Pennsylvania Department of Health
MANOR AT ST. LUKE VILLAGE, THE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MANOR AT ST. LUKE VILLAGE, THE - 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 May 06, 2024, it was determined that, The Manor at St. Luke Village, had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:

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.

§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.

Observations:
Name: - Component: -- - Tag: 0004

Based on observation and interview, the facility failed to maintain an annual updated comprehensive emergency preparedness program.

Findings include:

1. Observation on May 06, 2024, between 11:45 a.m., and 12:10 p.m., revealed the facility could not provide documents for an updated Emergency Plan review, for the last 12 months.

Interview at exit with the Executive Director and Director of Maintenance on May 06, 2024, at 12:15 p.m., confirmed the facility lacked documentation.

Plan of Correction - To be completed: 05/21/2024

1. Documentation of the required annual review of the Federal Emergency Preparedness Plan (Fed EP) will be completed.

2. There is only one required Fed EP, therefore no additional reviews were needed.

3. The Executive Director educated the Maintenance Director and Director of Clinical Services on the importance of 42 CFR 483.73(a) Develop EP Plan- Review and Update Annually specific to the required annual review of the Fed EPP. This item will be added to the facility's TELS Preventative Maintenance (PM) calendar and will continue to be monitored in accordance with the standard.

4. Any findings will be reported to the monthly QAPI Committee for further review.

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

Facility ID# 195202
Component 01
Building 01

Based on a Medicare/Medicaid Recertification Survey completed on May 06, 2024, it was determined that The Manor at St. Luke Village 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 483.70(a).

This is a one story, Type II (111), protected, noncombustible, fully sprinklered structure.

Plan of Correction:

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 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the floor/ceiling assembly, in one location, affecting one of one floors.

Findings include:

1. Observation on May 06, 2024, At 11:02 a.m., revealed there was a ceiling tile missing and 4 other ceiling tiles water damaged, preventing the tiles from being smoke tight, in the protected ceiling assembly of the Laundry Room..

Interview at exit with the Executive Director and Director of Maintenance on May 06, 2024, at 12:15 p.m., confirmed missing ceiling tile and ceiling tile damage.

Plan of Correction - To be completed: 05/21/2024

1. The ceiling tiles noted to be missing and water damaged in the Laundry Room were replaced.

2. Additional ceiling tiles were reviewed for being missing and/or water damaged.

3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Hazardous Ares- Enclosure specific to properly maintaining ceiling tiles and will continue to monitor in accordance with NFPA standards.

4. Any findings will be reported to the monthly QAPI Committee for further review

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 observations and interview, it was determined the facility failed to maintain the sprinkler system in two locations, affecting one of one floors.

Findings include:

1. Observation and interview on May 06, 2024, at 11:30 a.m., revealed the sprinkler head, in the Clean Linen Room, West Wing Nurses Station, was missing an escutcheon.

Interview at exit with the Executive Director and Director of Maintenance on May 06, 2024, at 12:15 p.m., confirmed the missing escutcheon.

2. Observation and interview on May 06, 2024, at 11:36 a.m., revealed the storage of combustible items within 18 inches of the sprinkler heads, West Wing, Activity Storage Room.

Interview at exit with the Executive Director and Director of Maintenance on May 06, 2024, at 12:15 p.m., confirmed the storage of combustible items within 18 inches of the sprinkler heads.

Plan of Correction - To be completed: 05/21/2024

1. The escutcheon noted to be missing on the sprinkler head in the West nurse's Station Clean Linen Room will be replaced. The combustible storage noted to be within 18 inches of the sprinkler heads in the sprinkler heads in the West Wing Activity Storage Room was removed.

2. Additional sprinkler heads will be reviewed for missing escutcheons and improper combustible storage within 18 inches.

3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Sprinkler System- Maintenance and Testing specific to properly maintaining the facility's sprinkler heads, and will continue to monitor in accordance with NFPA standards.

4. Any findings will be reported to the monthly QAPI Committee for further review.

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