Pennsylvania Department of Health
ELLEN MEMORIAL HEALTH CARE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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ELLEN MEMORIAL HEALTH CARE CENTER - 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 27, 2024, at Ellen Memorial Health Care Center, 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# 318502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 27, 2024, it was determined that Ellen Memorial Health Care Center 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 (000), unprotected, wood frame 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, it was determined the facility failed to maintain one hazardous area in two locations, affecting one of one floor.

Findings include:

1. Observation on March 27, 2024, at 11:03 a.m., revealed two of three Generator Set Room doors required adjustment to fully latch.

Exit interview, on March 27, 2024, between 12:00 p.m., and 12:15 p.m., with the Facilities Manager, confirmed the hazardous area enclosure deficiencies.

Plan of Correction - To be completed: 04/23/2024

0321
- The required adjustments to the two Generator Set Room doors have been made so the doors fully latch.
- Doors enclosing hazardous areas in the facility have been checked and if necessary adjusted so that they fully latch.
- Maintenance has provided a list of doors enclosing hazardous areas to the QA team. Maintenance will audit these doors weekly to assure they fully latch. The audit will be turned in to the QA team.
- April 23, 2024

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 observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of one floor.

Findings include:

1. Observation on March 27, 2024, at 11:23 a.m., revealed a ceiling tile was lacking within the Dish Network closet.

Exit interview, on March 27, 2024, between 12:00 p.m., and 12:15 p.m., with the Facilities Manager, confirmed the automatic sprinkler system deficiency.

Plan of Correction - To be completed: 04/23/2024

0353
- The ceiling block in the dish network closet has been replaced. Ceiling tiles in the closet have been checked and are in good working condition.
- Ceiling tiles have been checked throughout the facility to assure they are present and in good working condition.
- Areas throughout the facility (including closets) will be checked weekly so the automatic sprinkler system is maintained.
- April 23, 2024

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain one portable fire extinguishing device, affecting one of one floor.

Findings include:

1. Observation on March 27, 2024, at 10:49 a.m., revealed the K Type fire extinguisher, located within Dietary, was installed in excess of sixty inches from floor to handle.

Exit interview, on March 27, 2024, between 12:00 p.m., and 12:15 p.m., with the Facilities Manager, confirmed the fire extinguisher deficiency.

Plan of Correction - To be completed: 04/23/2024

0355
- The type K fire extinguisher, located in dietary has been reinstalled so the handle is not in excess of sixty inches from floor to handle.
- Fire extinguishers in the facility have been measured to assure they are mounted correctly (handles not in excess of sixty inches from the floor).
- Maintenance has provided a list of fire extinguishers in the facility to the QA team. A QA team designee will audit the list for compliance with life safety code.
- April 23 ,2024

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