Nursing Investigation Results -

Pennsylvania Department of Health
CHRIST THE KING MANOR
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
CHRIST THE KING MANOR
Inspection Results For:

There are  40 surveys for this facility. Please select a date to view the survey results.

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CHRIST THE KING 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 October 7-8, 2019, at Christ the King 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 # 290102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on October 7-8, 2019, it was determined that Christ the King Manor, 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 one-story, Type II (000), unprotected, noncombustible building, with a partial basement, that is fully sprinklered.







 Plan of Correction:


NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
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, the facility failed to maintain hazardous areas at two of over five hazardous area doors.

Findings include:

1. Observation on October 8, 2019, at 9:30 a.m., revealed the two kitchen dry storage room doors were blocked open with unauthorized hold-open devices.

Interview with the maintenance director on October 8, 2019, at 9:30 a.m. confirmed the above storage room doors were blocked open.




 Plan of Correction - To be completed: 10/31/2019

Christ the King provides this Plan of Correction solely to comply with State and Federal regulations. This Plan of Correction is in no way to be interpreted or construed as either an expression or implied admission or agreement by the facility concerning the veracity of this deficiencies, alleged or violations or finding by the Department of Health Division of Safety Inspection. By providing this Plan of Correction, the facility does not waive its rights available by law or equity.

Christ the King Manor intends to maintain hazardous area doors. Systematic changes that were put into effect to ensure the deficient practice does not recur were doors were cleared of door stops.

Corrective actions will be maintained and monitored by educating the staff on the importance of door being propped open.

The Safety Director or Designee shall check the doors to ensure the doors are free of obstruction daily for 14 days then weekly for 6 weeks then monthly for 3 months.

All findings from monitoring will be reported to Quality Assurance Committee for the additional recommendations to maintain compliance.
NFPA 101 STANDARD Fire Drills: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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on document review and interview, the facility failed to maintain fire drills to be held at unexpected times, under varying conditions, on one of three staff shifts.

Findings include:

1. Document review on October 7, 2019, at 10:00 a.m., revealed third shift fire drills, for the last four annual quarters, were not held at unexpected times (held within the 4:00 a.m. hour).

Interview with the maintenance director on October 7, 2019, at 10:00 a.m., confirmed third shift fire drills were not held at unexpected times, within the last year.





 Plan of Correction - To be completed: 10/31/2019

Christ the King Manor intends to conduct fire drills at unexpected times, under varying conditions, on one of three shifts.

Systemic changes that were put into place; the Safety Director conducted a drill on the 3rd shift at 3:30 a.m. on 10-08-19. The Safety Director will conduct all drills at various times on all three shift to adhere to Life Safety Code.

To ensure the deficient practice will not recur the Safety Director with will review or look back on previous months drill not to be complete on same times. The Executive Director or Administrator will monitor to ensure varying times for drills are being conducted for the next 3 months.

The results of drills will be reported to Quality Assurance Committee for further review or recommendation
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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 observation and interview, the facility failed to maintain essential electrical systems for one of over ten emergency generator functioning components.

Findings include:

1. Observation on October 8, 2019, at 11:15 a.m., revealed the emergency generator servicing this building, lacked a remote manual stop station, located outside the room housing the generator, in accordance with NFPA 110, 5.6.5.6.

Interview with the maintenance director on October 8, 2019, at 11:15 a.m. confirmed the emergency generator servicing this building lacked a remote manual stop station.






 Plan of Correction - To be completed: 10/31/2019

Christ the King Manor intents to maintain essential electrical systems for the emergency generator according to Life Safety regulations.

Systematic changes that were put into effect so the deficient practice does not recur; the Safety Director coordinated with electrician to install emergency stop per code.

The Maintenance staff shall receive education on this regulation for the safety and importance of exterior emergency stops.

The Safety Director shall be responsible for the installation of the emergency stops by 10-31-19.

The results of the to installation will be reported to Quality Assurance Committee for approval.
Initial comments:Name: CHAPEL - Component: 02 - Tag: 0000


Facility ID # 290102
Component 02
Chapel

Based on a Medicare/Medicaid Recertification Survey completed on October 7-8, 2019, it was determined that Christ the King Manor, 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 one-story, Type V (111), protected, wood frame building, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Fire Drills: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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: CHAPEL - Component: 02 - Tag: 0712

Based on document review and interview, the facility failed to maintain fire drills to be held at unexpected times, under varying conditions, on one of three staff shifts.

Findings include:

1. Document review on October 7, 2019, at 10:00 a.m., revealed third shift fire drills, for the last four annual quarters, were not held at unexpected times (held within the 4:00 a.m. hour).

Interview with the maintenance director on October 7, 2019, at 10:00 a.m., confirmed third shift fire drills were not held at unexpected times, within the last year.



 Plan of Correction - To be completed: 10/31/2019

Christ the King Manor intends to conduct fire drills at unexpected times, under varying conditions, on one of three shifts.
Systemic changes that were put into place; the Safety Director conducted a drill on the 3rd shift at 3:30 a.m. on 10-08-19. The Safety Director will conduct all drills at various times on all three shift to adhere to Life Safety Code.

To ensure the deficient practice will not recur the Safety Director with will review or look back on previous months drill not to be complete on same times. The Executive Director or Administrator will monitor to ensure varying times for drills are being conducted for the next 3 months.

The results of drills will be reported to Quality Assurance Committee for further review or recommendation
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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: CHAPEL - Component: 02 - Tag: 0918

Based on observation and interview, the facility failed to maintain essential electrical systems for one of over ten emergency generator functioning components.

Findings include:

1. Observation on October 7, 2019, at 1:35 p.m., revealed the emergency generator servicing this building, lacked a remote manual stop station, located outside the room housing the generator, in accordance with NFPA 110, 5.6.5.6.

Interview with the maintenance director on October 7, 2019, at 1:35 p.m. confirmed the emergency generator servicing this building lacked a remote manual stop station.







 Plan of Correction - To be completed: 10/31/2019

Christ the King Manor intents to maintain essential electrical systems for the emergency generator according to Life Safety regulations.
Systematic changes that were put into effect so the deficient practice does not recur; the Safety Director coordinated with electrician to install emergency stop per code.

The Maintenance staff shall receive education on this regulation for the safety and importance of exterior emergency stops.

The Safety Director shall be responsible for the installation of the emergency stops by 10-31-19.

The results of the to installation will be reported to Quality Assurance Committee for approval.
Initial comments:Name: NEW DEMENTIA WING - Component: 03 - Tag: 0000


Facility ID # 290102
Component 03
Dementia Unit

Based on a Medicare/Medicaid Recertification Survey completed on October 7-8, 2019, it was determined that Christ the King Manor, 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 one-story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Discharge from Exits:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7
Observations:
Name: NEW DEMENTIA WING - Component: 03 - Tag: 0271

Based on observation and interview, the facility failed to maintain exit discharge requirements at two of over four exit discharges.

Findings include:

1. Observation on October 7, 2019, between 1:15 p.m. and 1:30 p.m., revealed the following Memory Support Unit exit discharges, were not maintained with a hard-packed all weather travel surface to a public way (on the day of the survey, rain created a muddy, soft surface with water pools, that would prove difficult to move wheelchairs, walkers, or beds):
a. (1:15 p.m.) North side exit;
b. (1:30 p.m.) Activity room/courtyard exit.

Interview with the maintenance director on October 7, 2019, at 1:30 p.m. confirmed the above exit discharges were not a hard-packed surface to achieve exiting without difficulty.







 Plan of Correction - To be completed: 10/31/2019

Christ the King Manor intends to maintain exit discharge requirements.

Systematic changes put into effect is that the facility will submit plans to planning and review for installation of sidewalks. Upon approval the facility will complete installation of sidewalks.

Facility staff will be educated on the deficient practice and regulation requirements.

The Safety Director and Maintenance Director will be responsible for installation of sidewalks once approval by Planning and Review.

All corrections will be submitted to Quality Assurance Committee for compliance.
NFPA 101 STANDARD Fire Drills: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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: NEW DEMENTIA WING - Component: 03 - Tag: 0712

Based on document review and interview, the facility failed to maintain fire drills to be held at unexpected times, under varying conditions, on one of three staff shifts.

Findings include:

1. Document review on October 7, 2019, at 10:00 a.m., revealed third shift fire drills, for the last four annual quarters, were not held at unexpected times (held within the 4:00 a.m. hour).

Interview with the maintenance director on October 7, 2019, at 10:00 a.m., confirmed third shift fire drills were not held at unexpected times, within the last year.





 Plan of Correction - To be completed: 10/31/2019

Christ the King Manor intends to conduct fire drills at unexpected times, under varying conditions, on one of three shifts.
Systemic changes that were put into place; the Safety Director conducted a drill on the 3rd shift at 3:30 a.m. on 10-08-19. The Safety Director will conduct all drills at various times on all three shift to adhere to Life Safety Code.

To ensure the deficient practice will not recur the Safety Director with will review or look back on previous months drill not to be complete on same times. The Executive Director or Administrator will monitor to ensure varying times for drills are being conducted for the next 3 months.

The results of drills will be reported to Quality Assurance Committee for further review or recommendation
NFPA 101 STANDARD Smoking Regulations: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.
Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: NEW DEMENTIA WING - Component: 03 - Tag: 0741

Based on observation and interview, the facility failed to maintain smoking regulations at one of two designated smoking areas.

Findings include:

1. Observation on October 7, 2019, at 1:00 p.m., revealed the employee smoking area had combustible trash within the "cigarette butt only" container.

Interview with the maintenance director on October 7, 2019, at 1:00 p.m. confirmed cigarette butt container contained combustible trash.





 Plan of Correction - To be completed: 10/31/2019

Christ the King Manor intends to maintain smoking regulations in designated smoking areas.

Systematic changes put into effect to ensure the deficiency does not recur: education was conducted with facility staff to not place combustible trash within the cigarette butt only containers.

To ensure this practice does not recur: the Safety Director or designee will monitor the smoking areas daily for 4 weeks, then twice a week for 2 weeks and monthly for 3 months to ensure compliance.

All finding through monitoring and review will be submitted to Quality Assurance Committee for review and recommendations.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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: NEW DEMENTIA WING - Component: 03 - Tag: 0918

Based on observation and interview, the facility failed to maintain essential electrical systems for one of over ten emergency generator functioning components.

Findings include:

1. Observation on October 7, 2019, at 2:00 p.m., revealed the emergency generator servicing this building, lacked a remote manual stop station, located outside the room housing the generator, in accordance with NFPA 110, 5.6.5.6.

Interview with the maintenance director on October 7, 2019, at 2:00 p.m. confirmed the emergency generator servicing this building lacked a remote manual stop station.




 Plan of Correction - To be completed: 10/31/2019

Christ the King Manor intents to maintain essential electrical systems for the emergency generator according to Life Safety regulations.
Systematic changes that were put into effect so the deficient practice does not recur; the Safety Director coordinated with electrician to install emergency stop per code.

The Maintenance staff shall receive education on this regulation for the safety and importance of exterior emergency stops.

The Safety Director shall be responsible for the installation of the emergency stops by 10-31-19.

The results of the to installation will be reported to Quality Assurance Committee for approval.

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