fire Extinguishers:

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.

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, the facility failed to conduct monthly inspections of the portable fire extinguishers, affecting the entire facility.

Finding include:

1. April 25, 2024, at 10:45 a.m.: Monthly inspections were not performed on the fire extinguisher inside of the telephone equipment room.

2. April 25, 2024, at 11:30 a.m.: Monthly inspections were not performed on the fire extinguisher inside of the medical records room.

Exit interview with maintenance director and adminstrator on April 25, 2024, at 12:30 p.m., confirmed the lack of monthly visual inspections in these two portable fire extinguisher locations.

Plan of Correction - To be completed: 06/24/2024

For both observations, the Maintenance Director has created a monthly audit form to be filled out each time the monthly fire extinguisher inspection is completed.
Addition, For both observations, the Maintenance Director has properly inspected the noted fire extinguishers and created a monthly audit form to be filled out each time the monthly fire extinguisher inspection is completed.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, the facility failed to maintain the fire rating of the smoke barrier walls, affecting two of three building levels.

Findings include:

Observations on April 25, 2024, revealed smoke barrier wall unsealed penetrations in the following locations:

a. 11:05 a.m., Ground floor, above south hall smoke doors, around data wires;
b. 11:20 a.m., Second floor, above north hall smoke doors, around data wires;
c. 11:30 a.m., Second floor, above south hall smoke doors, around data wires.

Exit interview with the administrator and maintenance director on April 25, 2024, at 12:30 p.m., confirmed the wall penetrations.

Plan of Correction - To be completed: 06/24/2024

For the three observations, the Maintenance Director will perform a general inspection of the smoke wall barriers to verify all penetrations are properly sealed with 3M Fire Barrier Sealant FD-150+, 90G9 UL Listed. The facility will also ensure that any future penetrations made to smoke wall barriers will be properly sealed.
ADDITION/CORRECTION: For the three observations, the Maintenance Director will perform a general inspection of the smoke wall barriers to verify all penetrations are properly sealed. For the observations noted, the affected wires were single wires that penetrated the smoke barrier. Therefore, the data wires will be sealed in accordance with UL System W-L-3058 and sealed with 3M Fire Barrier Sealant FD-150+, 90G9 UL Listed, in the annular space with a �" crown. The facility will also ensure that any future penetrations made to smoke wall barriers will be properly sealed.

NFPA 101 STANDARD Utilities - Gas and Electric:

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 BUILDING 01 - Component: 01 - Tag: 0511

Based on observation and interview, the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting one of three building levels.

Findings include:

Observation on April 25, 2024, revealed non-GFCI outlets located within six feet of a sink in the below locations;

a. 11:10 a.m., Ground floor, occupational therapy counter.
b. 11:15 a.m., Ground floor, occupational therapy bathroom.

Reference NFPA 70 210.8(B)5

Exit interview with the administrator and maintenance director on April 25, 2024, at 12:30 p.m., confirmed the outlets were within six feet of a sink.

Plan of Correction - To be completed: 06/24/2024

For both observations, the Maintenance Director has visually audited and verified that all facility outlets that are within six (6) feet of water sources are ground fault protected via upstream Ground Fault breakers.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on document review and interview, the facility failed to conduct annual fire door inspections for one of one inspection.

Findings include:

Document review on April 25, 2024, at 9:30 a.m., revealed the facility could not produce documentation that an annual fire door inspection was performed.

Exit interview with the administrator and maintenance director on April 25, 2024, at 12:30 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 06/24/2024

For the observation, the Maintenance Director will perform the facility annual fire door inspection with standardized corporate form, and will perform inspection annually thereafter, placing completed forms in facility Life Safety book. Will audit one time per year for completion and compliance.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on document review and interview, the facility failed to maintain required testing of emergency generator components, affecting the entire facility.

Findings include:

Document review on April 25, 2024, at 9:30 a.m., revealed the facility lacked verifying documentation for the following emergency generator maintenance items:

a. Monthly conductance testing of the battery;
b. Annual 90-minute load bank;
c. Annual fuel quality test;
d. Three-year, four-hour load test.

Exit interview with the administrator and maintenance director on April 25, 2024, at 12:30 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 06/24/2024

For the first observation, the Maintenance Director will purchase a suitable conductivity meter in order to perform random weekly conductance tests of the emergency generator battery.
For the second and fourth observations, the facility will coordinate between the outside contractor and corporate to reassess the emergency generator contract to ensure it includes the annual 90-minute load bank test and the 3-year, 4-hour load test, then perform them at the earliest convenience. The previous 3-year, 4-hour load test paperwork has been located and was performed in July 2022 and is listed in TELS as not due again until July of 2026, but should be due in July of 2025.
For the third observation, the Maintenance director will obtain two (2) years of fuel sample test results and ensure that said documentation is provided to the facility every year after.

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 01 - Component: 01 - Tag: 0923

Based on observation and interview, the facility failed to maintain oxygen cylinder storage, affecting two of three building levels.

Findings include:

Observation on April 25, 2024, revealed unsecured and freestanding oxygen cylinders in the following locations:

a. 10:30 a.m., Ground floor, central hall, one cylinder;
b. 10:35 a.m., Ground floor, oxygen storage, two cylinders.
c. 11:30 a.m., Second floor, nurse lounge, one cylinder.

Exit interview with the administrator and maintenance director on April 25, 2024, at 12:30 p.m., confirmed the unsecured oxygen cylinders.

Plan of Correction - To be completed: 06/24/2024

For all three (3) observations, oxygen canisters were removed and properly stored per safety requirements. The Maintenance Director will ensure that all staff are properly trained on handling of oxygen canisters and their proper and safe storage requirements. Additionally, the Maintenance Director will conduct random weekly audits for 90 days ensuring that there are no freestanding canisters.

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