Nursing Investigation Results -

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

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MESSIAH LIFEWAYS AT MESSIAH VILLAGE
Inspection Results For:

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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 January 16, 2020, 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 January 16, 2020, 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 one-story, Type II (000), unprotected noncombustible structure, which is fully sprinklered.




 Plan of Correction:


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 doors in common walls to be self-closing, on one of three levels within the component.

Findings include:

1. Observation on January 16, 2020, at 1:30 PM revealed the double doors, on the 1st floor between the Main building and the Enhanced Living building, did not close and latch in the frame, when released from the hold-open magnets.

Exit interview with the Senior Director of Campus Support Services and the Vice-President of Operations on January 16, 2020, at 2:15 PM confirmed the doors did not fully close.



 Plan of Correction - To be completed: 01/17/2020

The referenced door was repaired on January 17, 2020 at 10:00 AM. It was determined that the plastic latching mechanism had shifted preventing the door from latching. The mechanism was adjusted and the door was tested to ensure proper operability. In addition to the Annual Fire Door Inspection conducted by Brand Services, Inc., an internal audit of all fire doors will be conducted and documented on a monthly basis x 3 months and random ongoing audits will be conducted each month to ensure proper operability. The results of the audit will be reported through the QAPI program.

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 rating of smoke barrier walls, one of two smoke barriers within the component.

Findings include:

1. Observation on Janaury 16, 2020, at 11:50 AM revealed the penetration of a conduit above the ceiling, near the Life Enrichment office, in the area between the Manchester and Wagner Neighborhoods.

Exit interview with the Senior Director of Campus Support Services and the Vice-President of Operations on January 16, 2020, at 2:15 PM confirmed there was a penetration.



 Plan of Correction - To be completed: 01/18/2020

The referenced penetration was repaired on January 18th at 3:00 PM utilizing an approved through penetration fire stop system.The facility will maintain the rating of the common walls. An internal audit will be conducted on a monthly basis x 3 months to ensure no penetrations are present and results will be reported through the QAPI Program.

NFPA 101 STANDARD Fire Drills: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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to conduct the required number of fire drills, on a random basis, for the component.

Findings include:

1. Review of documentation on January 16, 2020, between 9:15 AM and 11:00 AM, revealed the facility performed third ship fire drills within the same hour, and missed a fire drill, at the following times and dates:

a. The facility did not perform required fire drills, at random times. All 3rd shift fire drills were performed between 5:00 AM and 6:00 AM;
b. The facility failed to conduct a 3rd shift fire drill, for the 3rd calendar quarter of 2019.

Exit interview with the Senior Director of Campus Support Services and the Vice-President of Operations on January 16, 2020, at 2:15 PM confirmed the fire drills were not completed or randomly scheduled.




 Plan of Correction - To be completed: 03/16/2020

Fire Drill schedules/timing has been developed for 2020/2021 and shared with facility leadership for input and monitoring of compliance. The fire drill schedule will be adhered to moving forward with varying times scheduled during the 3rd shift. The fire drill logs will be audited for compliance on a monthly basis by the Senior Director of Campus Support Services or designee. The results of the audit will be reported through the QAPI program.

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 January 16, 2020, 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 two-story, Type II (111), protected noncombustible structure, with a basement, which 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: CHAPEL ADDITION - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain doors to hazardous areas to positively latch, on one of two floors within the component.

Findings include:

1. Observation January 16, 2020, at 1:05 PM revealed the door into the Boiler Room failed to close and latch in the frame.

Exit interview with the Senior Director of Campus Support Services and the Vice-President of Operations on January 16, 2020, at 2:15 PM confirmed the door failed to positively latch.


 Plan of Correction - To be completed: 03/16/2020

Facility has contacted Capital Door, Inc. to replace the boiler room door. The quote has been received and approved and the installation is scheduled within the next 45 days. Once installed the door will be inspected to ensure a positive latch. An audit of the door's operability will be conducted and documented on a monthly basis x 3 months and random ongoing audits will be conducted each month to ensure proper operability. The results of the audit will be reported through the QAPI program.


NFPA 101 STANDARD Fire Drills: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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: CHAPEL ADDITION - Component: 02 - Tag: 0712

Based on document review and interview, it was determined the facility failed to conduct the required number of fire drills, on a random basis, for the component.

Findings include:

1. Review of documentation on January 16, 2020, between 9:15 AM and 11:00 AM, revealed the facility performed third ship fire drills within the same hour, and missed a fire drill, at the following times and dates:

a. The facility did not perform required fire drills, at random times. All 3rd shift fire drills were performed between 5:00 AM and 6:00 AM;
b. The facility failed to conduct a 3rd shift fire drill, for the 3rd calendar quarter of 2019.

Exit interview with the Senior Director of Campus Support Services and the Vice-President of Operations on January 16, 2020, at 2:15 PM confirmed the fire drills were not completed or randomly scheduled.




 Plan of Correction - To be completed: 03/16/2020

Fire Drill schedules/timing has been developed for 2020/2021 and shared with facility leadership for input and monitoring of compliance. The fire drill schedule will be adhered to moving forward with varying times scheduled during the 3rd shift. The fire drill logs will be audited for compliance on a monthly basis by the Senior Director of Campus Support Services or designee. The results of the audit will be reported through the QAPI program.

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 January 16, 2020, 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 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: ENHANCED LIVING BUILDING - Component: 03 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain doors in common walls to self-close, on one of three levels within the component.

Findings include:

1. Observation on January 16, 2020, at 1:30 PM revealed the double doors, on the 1st floor between the Main building and the Enhanced Living building, did not close and latch in the frame, when released from the hold-open magnets.

Exit interview with the Senior Director of Campus Support Services and the Vice-President of Operations on January 16, 2020, at 2:15 PM confirmed the doors did not self-close.



 Plan of Correction - To be completed: 01/17/2020

The referenced door was repaired on January 17, 2020 at 10:00 AM. It was determined that the plastic latching mechanism had shifted preventing the door from latching. The mechanism was adjusted and the door was tested to ensure proper operability. In addition to the Annual Fire Door Inspection conducted by Brand Services, Inc., an internal audit of all fire doors will be conducted and documented on a monthly basis x 3 months and random ongoing audits will be conducted each month to ensure proper operability. The results of the audit will be reported through the QAPI program.


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 rating of the stairtowers, in one of two stairtowers within the component.

Findings include:

1. Observation on January 16, 2020, at 1:15 PM revealed an unsealed sprinkler pipe penetration of the stairtower, at the door leading into the Asper Neighborhood, on the 2nd floor.

Exit interview with the Senior Director of Campus Support Services and the Vice-President of Operations on January 16, 2020, at 2:15 PM confirmed the there was a penetration.



 Plan of Correction - To be completed: 01/17/2020

The referenced penetration was repaired on January 17th at 1:00 PM utilizing an approved through penetration fire stop system. The facility will maintain the rating of the stair towers. An internal audit will be conducted on a monthly basis x 3 months to ensure no penetrations are present and results will be reported through the QAPI Program.

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: ENHANCED LIVING BUILDING - Component: 03 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the sprinkler heads to be installed per manufactuere recommendations, on one of three floors within the component.

Findings include:

1. Observation on January 16, 2020, at 1:30 PM revealed an escutcheon was missing from a sprinkler head in Room 277, of Asper Neighborhood.

Exit interview with the Senior Director of Campus Support Services and the Vice-President of Operations on January 16, 2020, at 2:15 PM confirmed the escutcheon was missing.



 Plan of Correction - To be completed: 03/15/2020

The escutcheon was replaced on January 17th, at 11:00 AM. A one-time facility wide sweep will be performed for sprinkler escutcheons by the Life Safety Coordinator at Messiah. An in-house audit of sprinkler heads will be conducted quarterlyby the Life Safety Coordinator at Messiah. The facility will continue to contract sprinkler inspection services on a quarterly basis.This audit will be reported through the QAPI program.


NFPA 101 STANDARD Fire Drills: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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: ENHANCED LIVING BUILDING - Component: 03 - Tag: 0712

Based on document review and interview, it was determined the facility failed to conduct the required number of fire drills, on a random basis, for the component.

Findings include:

1. Review of documentation on January 16, 2020, between 9:15 AM and 11:00 AM, revealed the facility performed third ship fire drills within the same hour, and missed a fire drill, at the following times and dates:

a. The facility did not perform required fire drills, at random times. All 3rd shift fire drills were performed between 5:00 AM and 6:00 AM;
b. The facility failed to conduct a 3rd shift fire drill, for the 3rd calendar quarter of 2019.

Exit interview with the Senior Director of Campus Support Services and the Vice-President of Operations on January 16, 2020, at 2:15 PM confirmed the fire drills were not completed or randomly scheduled.


 Plan of Correction - To be completed: 03/16/2020

Fire Drill schedules/timing has been developed for 2020/2021 and shared with facility leadership for input and monitoring of compliance. The fire drill schedule will be adhered to moving forward with varying times scheduled during the 3rd shift. The fire drill logs will be audited for compliance on a monthly basis by the Senior Director of Campus Support Services or designee. The results of the audit will be reported through the QAPI program.


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