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28 Pa. Code § 201.14(a). RESPONSIBILITY OF THE LICENSEE
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.
35 P.S. § 448.808. Issuance of license.
(a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:
(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained, and operated to safely and efficiently render the services offered.
Based on document review, observation and interview, it was determined the facility failed to meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component.
Findings include:
1. Review of documentation, observation and interview on July 23, 2024, between 10:00 AM and 12:00 PM, revealed the facility portable life safety drawings of lacked door swings, resident room capacities and hazardous areas delineated.
Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the available floor plans lacked some of the required information.

Based on observation and interview, it was determined the facility failed to maintain exit access to be readily accessible, on one of four floors within the component.

Findings include:

1. Observation on July 23, 2024, at 1:00 PM, revealed the 3rd floor Activity Room 341 and 342 doors could be locked against egress, with an unseen leaver in the knob set, which did not automatically release.

Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:00 PM, confirmed the doors could be locked against egress.

Based on observation and interview, it was determined the facility failed to maintain self-closing doors, to be free of obstruction from closing, in one of five smoke zones within the component.

Findings include:

1. Observation on July 23, 2024, at 1:20 PM, revealed the door, to B Wing Activity Room 134, was held open with a folded paper plate, on the 1st floor.

Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the door was wedged open.

Based on observation and interview, it was determined the facility failed to maintain stairtower doors to positively latch, to be within the allowed gap margins, and to be capable of self-closing, on three of four floors within the component.

Findings include:

1. Observation on July 23, 2024, between 11:25 AM and 1:05 PM, revealed stairtower doors failed to positively latch, at the following locations:

a. 11:25 AM, 4th floor, the double doors to Stairtower #4, did not latch;
b. 1:05 PM, 2nd floor, the double doors to Stairtower #3, did not latch, when closed;

Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the stairtower doors failed to positively latch.


2. Observation on July 23, 2024, between 11:30 AM and 1:30 PM, revealed stairtower doors had gaps that exceeded the allowed gap margins, at the following locations:

a. 11:30 AM, 4th floor, the stairtower to the Penthouse, had gaps, greater than 3/16 inch;
b. 12:10 PM, 3rd floor, the #2 Stairtower door, had gaps, greater than 3/16 inch;
c. 1:30 PM, 2nd floor, the #5 Stairtower door, had gaps, greater than 3/16 inch;

Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the stairtower doors exceeded the allowed gap margins.


3. Observation on July 23, 2024, at 12:25 PM, revealed Stairtower 1 doors were hitting on the meeting edge and failed to self-close.

Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the door failed to self-close.

Based on observation and interview, it was determined the facility failed to maintain the stairtower doors, to positively latch, in one of five stairtowers within the component.

Findings include:

1. Observation on July 23, 2024, at 12:45 PM, revealed Stairtower Door 179 failed to positively latch in frame.

Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the door failed to positively latch.

Based on document review and interview, it was determined the facility failed to perform functional tests of battery-powered emergency lighting source at the generator, which serves the entire component.

Findings include:

1. Review of documentation on July 23, 2024, between 10:00 AM and 12:00 PM, revealed the facility lacked documentation, verifying the Generator Room battery back-up emergency lighting was tested for 30 seconds a month and 90 minutes annually.

Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the facility failed to record the monthly and annual testing.

Based on document review and interview, it was determined the facility failed to perform functional tests of battery-powered emergency lighting source, at the generator, which serves the entire component.

Findings include:

1. Review of documentation on July 23, 2024, between 10:00 AM and 12:00 PM, revealed the facility lacked documentation, verifying the Generator Room battery back-up emergency lighting was tested for 30 seconds a month and 90 minutes annually.

Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the facility failed to record the monthly and annual testing.

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of hazardous area enclosures, affecting one of five floors within the component.

Findings include:

1. Observation on July 23, 2024, at 1:16 PM, revealed the door, to 1st floor Storage Room 138, failed to automatically close and positively latch within the door frame.

Interview with Maintenance Repairman 1 on July 23, 2024, at 1:16 PM, confirmed the door did not automatically close and positively latch within the frame.

Based on observation and interview, it was determined the facility failed to provide the hydraulic nameplate, and the sprinkler piping to be free of extraneous weight, affecting the entire component.

Findings include:

1. Observation on July 23, 2024, at 12:45 PM, revealed the sprinkler system lacked a hydraulic nameplate.

Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the lack of a hydraulic nameplate.


2. Observation on July 23, 2024, at 12:50 PM, revealed multiple wires attached to the sprinkler bracket and sprinkler pipes, above the ceiling, by the Horticultural Room.

Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed various items attached to the automatic sprinkler system.

Based on observation and interview, it was determined the facility failed to ensure that corridor doors would properly close and resist the passage of smoke, on two of four floors within the component.

Findings include:

1. Observation on July 23, 2024, between 12:20 PM and 1:10 PM, revealed corridors doors were hitting the frame and could not be closed, at the following locations:

a. 12:20 PM, 3rd floor, Resident Room 319;
b. 12:42 PM, 3rd floor, Clean Linen 366;
c. 12:43 PM, 3rd floor, Resident Room 364;
d. 12:47 PM, 3rd floor, Resident Room 355;
e. 12:47 PM, 3rd floor, Resident Room 354;
f. 1:10 PM, 2nd floor, Big Day Room 206.

Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the corridor doors were obstructed from closing.


2. Observation on July 23, 2024, between 12:35 PM and 12:40 PM, revealed corridors doors failed to positively latch in the frame, at the following locations:

a. 12:35 PM, 3rd floor, Day Room 376;
b. 12:40 PM, 3rd floor, Resident Room 371.

Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the corridor doors failed to positively latch.


3. Observation on July 23, 2024, between 12:30 PM and 1:15 PM, revealed corridors doors had gaps, exceeding 1/2 inch, at the following locations:

a. 12:30 PM, 3rd floor, Resident Room 315;
b. 12:44 PM, 3rd floor, Smal Kitchen 361;
c. 12:44 PM, 3rd floor, Resident Room 353;
d. 1:15 PM, 2nd floor, Room 211.

Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the corridor doors had gaps, greater than 1/2 inch.

Based on observation and interview, it was determined the facility failed to maintain the smoke barrier doors to self-close, in two of three smoke compartments within the component.

Findings include:

1. Observation on July 23, 2024, at 12:00 PM, revealed the 3rd floor smoke barrier door self-closing device had been disconnected, by Room 303.

Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the closure was disconnected.

Based on observation and interview, it was determined the facility failed to maintain components of the electrical hardware, affecting the entire component.

Findings include:

1. Observation on July 23, 2024, at 11:49 AM, revealed an open electrical junction box, located on Walk-In Unit #2, by the exterior exit door.

Interview with Maintenance Repairman 1 on July 23, 2024, at 11:49 AM, confirmed the junction box was not covered.

Based on observation and interview, it was determined the facility failed to maintain the HVAC system, to have a closed plenum system, affecting one of four floors within the component.

Findings include:

1. Observation on July 23, 2024, at 11:25 AM, revealed the 4th floor exit egress corridor was used as a return air plenum for Rooms 401, 402, 406, 408, 410, 414, 415, 416, 417, 418, 419 and 420.

Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the corridor was used as a return air plenum.

Based on observation and interview, it was determined the facility failed to maintain self-closing doors to positively latch, affecting one of one elevator machine rooms within the component.
Findings include:
1. Observation on July 23, 2024, at 12:35 PM, revealed Elevator Machinery door failed to latch in frame, due to dragging on the floor.
Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the door failed to latch in frame.

Based on observation and interview, it was determined the facility failed to provide a protected space for soiled-linen and trash containers, exceeding 32 gallons, in two of three smoke compartments on the 3rd floor within the component.

Findings include:

1. Observation on July 23, 2024, between 12:05 PM and 12:55 PM, revealed soiled-linen and trash containers were stored in shower rooms, which did not have a 1-hour protected rating, at the following locations:

a. 12:05 PM, Women's Shower Room 338;
b. 12:55 PM, Shower Room 348.

Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the soiled-linen/trash was not stored in a rated assembly.

Based on observation and interview, it was determined the facility failed to maintain rated doors, to be repaired with approved accessories per NFPA 80, in one of three smoke compartments on the 3rd floor within the component.

Findings include:

1. Observation on July 23, 2024, at 12:20 PM, revealed the door, to Supply Room 328, had penetrations filled with putty.

Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the door was filled with an unauthorized filler.

Based on document review and interview, it was determined the facility failed to verify the emergency generator fuel sample test had been completed, affecting the entire component.

Findings include:

1. Review of documentation on July 23, 2024, between 10:00 AM and 12:00 PM, revealed the facility failed to verify the quality of the emergency fuel reserve test had been performed, within the previous twelve months.

Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the facility could not provide verification whether the fuel test had been completed.

Based on observation and interview, it was determined the facility failed to monitor the use of surge suppressors and receptacle multipliers, affecting one of four floors within the component.

Findings include:

1. Observation on July 23, 2024, at 12:20 PM, revealed a surge suppressor was supplying electrical power to another surge suppressor, in the basement I.T. Phone Room (Room 4).

Interview with Maintenance Repairman 1 on July 23, 2024, at 12:20 PM, confirmed the daisy-chained surge suppressors.


2. Observation on July 23, 2024, at 12:39 PM, revealed a receptacle multiplier supplying electrical power to an extension cord in the basement Auditorium.

Interview with Maintenance Repairman 1 on July 23, 2024, at 12:39 PM, confirmed the use of a receptacle multiplier.