Pennsylvania Department of Health
QUINCY 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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QUINCY 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 March 18, 2024, at Quincy 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 - Component: 01 - Tag: 0000

Facility ID #170202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 18, 2024, it was determined that Quincy 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 (000), unprotected noncombustible 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 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain the means of egress to be unobstructed, in two of six smoke compartments within the component.

Findings include:

1. Observation on March 18, 2024, between 12:15 PM and 12:50 PM, revealed corridors were obstructed by utility carts and furniture, at the following locations:

a. 12:15 PM, first floor, soiled-linen cart and trash container were stored outside Resident Room 155;
b. 12:30 PM, first floor, side chair, outside Resident Room 169;
c. 12:50 PM, first floor, soiled-linen cart and trash containers were stored in the exit corridor, near the outside exit door, by the Quincy Room.

Interview with the Director of Maintenance on March 18, 2024, at 1:00 PM, confirmed the corridor was obstructed.

Plan of Correction - To be completed: 04/19/2024

The Chair was placed back in the resident's room. Smaller isolation containers were ordered. Smaller trash containers 13 gallons will be placed inside resident room to eliminate the need for the hallway trash containers. Maintenance Manager or designee will be auditing the containers and trash can on a weekly basis to insure they are required and remove them once the isolation requirement has been removed. Maintenance Manager or Designee will conduct an on-spot education of the nursing staff in the importance of not blocking any means of egress by allowing non-transport items in the hallways. Maintenance Manager or Designee will create recurring inspection to check the need and use of isolation containers in the hallways. In addition, non-transportation devices being stored in the hallways, auditing will be conducted weekly and results will be reported to QAPI committee.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain rated hazardous area doors to be within the allowed gap margins, in one of six smoke compartments within the component.

Findings include:

1. Observation on March 18, 2024, at 11:50 AM, revealed the rated door to the 1st floor Storage Room, by Resident Room 151, had gaps greater than 1/8 inch.

Interview with the Director of Maintenance on March 18, 2024, at 11:50 AM, confirmed the door had gaps greater than 1/8 inch.

Plan of Correction - To be completed: 04/19/2024

Audit was conducted on all doors to asses allowed gap margins. We have installed a Crown Fire Door 90 minute door gap solution to repair assembles to make repair to this door to meet gap standard, door repair assembly is affixed with the UL rating label and we will keep UL rating paper work in the Life Safety book. Maintenance Manager; educated on-spot education of the maintenance staff in the importance of NFPA 101/80 smoke/Fire door inspections. We will re-inspect all our doors in all critical areas to make sure the meet the standards, and if not we will order the approved smoke/fire seal kits from Crown products. Audit will be conducted Quarterly to ensure it remains with in compliance. QAPI will also be informed of the inspection results.

NFPA 101 STANDARD Corridor - Doors:

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 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors to be unobstructed from closing, in one of six smoke compartments within the component.

Findings include:

1. Observation on March 18, 2024, at 1:12 PM, revealed the 2nd floor Utility Room door was equipped with a self-closing device and was being held open by a wastebasket, behind the nurses' station.

Interview with the Director of Maintenance on March 18, 2024, at 1:12 PM, confirmed the self-closing door was impeded from closing.

Plan of Correction - To be completed: 04/19/2024

Wastebasket was removed to allow the door to close properly. Will follow up with Staff education. Staff education on the proper operation of closured affixed doors. Maintenance Director or Designee will monitor this area and door on a weekly basis and complete audit tool. Maintenance Manager or Designee will conduct an on-spot education of the nursing staff in the importance of NFPA 101/80 smoke/Fire door inspection and proper closure of same doors. Maintenance Manager or Designee will audit this area and door on a weekly basis and document on audit tool and will be reported to QAPI Committee.

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 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of smoke barrier walls, in one of six smoke compartments within the component.

Findings include:

1. Observation on March 18, 2024, at 11:40 AM, revealed a penetration around black and yellow data wires, over the double smoke doors, on the 1st floor, by the Quincy Room.

Interview with the Director of Maintenance on March 18, 2024, at 11:40 AM, confirmed the unsealed penetration.

Plan of Correction - To be completed: 04/19/2024

The repair was made using an approved through penetration fire stop system.
We will audit the areas by all our smoke barrier doors to ensure all penetrations are proper fire caulked with an approved fire stop system, we will maintain the ratings of the smoke barrier wall though out the facility. The audit will be completed by 4.19.2024 Maintenance Manager or Designee will conduct on-spot education of the maintenance staff in the importance of NFPA 101 smoke barrier inspection and proper repairs of smoke penetrations. Maintenance Manager or designee will conduct recurring inspection to check smoke walls for unsealed penetrations Quarterly. Additional inspection by Maintenance or designee while and after any work is done above ceilings to smoke walls. Results of inspection will be reported to QAPI.

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