Nursing Investigation Results -

Pennsylvania Department of Health
QUARRYVILLE PRESBYTERIAN RETIREMENT COMMUNITY
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
QUARRYVILLE PRESBYTERIAN RETIREMENT COMMUNITY
Inspection Results For:

There are  29 surveys for this facility. Please select a date to view the survey results.

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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 October 7, 2019, 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 October 7, 2019, 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 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 THOMPSON - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain exit access corridors to be clear and unobstructed, on one of four floors within the component.

Findings include:

1. Observation on October 7, 2019, at 1:30 PM revealed a side chair was stored in the 1st floor corridor, by the T112 Vending Room and the Elevator. This item was not fixed to the wall or floor.

Interview with the Director of Facilities on October 7, 2019, at 1:30 PM confirmed the unfixed furniture in the corridor.



 Plan of Correction - To be completed: 10/20/2019

It was determined that the chair in corridor was left by a family and donated to the facility. The chair was removed. Administrator or designee(s) will routinely monitor, at least weekly, all exit access corridors to ensure no unfixed chairs or furnishings are in obstruction.
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 THOMPSON - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain sprinkler heads to be unobstructed, on one of four floors within the component.

Findings include:

1. Observation on October 7, 2019, at 1:05 PM revealed storage within 18 inches of the sprinkler in the 2nd floor Supply Closet.

Interview with the Director of Facilities on October 7, 2019, at 1:05 PM confirmed the storage was within 18 inches of the sprinkler head.



 Plan of Correction - To be completed: 10/20/2019

The item stored on the top shelf blocking the sprinkler head was removed on 10/07/2019. A red barrier will be marked on shelving and staff will be trained to not store any items within the red barrier. Administrator or designee(s) will audit storage areas routinely to ensure compliance. Information from routine audits will be discussed at QAPI meetings.
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, on one of four floors within the component.

Findings include:
1. Observation on October 7, 2019, at 1:35 PM revealed the door to Resident Room T216, on the 2nd floor, did not close and latch.

Interview with the Director of Facilities on October 7, 2019, at 1:35 PM confirmed the door failed to positively latch.



 Plan of Correction - To be completed: 10/20/2019

Door to T216 was adjusted on 10/7/2019 to ensure proper closing and latching. Routine inspections at least quarterly will be done by maintenance director or designee(s) to ensure compliance. Results of inspection will be shared with QAPI committee.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: MAIN BUILDING THOMPSON - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier door hardware to function as intended, affecting one of four floors within the component.

Findings include:

1. Observation on October 7, 2019, at 2:15 PM revealed the double smoke barrier doors 13, on the Garden Level, were equipped with latching hardware which failed to positively latch during the survey.

Interview with the Director of Facilities on October 7, 2019, at 2:15 PM confirmed the smoke barrier door hardware failed to function as intended.



 Plan of Correction - To be completed: 10/20/2019


Double smoke door #13 on garden level was adjusted on 10/7/2019 to ensure proper closing and latching. Routine inspections at least quarterly will be done by maintenance director or designee(s) to ensure compliance. Results of inspection will be shared with QAPI committee.
NFPA 101 STANDARD Soiled Linen and Trash Containers: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.
Soiled Linen and Trash Containers
Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended.
Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent.
18.7.5.7, 19.7.5.7
Observations:
Name: MAIN BUILDING THOMPSON - Component: 01 - Tag: 0754

Based on observation and interview, it was determined the facility failed to store receptacles with combined or single capacities exceeding 32 gallons in a hazardous area, on one of four floors within the component.

Findings include:

1. Observation on October 7, 2019, at 1:45 PM revealed soiled-linen and trash containers exceeded 32 gallons were being stored in the 1st floor Bath T103.

Interview with the Director of Facilities on October 7, 2019, at 1:45 PM confirmed the soiled-linen and trash containers were stored outside of a protected hazardous storage area.





 Plan of Correction - To be completed: 10/20/2019

It was determined that staff had put a soiled linen cart in the 1st floor bath T103 next to the soiled linen containers permanently stationed in that location. The soiled linen cart was removed and placed back in its location in the soiled utility room on 10/07/2019. Staff will be in-serviced and a sign will be placed in this location reminding staff of this policy.

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