Pennsylvania Department of Health
MASONIC VILLAGE AT ELIZABETHTOWN
Building Inspection Results

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MASONIC VILLAGE AT ELIZABETHTOWN
Inspection Results For:

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MASONIC VILLAGE AT ELIZABETHTOWN - 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 10, 2024, at Masonic Village at Elizabethtown, 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 #131502
Component 01
Washington/Roosevelt/Clinic/Ben Franklin/Lafayette Buildings

Based on a Medicare/Medicaid Recertification Survey completed on January 10, 2024, it was determined that Masonic Village at Elizabethtown 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 four-story, Type II (222), fire resistive structure, with a basement, which is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain the maximum force required to operate exit discharge doors, affecting one of 43 smoke zones within the component.

Findings include:

1. Observation on January 10, 2024, at 12:40 PM, revealed stairtower exit discharge door, 1st floor, Ben Franklin East, required a force of more than 30 pounds to set the doors in motion.

Interview at the time of the exit conference with the Administrator, Asst. Director of Facilities, Director of Safety and Security and Maintenance Supervisor on January 10, 2024, at 2:00 PM, confirmed the door did not begin to swing with an applied force of 30 pounds.



 Plan of Correction - To be completed: 02/16/2024

The Ben Franklin East exit discharge door, 1st floor, was repaired so that it requires less than 30 pounds of force to set the door in motion.

Maintenance staff will be educated that exit discharge doors must be maintained to open with less than 30 pounds of force.

The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that exit discharged doors require less than 30 pounds of force to set the door in motion. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment and need for further audit.

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 stairtower doors to be within the allowed gap margins, on four of thirteen stairtowers within the component.

Findings include:

1. Observation on January 10, 2024, between 10:50 AM and 12:15 PM, revealed gaps on stairtower doors exceeded one eighth of an inch, at the following locations:

a. 10:50 AM, 1st floor, Clinic, Stairtower South, top of door;
b. 11:20 AM, 2nd floor, Clinic, Stairtower West, top of door;
c. 11:25 AM, 3rd floor, Clinic, Stairtower South, top and latch side of door;
d. 12:15 AM, 1st floor, Ben Franklin, Stairtower South, top of door.

Interview at the time of the exit conference with the Administrator, Asst. Director of Facilities, Director of Safety and Security and Maintenance Supervisor on January 10, 2024, at 2:00 PM, confirmed the stairtower doors exceeded the allowed gap margins.




 Plan of Correction - To be completed: 02/16/2024

Tag 1. a. The gap exceeding 1/8" at the top of the 1st floor, Clinic, Stairtower South, door was corrected with approved Fire Door hardware.
b. The gap exceeding 1/8" at the top of the 2nd floor, Clinic, Stairtower West, door was corrected with approved Fire Door hardware.
c. The gap exceeding 1/8" at the top and latch side of the 3rd floor, Clinic, Stairtower South, door was corrected with approved Fire Door hardware.
d. The gap exceeding 1/8" at the top of the 1st floor, Ben Franklin, Stairtower South, door will be corrected with door adjustment.

Maintenance staff will be educated about using an approved fire rated door system to prevent a gap of
more than 1/8".

The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to assure that the approved fire rated door system is being used to prevent a gap of more than 1/8". The results of the audit will be forwarded monthly to the Quality Assurance Committee for review and comment and need for further audit.

NFPA 101 STANDARD Exit Signage:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0293
Based on observation and interview, it was determined the facility failed to maintain the illumination of exit signs, affecting one of 43 smoke compartments within the component.

Findings include:

1. Observation on January 10, 2024, at 12:25 PM, revealed the exit sign next to Resident Room 3649, in Roosevelt 3 East, was not illuminated.

Interview with the Maintenance Technician on January 10, 2024, at 12:25 PM, confirmed the exit sign was not illuminated.


 Plan of Correction - To be completed: 02/16/2024

The exit sign next to room 3649 will be replaced to ensure illumination of exit signs.

Maintenance staff will be educated about maintaining the illumination of exit signs.

The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure the illumination of exit signs. The results of the audit will be forwarded monthly to the Quality Assurance Committee for review and comment and need for further audits.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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 - Component: 01 - Tag: 0353
Based on observation and interview, it was determined the facility failed to maintain the sprinkler piping system to be free of extraneous weight, affecting one of 43 smoke compartments within the component.

Findings include:

1. Observation on January 10, 2024, at 1:10 PM, revealed multiple data wires, Romex, and rigid ducting laying across the sprinkler pipes above the ceiling in the Elevator Lobby, between Resident Room 3883 and Coat Room, on the third floor.

Interview at the time of the exit conference with the Administrator, Asst. Director of Facilities, Director of Safety and Security and Maintenance Supervisor on January 10, 2024, at 2:00 PM, confirmed multiple items laying across the sprinkler piping system.


 Plan of Correction - To be completed: 02/16/2024

The data wires, Romex and rigid ducting laying across the sprinkler pipes above the ceiling in the Elevator Lobby, between Resident Room 3883 and the Coat Room on 3rd floor Ben Franklin will be corrected to maintain the sprinkler piping system to be free of extraneous weight.

Maintenance staff will be educated in maintaining the sprinkler piping system free of extraneous weight.

The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to assure that the sprinkler piping system is free of extraneous weight. The results of the audit will be forwarded monthly to the Quality Assurance Committee for review and comment and need for further audits.

NFPA 101 STANDARD Portable Fire Extinguishers:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0355
Based on document review and interview, it was determined the facility failed to provide documentation verifying portable fire extinguishers had been inspected monthly and annually, within the previous 12 months, affecting two of 43 smoke compartments within the component.

Findings include:

1. Review of documentation on January 10, 2024, at 1:10 PM, revealed the facility lacked documentation verifying the portable fire extinguisher located within the North Tub Room, on the first floor, Lafayette East, had been subjected to annual and monthly inspections, since September 2021.

Interview with the Maintenance Technician on January 10, 2024, at 1:10 PM, confirmed the lack of documentation verifying the portable fire extinguisher had been inspected since September 2021.


2. Review of documentation on January 10, 2024, at 1:20 PM, revealed the facility lacked documentation verifying the portable fire extinguisher, located within the 1st floor Mechanical Room, in the Washington North Hall, had been subjected to an annual inspection since October 2022.

Interview with the Maintenance Technician on January 10, 2024, at 1:20 PM, confirmed the lack of documentation verifying the portable fire extinguisher had been subjected to an annual inspection since October 2021.




 Plan of Correction - To be completed: 02/16/2024

East, was replaced with a fire extinguisher selected, installed, inspected, and maintained in accordance with NFPA10, Standard for Portable Fire Extinguishers.
2. The portable fire extinguisher located in the 1st floor mechanical room, in the Washington North Hall, was replaced with a portable fire extinguisher selected, installed, inspected, and maintained in accordance with NFPA10, Standard for Portable Fire Extinguishers.

Maintenance and Security staff will be educated that portable fire extinguishers will be selected, installed, inspected, and maintained in accordance with NFPA10, Standard for Portable Fire Extinguishers.

The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA10, Standard for Portable Fire Extinguishers. The results of the audit will be forwarded monthly to the Quality Assurance Committee for review and comment and need for further audits.

NFPA 101 STANDARD Elevators: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.
Elevators
2012 EXISTING
Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter's Service is operated monthly with a written record.
Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter's Service Requirements of ASME/ANSI A17.3. (Includes firefighter's service Phase I key recall and smoke detector automatic recall, firefighter's service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.)
19.5.3, 9.4.2, 9.4.3
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0531

Based on observation and interview, it was determined the facility failed to maintain the Elevator Machine Room door to close and positively latch, affecting one of six elevator machinery rooms within the component.

Findings include:

1. Observation on January 10, 2024, at 1:35 PM, revealed Elevator Machine Room door failed to close and latch in the frame.

Interview at the time of the exit conference with the Administrator, Asst. Director of Facilities, Director of Safety and Security and Maintenance Supervisor on January 10, 2024, at 2:00 PM, confirmed the door failed to close and positively latch.


 Plan of Correction - To be completed: 02/16/2024

The elevator machine room door for the Ben Franklin elevators was repaired by adding an approved automatic door closer.

Maintenance staff will be educated in maintaining that elevator Machine Room doors automatically close and positively latch.

The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that Elevator Machine Room doors automatically close and latch. The results of the audit will be forwarded monthly to the Quality Assurance Committee for review and comment and need for further audits.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0920
Based on observation and interview, it was determined the facility failed to monitor the use of receptacle multipliers, affecting one of 43 smoke compartments within the component.

Findings include:

1. Observation on January 10, 2024, at 1:22 PM, revealed a three-to-one receptacle multiplier supplying electrical power to computer equipment within the Washington 1st floor North Hall Conference Room.

Interview with the Maintenance Technician on January 10, 2024, at 1:22 PM, confirmed the use of a receptacle multiplier.


 Plan of Correction - To be completed: 02/16/2024

The three-to-one receptacle multiplier supply in electrical power to computer equipment within the Washington 1st floor North Hall Conference Room was replaced with an approved surge suppressor power strip.

Maintenance staff will be educated in monitoring the use of receptacle
multipliers.

The Director of Security and/or Maintenance Assistant Director or designee will monitor the building for receptacle multipliers. The results of the audit will be forwarded monthly to the Quality Assurance Committee for review and comment and need for further audits.

Initial comments:Name: ASSEMBLY - Component: 02 - Tag: 0000


Facility ID #131502
Component 02
Assembly Building

Based on a Medicare/Medicaid Recertification Survey completed on January 10, 2024, at Masonic Village at Elizabethtown, 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, without a basement, which is fully sprinklered.




 Plan of Correction:



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