QA Investigation Results

Pennsylvania Department of Health
EBENSBURG CENTER
Building Inspection Results

EBENSBURG CENTER
Building Inspection Results For:


There are  42 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on March 2, 2021, at Ebensburg Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.


Plan of Correction:




Initial Comments:
Name - MAIN BUILDING 01 Component - 01

Facility ID# 05141100
Component 01
Villa

Based on a revisit to a Medicaid Recertification Survey completed on March 2-3, 2021, it was determined that Ebensburg Center was in substantial compliance with the requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).

This is a one-story, with a basement, Type II (222), fire resistive building, that is partially sprinklered.





Plan of Correction:




Initial Comments:
Name - BUILDING 02 Component - 02

Facility ID# 05141100
Component 02
Horizon

Based on a revisit to a Medicaid Recertification Survey completed on March 2-3, 2021, it was determined that Ebensburg Center was in substantial compliance with the requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).

This is a one-story, with a basement, Type II (222), fire resistive building, that is partially sprinklered.





Plan of Correction:




Initial Comments:
Name - BUILDING 03 Component - 03

Facility ID# 05141100
Component 03
Harmony

Based on a revisit to a Medicaid Recertification Survey completed on March 2-3, 2021, it was determined that Ebensburg Center was in substantial compliance with the requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).

This is a one-story, with a basement, Type II (222), fire resistive building, that is partially sprinklered.




Plan of Correction:




Initial Comments:
Name - BUILDING 04 Component - 04

Facility ID# 05141100
Component 04
Sunset

Based on a revisit to a Medicaid Recertification Survey completed on March 2-3, 2021, it was determined that Ebensburg Center was not in compliance with the following requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).

This is a one-story, with a basement, Type II (222), fire resistive building, that is partially sprinklered.





Plan of Correction:




NFPA 101 STANDARD
Vertical Openings - Enclosure

Name - BUILDING 04 Component - 04
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.

Observations:

Based on observation and interview, it was determined the facility failed to maintain vertical opening enclosures in two instances, affecting three of four smoke compartments.

Findings include:

1. Observations on March 2, 2021, revealed the following:


a) 2:27 p.m. facility failed maintain the concrete deck seperating the basement from the main floor, to be free of unsealed penetrations. In building four basement, there was a penetration in the concrete deck, in room 0013
b) 2:32 p.m. facility failed maintain the concrete deck seperating the basement from the main floor, to be free of unsealed penetrations. In building four basement, there was a unsealed drain pipe in the concrete deck, in the 0028 west wing/room, by the exit door.


Interview with the Facility Administration, Maintenance Staff and Facility Safety Staff on March 3, 2021, at 1:00 p.m., confirmed the vertical enclosure penetration.

Based on a revisit to Ebensburg Center on June 15, 2021, it was determined that item (a) had not been repaired.

Interview with the facility COO and the Facility Fire Marshall on June 15, 2021 at 11:30 a.m., confirmed the repairs to item (a) unsealed penetration in the concrete deck in room 0013, had not been completed.















Plan of Correction:

a) A Maintenance Work Order (MWO) will be submitted by the Fire/Safety Marshal to seal penetration in the concrete deck in Room 0013. Review of area penetration is monitored by the Fire/Safety Marshal through the Monthly Building Inspection. Review of completed MWO's is done by the Fire/Safety Marshal and the Facility
Chief Operating Officer.

Completion Date: July 23, 2021

b) - A Maintenance Work Order (MWO) will be submitted by the Fire/Safety Marshal to seal penetrations at the drainpipe in the concrete deck in Room 0028 by the exit door. Review of area for penetration is monitored by the Fire/Safety Marshal through the Monthly Building Inspection. Review of completed MWO's is done by the Fire/Safety Marshal and Facility Chief Operating Officer.

Completion Date: July 23, 2021



Initial Comments:
Name - BUILDING 05 Component - 05
Facility ID# 05141100
Component 05
Laurel

Based on a revisit to a Medicaid Recertification Survey completed on March 2-3, 2021, it was determined that Ebensburg Center was not in compliance with the following requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).

This is a one-story, with a basement, Type II (222), fire resistive building, that is partially sprinklered.




Plan of Correction:




NFPA 101 STANDARD
Vertical Openings - Enclosure

Name - BUILDING 05 Component - 05
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.

Observations:

Based on observation and interview, it was determined the facility failed to maintain vertical opening enclosures in one instance, affecting two of four smoke compartments.

Findings include:

1. Observation on March 3, 2021, at 9:50 a.m., revealed the facility failed maintain the concrete deck seperating the basement from the main floor, to be free of unsealed penetrations. In building five basement, there were two unsealed pipes in the concrete deck, in the 0028 west wing/room, by the first fire strobe.

Interview with the Facility Administration, Maintenance Staff and Facility Safety Staff on March 3, 2021, at 1:00 p.m., confirmed the vertical enclosure penetration.

Based on a revisit to Ebensburg Center on June 15, 2021, it was determined that item (1) had not been repaired.

Interview with the facility COO and the Facility Fire Marshall on June 15, 2021 at 11:30 a.m., confirmed the repairs to item (1) two unsealed pipe penetration in the concrete deck in room 0028, had not been completed.











Plan of Correction:

A Maintenance Work Order (MWO) will be submitted by the Fire/Safety Marshal to seal 2 drainpipes in the concrete deck in Room 0028 West by the first fire strobe. Review of area for penetration is monitored by the Fire/Safety Marshal through the Monthly Building Inspection. Review of completed MWO's is done by the Fire/Safety Marshal and Facility Chief Operating Officer.

Completion Date: July 23, 2021


Initial Comments:
Name - BUILDING 06 Component - 06

Facility ID# 05141100
Component 06
JFK Learning

Based on a revisit to a Medicaid Recertification Survey completed on March 2-3, 2021, it was determined that Ebensburg Center was in substantial compliance with the requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).

This is a one-story, with a basement, Type II (222), fire resistive building, that is partially sprinklered.





Plan of Correction:




Initial Comments:
Name - BUILDING 07 Component - 07
Facility ID# 05141100
Component 07
Keystone

Based on a revisit to a Medicaid Recertification Survey completed on March 2-3, 2021, it was determined that Ebensburg Center was not in compliance with the following requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).

This is a one-story, with a basement, Type II (222), fire resistive building, that is partially sprinklered




Plan of Correction:




NFPA 101 STANDARD
Doors with Self-Closing Devices

Name - BUILDING 07 Component - 07
Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:

Based on observation and interview, it was determined the facility failed to maintain self-closing doors in one instance, affecting one of four smoke comaprtments.

Findings include:

1. Observation on March 3, 20021, at 9:22 a.m., revealed that door 0017 was being held open by an unapproved hold open device.


Interview with the Facility Administration, Maintenance Staff and Facility Safety Staff on March 3, 2021, at 1:00 p.m., confirmed the self-closing door deficiency.


Based on a revisit to Ebensburg Center on June 15, 2021, it was determined that item (1) had not been repaired.

Interview with the facility COO and the Facility Fire Marshall on June 15, 2021 at 11:30 a.m., confirmed the repairs to item (1) door 0017, being held open with unapproved hold open device, had not been completed.






Plan of Correction:

A Maintenance Work Order (MWO) will be submitted by the Fire/Safety Marshal to remove any item that could be used as a hold open device of any door.

An In-Service will be written by the Facility Chief Operating Officer and presented in "lecture" form by the Fire/Safety Marshal to the Maintenance and Housekeeping Departments at the
department meeting.

The Fire/Safety Marshal monitors all areas for deficiencies and submit a MWO to eliminate those deficiencies. Fire/Safety Marshal monitors all
areas through the Monthly Building Inspection and reports to the Facility Chief Officer.

Completion Date: July 30, 2021