Pennsylvania Department of Health
MESSIAH LIFEWAYS AT MESSIAH VILLAGE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MESSIAH LIFEWAYS AT MESSIAH VILLAGE - 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 July 8, 2024, at Messiah Lifeways at Messiah Village, 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 #910802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on July 8, 2024, at Messiah Lifeways at Messiah Village, 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 II (000), unprotected noncombustible structure, which is fully sprinklered.

Plan of Correction:

Initial comments:Name: CHAPEL ADDITION - Component: 02 - Tag: 0000

Facility ID #910802
Component 02
Chapel Addition

Based on a Medicare/Medicaid Recertification Survey completed on July 8, 2024, at Messiah Lifeways at Messiah Village, 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 two-story, Type II (111), protected noncombustible structure, with a basement, which is fully sprinklered.

Plan of Correction:

Initial comments:Name: ENHANCED LIVING BUILDING - Component: 03 - Tag: 0000

Facility ID #910802
Component 03
Enhanced Living Building

Based on a Medicare/Medicaid Recertification Survey completed on July 8, 2024, it was determined that Messiah Lifeways at Messiah Village 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 three-story, Type II (111), protected noncombustible structure, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

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.

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: ENHANCED LIVING BUILDING - Component: 03 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the fire resistance and unobstructed means of egress of exit stairtower enclosures, affecting one of three floors within the component.

Findings include:

1. Observation on July 8, 2024, at 11:50 AM, revealed the Level 1 door, to Stair 69, had a fire resistance rating of 45 minutes.

Interview with the Life Safety Manager on July 8, 2024, at 11:50 AM, confirmed the stairtower door did not have a minimum fire resistance rating of at least 60 minutes.

2. Observation on July 8, 2024, at 12:04 PM, revealed two boxes of air filters stored within the Level 1 area of Stair 68.

Interview with the Life Safety Manager on July 8, 2024, at 12:04 PM, confirmed the storage within the stairtower.

Plan of Correction - To be completed: 07/26/2024

Observation 1
1. An audit of all stair tower doors was completed to ensure they are properly rated. Audit was complete by 7/19/2024. A new door has been ordered on 7/26/24 and has a minimum fire resistance rating of 90 minutes and will be installed upon delivery.
2. Complete Door & Access (vendor) will inspect all doors annually in June to ensure they are properly rated and to identify deficiencies if applicable.
3. The results of the audit will be reported through the QAPI program.
4. 7/26/24
Observation 2
1. Beginning July 19, 2024 and continuing on a weekly basis thereafter; the Life Safety Manager/designee will began a process of weekly stairway or stair tower enclosure storage inspections. This process includes verifying all stairway or stair tower enclosures are free of items being stored.
2. The corrective action as detailed above has been established by beginning a weekly stairway or stair tower enclosure storage inspection process utilizing Worxhub. Each week, Worxhub will automatically generate a detailed work order once this weekly inspection becomes due. Worxhub's electronically generated work order will allow for recording of all weekly inspections i.e., inspection date/time of completion, by whom, recording of any noted deficiencies and corrective action taken if necessary.
3. The results of the audit will be reported through the QAPI program.
4. 7/19/24

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