Pennsylvania Department of Health
QUARRYVILLE PRESBYTERIAN RETIREMENT COMMUNITY
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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QUARRYVILLE PRESBYTERIAN RETIREMENT COMMUNITY - 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 16, 2024, at Quarryville Presbyterian Retirement Community, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

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

Facility ID #170102
Component 01
Building 01

Based on a Medicare/Medicaid Recertification Survey completed on July 16, 2024, it was determined that Quarryville Presbyterian Retirement Community 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 three-story, Type II (222), fire resistive structure, with a basement, which is fully sprinklered.

Plan of Correction:

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 BUILDING THOMPSON - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors to positively latch, in one of three smoke compartments on the 2nd floor within the component.

Findings include:

1. Observation on July 16, 2024, at 1:15 PM, revealed the corridor door to Resident Room T219 failed to positively latch, when closed.

Interview with the V.P. of Facilities on July 16, 2024, at 1:15 PM, confirmed the door did not positively latch.

Plan of Correction - To be completed: 08/13/2024

The door to Resident Room T219 was repaired and now latches properly and in accordance with this regulation.

The Vice President of Facility Services re-educated the Maintenance Manager on the requirements of this regulation.

The Maintenance Manager / designee will perform a baseline audit of all doors protecting the corridor openings to ensure that they latch properly and are in compliance with this regulation.

The Maintenance Manager / designee will audit a minimum of 10 random doors protecting the corridor openings each week for 4 weeks then monthly for 3 months to ensure compliance with this regulation.

The Maintenance Manager / Designee will perform random door audits on a monthly basis to ensure compliance with this regulation.

The results of these audits will be reviewed by the facility's Quality Assurance / Process Improvement team for further recommendations.

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