Nursing Investigation Results -

Pennsylvania Department of Health
UNITED ZION RETIREMENT COMMUNITY
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
UNITED ZION RETIREMENT COMMUNITY
Inspection Results For:

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UNITED ZION RETIREMENT COMMUNITY - 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 Janaury 7, 2020, at United Zion Retirement Community, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


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


Facility ID #470402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 7, 2020, it was determined that United Zion Retirement Community 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 two-story, Type II (111), protected noncombustible structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0100

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.
35 P.S. 448.808. Issuance of license.
(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:
(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.
Based on observation and interview, it was determined the following item did not meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and Local agencies responsible for the health and welfare of residents within the component.
Findings include:

1. Observation on January 7, 2020, between 10:45 AM and 2:00 PM revealed the facility failed to supply the required accurate floor plans, showing all the required information for the Life Safety Survey.

Interview with the Director of Maintenance on January 7, 2020, at 2:00 PM confirmed accurate floor plans were not supplied.




 Plan of Correction - To be completed: 03/07/2020

K Tag 100- The facility building floor plan will be updated by 3/15/2020 and the updated floorplan will reflect building construction that occurred in 2018. An audit will be completed quarterly to ensuring an updated floor plan is current and placed in the Life Safety book and sent to the QAPI Committee.
NFPA 101 STANDARD Multiple Occupancies - Construction Type: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.
Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain common wall doors to be within the allowed gap margins, on one of two floors within the component.

Findings include:

1. Observation on January 7, 2020, at 1:30 PM revealed the common wall doors separating the Nursing Care from Personal Care, to the Chapel, had a gap greater than 1/8 inch between the doors.

Interview with the Director of Maintenance on January 7, 2020, at 1:30 PM confirmed the doors exceeded the allowed gap margins.





 Plan of Correction - To be completed: 03/07/2020

K-133- the common doors separating the Nursing Care from Personal Care, to the Chapel, will be replaced/repaired to be within the allowed gap margins by 7/1/2020. A Time Waiver request will be sent to Life Safety. Environmental Services staff will Audit the door gap quarterly and placed in the Life Safety notebook and results will be reported to the QAPI Committee.
NFPA 101 STANDARD Stairways and Smokeproof Enclosures:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the stairtower doors to be within the allowed gap margins, and for the doors to positively latch, on two of two floors within the component.

Findings include:

1. Observation on January 7, 2020, between 12:00 PM and 2:30 PM revealed stairtower doors exceeded the allowed gap margins, at the following locations:

a. 12:00 PM, basement, West Hall stairtower door had a gap on the top, of + 3/16 inch;
b. 12:30 PM, basement, North Hall stairtower door had a gap on the top, of + 3/16 inch;
c. 1:00 PM, first floor, stairtower door by Resident Room 23C, had gaps, greater than 1/8 inch.

Interview with the Director of Maintenance on January 7, 2020, at 2:30 PM confirmed the rated door deficiencies.


2. Observation on January 7, 2020. at 12:30 PM, revealed the North Hall stairtower door, at the basement level, failed to positively latch.

Interview with the Director of Maintenance on January 7, 2020, at 2:30 PM confirmed the door failed to positively latch.




 Plan of Correction - To be completed: 03/07/2020

K- 225 -the stair tower doors, basement West Hall, basement North Hall, exceeded gaps at the top of the door, and first floor stair tower door by resident room 23C, door gaps greater than 1/8 inch, which will be repaired by 7/1/2020 to be within the allowed gap margins. A Time Waiver request will be sent to Life Safety. Environmental Services staff will audit the doors gap margins quarterly and placed in the Life Safety notebook and the results reported to the QAPI Committee.
NFPA 101 STANDARD Emergency Lighting:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0291

Based on document review and interview, the facility failed to perform functional tests of battery-powered emergency lighting, which servers the entire component.

Findings include:

1. Review of documentation on January 7, 2020, between 9:45 AM and 10:45 AM, revealed the facility lacked documentation verifying battery back-up emergency lighting was tested, annually, for not less than 90 minutes.

Interview with the Director of Maintenance on January 7, 2020, at 10:45 AM confirmed the lack of documentation.



 Plan of Correction - To be completed: 01/31/2020

K Tag-291 – Documentation will be completed to verify the functional tests of battery back – up emergency lighting, tested semi-annually, for no less than 90 minutes. This will be completed by 1/31/2020. Environmental Services staff will audit statement of required semi-annual testing to be done every six months and placed in the Life Safety notebook and results will be reported to the QAPI Committee.
NFPA 101 STANDARD Hazardous Areas - Enclosure:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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.
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 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors to be within the allowed gap margins, on two of two floors within the component.

Findings include:

1. Observation on January 7, 2020, between 11:30 AM and 1:15 PM revealed hazardous area doors had gaps exceeding one eighth of an inch, at the following locations:

a. 11:30 AM, basement, Laundry washer door;
b. 11:45 AM, basement, Elevator Equipment Room;
c. 12:45 PM, 1st floor, North Hall soiled utility door, by Resident Room 33;
d. 1:15 PM, 1st floor, South Hall soiled utility door, by Resident Room 10.

Interview with the Director of Maintenance on January 7, 2020, at 1:15 PM confirmed hazardous area doors exceeded the allowed gap margins.



 Plan of Correction - To be completed: 03/07/2020

K-321- The Hazardous area door gaps that exceed one eighth of an inch, the basement laundry washer door; basement Elevator Equipment Room; North Hall soiled utility door by resident room #33; and South Hall soiled utility door, by resident room #10 will be repaired by 3/15/2020 to be within the allowed margins. Environmental Services staff will audit the door gap quarterly and placed in the Life Safety notebook and results will be reported to the QAPI Committee.
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 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors to resist the passage of smoke, and to be free of impediment from closing, on one of two floors within the component.

Findings include:

1. Observation on January 7, 2020, at 12:55 PM revealed the door to West Hall Therapy had a gap, greater than 1/2 inch, between the door and the door stop, when in the closed position.

Interview with the Director of Maintenance on January 7, 2020, at 12:55 PM confirmed the door could not resist the passage of smoke.


2. Observation on January 7, 2020, between 1:03 PM and 1:20 PM, revealed doors failed to close into the frame, at the following locations:

a. 1:03 PM, the Snack Room in the Scenic View Lounge;
b. 1:20 PM, the Activity Room off the Lobby.

Interview with the Director of Maintenance on January 7, 2020, at 1:20 PM confirmed the doors failed to close.




 Plan of Correction - To be completed: 03/01/2020

K-363 - The West Hall Therapy Door gap of more than ½" will be repaired by 3/15/2020 to be within the allowed gap margins. The snack room door in Scenic View Lounge will be repaired by 3/15/2020 to close into its frame. Activity Room Lobby door was repaired on 1/15/2020 to close into the frame. Environmental Services staff will audit the West Hall Therapy and the snack room door in Scenic View Lounge doors gap margins and the Activity Room Lobby door to close into its frame, quarterly and placed in the Life Safety notebook and the results reported to the QAPI Committee.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the the rating of smoke barrier walls, on one of two floors within the component.

Findings include:

1. Observation on January 7, 2020, at 12:50 PM revealed an unsealed data wire conduit over the smoke barrier doors to the North Hall, on the 1st floor, by Resident Room 27.

Interview with the Director of Maintenance on January 7, 2020, at 12:50 PM confirmed


2. Observation on January 7, 2020, at 1:10 PM revealed an unsealed data wire conduit over the smoke barrier doors to the South Hall, by Resident Room 2, on the 1st floor.

Interview with the Director of Maintenance on January 7, 2020, at 1:10 PM confirmed the conduit was not sealed.




 Plan of Correction - To be completed: 01/31/2020

K-372 - The unsealed penetration inside an unsealed data wire conduit over the smoke barrier doors in North Hall, by resident's room 27 on first floor and the unsealed penetration inside an unsealed data wire conduit over the smoke barrier doors in South Hall, by resident's room 2 on first floor was sealed 1/7/2020 with red fire-rated caulking an approved through penetration fire stop system.
A reminder letter will be sent by 1/30/2020 to our mechanical support vendors to remind them that each and every time there are penetrations in smoke barriers created, they are required to seal those penetrations with red fire –rated caulk. Environmental Services staff will audit the fire rated walls quarterly to ensure penetrations are sealed and the facility will maintain the rating of the smoke barrier walls. Results will placed in the Life Safety notebook and reported to the QAPI Committee.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain the smoke barrier door hardware to function as intended, and to be free of impediment to closing, on one of two floors within the component.

Findings include:

1. Observation on January 7, 2020, at 12:40 PM revealed the double smoke barrier doors, to the Farm House, with latching hardware, did not close and latch.

Interview with Director of Maintenance on January 7, 2020, at 12:40 PM confirmed the door hardware did not function.


2. Observation on January 7, 2020, at 1:05 PM revealed the smoke barrier doors on the 1st floor, to the South Hall, were impeded from closing by a large trash container.

Interview with Director of Maintenance on January 7, 2020, at 1:05 PM confirmed the doors were impeded.




 Plan of Correction - To be completed: 03/01/2020

The double smoke barrier doors to the farmhouse, with latching hardware will be adjusted to ensure closure on 7/1/2020 to latch when closed. A Time Waiver will be requested for the doors to be repaired. The smoke barrier doors on the first floor on South Hall, were impeded from closing by a large trash container, which was moved immediately 1/7/2020. Weekly checks of the double door latch closure and free from objects blocking smoke barrier doors will be conducted by Environmental Services staff and results reported to the QAPI Committee.
Initial comments:Name: SUNROOM - Component: 03 - Tag: 0000


Facility ID #470402
Component 03
Sunroom Building

Based on a Medicare/Medicaid Recertification Survey completed on January 7, 2020, at United Zion Retirement Community, it was determined there were no deficiencies identified under the 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 structure, without a basement, which is fully sprinklered.



 Plan of Correction:



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