Pennsylvania Department of Health
EMMANUEL CENTER FOR NURSING AND REHAB AT MARIA JOSEPH MANOR
Building Inspection Results

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EMMANUEL CENTER FOR NURSING AND REHAB AT MARIA JOSEPH MANOR
Inspection Results For:

There are  36 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.
EMMANUEL CENTER FOR NURSING AND REHAB AT MARIA JOSEPH 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 December 17, 2024, at Emmanuel Center for Nursing and Rehab at Maria Joseph 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# 391302
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on December 17, 2024, it was determined that Emmanuel Center for Nursing and Rehabilitation at Maria Joseph Manor was not in compliance with the following requirements of the Life Safety Code for 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 V (111), protected, wood frame building, with a partial basement, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 two instances, affecting one of one floors.

Findings include:

1. Observation on December 17, 2024, between 9:46 a.m., and 10:10 a.m., revealed the following:

a. At 9:46 a.m., 100 Hall, Corridor ceiling tile had an unsealed penetration, near Resident Room 108.
b. At 10:10 a.m., Dietary, Walk-In freezer, was missing an escutcheon above the door.

Exit interview with the Facility Acting Administrator, Facilities Manager, and the Environmental Director, on December 17, 2024, at 11:00 a.m., confirmed the automatic sprinkler system deficiencies.







 Plan of Correction - To be completed: 01/15/2025

1. a). 100 hall ceiling tile penetration near resident room 108 was sealed with appropriate fire rated sealant by maintenance director or designee on 12/27/24.

1. b). Escutcheon in the dietary freezer replaced by maintenance director or designee on 12/27/24.

2. Maintenance director or designee will inspect ceiling tiles and sprinkler heads weekly and following contractor work to assure there are no unsealed penetrations or missing escutcheons.

3. Inspections will be reported at the monthly safety and QAPI meetings for further review and recommendations.

NFPA 101 STANDARD Corridor - Doors: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.
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 corridor openings in three locations, affecting one of one floors.

Findings include:

1. Observation on December 17, 2024, between 9:45 a.m., and 10:36 a.m., revealed the following:

a. At 9:45 a.m., 100 Hall, Resident Room 112, door failed to latch into frame when tested.
b. At 10:02 a.m., 100 Hall, Shower Room, door was not smoke tight when closed into frame.
c. At 10:36 a.m., 300 Hall, Dining Room, door failed to latch into frame when tested.

Exit interview with the Facility Acting Administrator, Facilities Manager, and the Environmental Director, on December 17, 2024, at 11:00 a.m., confirmed the corridor opening deficiencies.







 Plan of Correction - To be completed: 01/15/2025

1. All identified door latches corrected to assure positive latching by maintenance director or designee on 12/27/24.
All other facility doors will be inspected by maintenance director or designee to assure positive latching occurs by 1/10/25.

2. Maintenance director or designee will inspect 10 doors weekly to assure positive latching is functioning properly.

3. Results of inspections will be reported monthly to the safety and QAPI committees for further review and recommendations.

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