Pennsylvania Department of Health
MORAVIAN HALL SQUARE HEALTH AND WELLNESS CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MORAVIAN HALL SQUARE HEALTH AND WELLNESS 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 March 12, 2024, at Moravian Hall Square Health and Wellness 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# 392702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 12, 2024, it was determined that Moravian Hall Square Health and Wellness 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 three story, Type II (111), protected, noncombustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies:

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 - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain one common wall affecting one of three floors.

Findings include:

1. Observation on March 12, 2024, at 10:50 a.m., revealed the distance between the second floor, Applewood, common wall doors, exceeded one-eighth-inch.

Exit interview on March 12, 2024, between 12:10 p.m., and 12:20 p.m., with the Facilities Manager confirmed the common wall deficiency.

Plan of Correction - To be completed: 04/30/2024

The second floor, Applewood common wall door latch and closer will be adjusted to ensure that the door fully closes within the corresponding door frame assembly while maintaining a one-eight inch gap or less between doors. Quarterly preventative maintenance will be scheduled and performed on all doors to ensure that they fully latch within the corresponding door frame assembly. Corrective actions will be taken if necessary. The Director of Building Operations and/or designee will monitor for compliance.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain four hazardous area enclosures, affecting two of three floors.

Findings include:

1. Observation on March 12, 2024, between 10:44 a.m., and 11:25 a.m., revealed the following:

a. 10:44 a.m., the first floor Housekeeping Room door lacked a self-closing device (hazardous contents stored within).
b. 10:55 a.m., the distance between the Applewood Equipment Room doors exceeded one-eighth-inch.
c. 11:11 a.m., the Primrose Equipment Room doors required adjustment to fully latch one to another.
d. 11:25 a.m., storage items were located within the lower level, Elevator Machine Room.

Exit interview on March 12, 2024, between 12:10 p.m., and 12:20 p.m., with the Facilities Manager confirmed the hazardous area enclosure deficiencies.

Plan of Correction - To be completed: 04/30/2024

a. A self-closing device will be ordered and installed on the first floor Housekeeping Room door.
Completion Date: April 30th, 2024
b. The Applewood Equipment door latch and closer will be adjusted to ensure that the door fully closes within the corresponding door frame assembly while maintaining a one-eight inch gap or less between doors. Quarterly preventative maintenance will be scheduled and performed on all doors to ensure that they fully latch within the corresponding door frame assembly. Corrective actions will be taken if necessary. The Director of Building Operations and/or designee will monitor for compliance.

Completion Date: April 30th, 2024
c. The Primrose Equipment Room doors will be adjusted to properly latch while not to exceed a one-eight inch gap or less to ensure smoke tight integrity. Quarterly preventative maintenance will be scheduled and performed on all doors to ensure smoke-tight integrity. Corrective actions will be taken if necessary. The Director of Building Operations and/or designee will monitor for compliance.

Completion Date: April 30th, 2024

d. Storage items were removed from the lower level, Elevator Machine Room. Daily Environmental Services rounds will be conducted to ensure to there are no items stored in elevator machine rooms. Corrective action will be taken if necessary at the time of the Environmental Services Round.
Completion Date: April 30th, 2024

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 one location, affecting one of three floors.

Findings include:

1. Observation on March 12, 2024, between 11:07 a.m., and 11:32 a.m., revealed the following:

a. 11:07 a.m., a corroded sprinkler head assembly, located within the lower level, Mechanical Room 11A.
b. 11:08 a.m., a ceiling tile, missing within lower level, Mechanical Room 11A.
c. 11:32 a.m., items stored within eighteen inches of an adjacent sprinkler head assembly, located within the Dietary freezer.

Exit interview on March 12, 2024, between 12:10 p.m., and 12:20 p.m., with the Facilities Manager confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 04/30/2024

a. The corroded sprinkler head assembly will be ordered and work will be conducted by vendor to install a new sprinkler head assembly. Quarterly preventative maintenance will be scheduled to inspect all sprinkler head assemblies. Corrective actions will be taken if necessary. The Director of Building Operations and/or designee will monitor for compliance.
Completion Date: April 30th, 2024
b. Ceiling tile will be replaced. Environmental Services rounds will be conducted to ensure to that all ceiling tiles are intact, free from damage, or stains. Corrective action will be taken if necessary at the time of the Environmental Services Round

Completion Date: April 30th, 2024

c. All items stored within eighteen inches located in the Dietary freezer have been relocated. Culinary Services will train employees that the minimal vertical clearance between a sprinkler head assembly and material shall be eighteen inches. Culinary Services will also conduct rounds to ensure that all items are stored eighteen inches below a sprinkler head assembly. Corrective action will be taken if necessary at the time of the inspection.
Completion Date: April 30th, 2024

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 one corridor opening, affecting one of three floors.

Findings include:

1. Observation on March 12, 2024, at 11:18 a.m., revealed the second floor, Core Area, Medication Room door was not smoke-tight.

Exit interview on March 12, 2024, between 12:10 p.m., and 12:20 p.m., with the Facilities Manager confirmed the corridor opening deficiency.

Plan of Correction - To be completed: 04/30/2024

The Core Area, Medication Room door latch and closer will be adjusted to ensure that the door fully closes within the corresponding door frame assembly. Seals will be replaced and maintained to ensure smoke tight integrity. Quarterly preventative maintenance will be scheduled and performed on all doors to ensure that they fully latch within the corresponding door frame assembly. Corrective actions will be taken if necessary. The Director of Building Operations and/or designee will monitor for compliance.
Completion Date: April 30th, 2024

NFPA 101 STANDARD Fire Drills:

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.

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 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to conduct fire drills in two of twelve instances, affecting three of three floors.

Findings include:

1. Observation on March 12, 2024, at 11:55 a.m., revealed the facility lacked a first shift fire drill for the second quarter of 2023, as well as second shift fire drill for the fourth quarter of 2023.

Exit interview on March 12, 2024, between 12:10 p.m., and 12:20 p.m., with the Facilities Manager confirmed the fire drill deficiencies.

Plan of Correction - To be completed: 04/30/2024

An Emergency Preparedness Committee Schedule of drills has been developed to ensure that fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. Staff will be trained on the procedures to ensure that they are aware that drills are part of established routine.
Completion Date: April 30th, 2024

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

Facility ID# 392702
Component 02
Addition

Based on a Medicare/Medicaid Recertification Survey completed on March 12, 2024, at Moravian Hall Square Health and Wellness Center, 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 Three story, Type II (111), protected, noncombustible building, with a crawl space, that is fully sprinklered.

Plan of Correction:

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