Nursing Investigation Results -

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

ELLEN MEMORIAL HEALTH CARE CENTER
Inspection Results For:
There are 42 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


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 May 24, 2022, 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 May 23, 2022, 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 Exit Signage:

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.

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed to install exit signage in three locations, affecting one of one floor.

Findings include:

1. Observation on May 24, 2022, between 10:35 a.m., and 11:05 a.m., revealed exit signage was lacking in the following locations:

a. 10:35 a.m., two locations within the Therapy corridor.
b. 11:05 a.m., at the Memory Care entrance doors.

Exit interview with Facility Representative One on May 24, 2022, between 11:50 a.m., and 12:00 p.m., confirmed the exit signage deficiencies.

Plan of Correction - To be completed: 06/07/2022

Exit signs were installed at the two locations within the therapy corridor and at the memory care entrance doors.
There were no other areas identified as not having an exit sign.
Maintenance director and assistant are educated on the need to have proper exit signage.
An audit will be done weekly on a random corridor to assure there are appropriate exit signs in each unit corridor.

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 May 24, 2022, at 10:51 a.m., revealed the K-Type fire extinguisher placard, located within Dietary, was improperly installed.

Exit interview with Facility Representative One on May 24, 2022, between 11:50 a.m., and 12:00 p.m., confirmed the fire extinguisher deficiency.

Plan of Correction - To be completed: 06/07/2022

The K Type fire extinguisher placard located within dietary was properly installed.
There were no other K fire extinguisher placards identified as not properly installed.
Maintenance Director and assistant are educated on the need to maintain properly installed K-Type portable fire extinguisher placards
An audit will be done weekly to assure K-Type fire extinguisher placards are properly installed.

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 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain three corridor openings, affecting one of one floor.

Findings include:

1. Observation on May 24, 2022, between 10:37 a.m., and 11:09 a.m., revealed the following:

a. 10:37 a.m., the Staff Lounge door was difficult to open/close.
b. 10:55 a.m., the Housekeeping Office door required adjustment to fully latch.
c. 11:09 a.m., the Chapel door required adjustment to fully latch.

Exit interview with Facility Representative One on May 24, 2022, between 11:50 a.m., and 12:00 p.m., confirmed the corridor opening deficiencies.

Plan of Correction - To be completed: 06/07/2022

The staff Lounge door was adjusted to allow for proper opening and closing.
The housekeeping office door and chapel door were adjusted to fully latch.
There were no other doors identified as not opening or closing properly or not latching.
The maintenance Director and assistant are educated on the need to maintain corridor openings and have doors adjusted to fully latch and open and close properly.
An audit will be done on these three doors weekly to assure they are closing properly in addition to ten other random doors weekly.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical equipment in two locations, affecting one of one floor.

Findings include:

1. Observation on May 24, 2022, between 10:28 a.m. and 11:16 a.m., revealed the following:

a. 10:28 a.m., an outlet multiplier was in use at the main entrance area.
b. 11:16 a.m., an extension cord was in use at the fish tank.

Exit interview with Facility Representative One on May 24, 2022, between 11:50 a.m. and 12:00 p.m., confirmed the electrical equipment deficiencies.

Plan of Correction - To be completed: 06/07/2022

The outlet multiplier was removed from the main entrance area and the extension cord was removed from the fish tank.
The facility was checked for other multipliers and extension cords and any found were removed immediately.
Facility staff are being made aware outlet multipliers and extension cords are not allowed to be used due to potential fire hazard.
Maintenance will audit 10 rooms/areas weekly to assure no outlet multipliers or extension cords are in use.

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