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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 observation and interview, it was determined the following item did not 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. Observation on January 4, 2022, at 11:30 AM revealed the facility failed to provide accurate and complete floor plans for this component, showing smoke barrier walls on the 1st floor.
Interview with the Fire Marshall on January 4, 2022, at 11:30 AM confirmed the plans provided were incorrect.

Based on observation and interview, it was determined the facility failed to maintain common wall doors to self-close and positively latch, on one of four floors within the component.

Findings include:

1. Observation on January 3, 2022, at 12:10 PM revealed the double corridor fire rated doors separating Component 02 Building 34 and Component 03 Building 35, in the basement, would not close and latch in the frame.

Interview with the Fire Marshall on January 3, 2022, at 12:10 PM confirmed the doors did not latch.


2. Observation on January 3, 2022, at 12:30 PM revealed the double corridor fire rated doors separating Component 02 Building 34 and Component 01 Building 37, in the basement, would not close and latch in the frame.

Interview with the Fire Marshall on January 3, 2022, at 12:30 PM confirmed the doors did not latch.

Based on observation and interview, it was determined the facility failed to maintain common wall doors to be within allowed gap margins, on one of four floors within the component.

Findings include:

1. Observation on January 4, 2022, at 12:25 PM revealed the double common wall door 22, seperating Building 35 and Building 34, had gaps greater than 3/16 inch.

Interview with the Fire Marshall on January 4, 2022, at 12:25 PM confirmed common wall doors exceeded the allowed gap margins.

Based on observation and interview, it was determined the facility failed to maintain common wall doors to match the rating of the common walls, affecting one of four floors within the component.

Findings include:

1. Observation on January 3, 2022, at 12:05 PM revealed the single door, door frame, and associated window, separating the 04 Component (Storage Room) from the 02 Component (Building 34), lacked a minimum fire resistance rating of ninety minutes.

Interview with Facility Maintenance Manager 1 on January 3, 2022, at 12:05 PM confirmed the common wall doors failed to maintain the rating of the fire barrier.

Based on observation and interview, it was determined the facility failed to maintain the rated horizontal access fire doors to close and latch within the frame, in one of 10 smoke zones within the component.
Findings include:
1. Observation on January 3, 2022, between 1:00 PM and 1:05 PM, revealed sets of horizontal fire rated doors, on the 2nd floor, required springs be attached, to self-close and latch in the frame, at the following locations:
a. 1:00 PM, overhead ceiling, above Vender Machine Room #205;
b. 1:05 PM, overhead ceiling, above elevator.
Interview at the time of the exit conference with the Director of Maintenance, COO and Fire Marshall on January 4, 2022, at 2:00 PM confirmed the Horizontal Fire Rated Doors would not self-close and latch.

Based on observation and interview, it was determined the facility failed to maintain the egress doors to open, affecting the entire component.

Findings include:

1. Observation on January 3, 2022, at 12:10 PM revealed the emergency release from Cooler #2 required excessive force to release the latching mechanism.

Interview with Facility Maintenance Manager 1 on January 3, 2022, at 12:10 PM confirmed the excessive force required to open the door.

1. Observation on January 4, 2022, between 10:47 AM and 12:11 PM, revealed stairtower doors had gaps exceeding 3/16th of an inch, at the following locations:

a. 10:47 AM, Stairtower 1, Door 236;
b. 11:00 AM, Stairtower 2, Door 242;
c. 12:11 PM, Stairtower 2, Door 004.

Interview with the Fire Marshall on January 4, 2022, at 12:11 PM confirmed the doors exceeded the allowed gap margins.

Based on observation and interview, it was determined the facility failed to maintain the stairtower door to self-close and latch in the door frame, in one of five stairtowers within the component.

Findings include:

1. Observation on January 4, 2022, at 12:40 PM revealed Stairtower 3 door failed to close and latch in the door frame, on the 1st floor.

Interview at the time of the exit conference with the Director of Maintenance, COO and Fire Marshall on January 4, 2022, at 2:00 PM confirmed the stairtower door failed to self-close.

Based on observation and interview, it was determined the facility failed to maintain the stairtower doors to be within allowed gap margins, in three of five stairtowers within the component.

Findings include:

1. Observation on January 3, 2022, between 12:20 PM and 1:40 PM, revealed the stairtower doors had a gap exceeding 3/16 of an inch, in the following locations:

a. 12:20 PM, Center Stairtower Door, in the basement;
b. 12:37 PM, Stairtower Door #20, in the basement;
c. 1:00 PM, Stairtower Door #170, on the 1st floor;
d. 1:20 PM, Stairtower Door #2229, 2nd floor;
e. 1:30 PM, Stairtower Door #3328, on the 3rd floor;
f. 1:40 PM, Stairtower Door #285, 2nd floor.

Interview at the time of the exit conference with the Director of Maintenance, COO and Fire Marshall on January 4, 2022, at 2:00 PM confirmed the doors exceeded the allowed gap margin.

Based on observation and interview, it was determined the facility failed to maintain exit signage, affecting one of five floors within the component.

Findings include:

1. Observation on January 4, 2022, at 11:21 AM revealed the 3rd floor Exit Stairtower Enclosure, across from Room 317, lacked an exit sign.

Interview with Facility Maintenance Manager 1 on January 4, 2022, at 11:21 AM confirmed the lack of exit signage.

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors to be self-closing, and within allowed gap margins, and the rating of hazardous area walls, on two of four floors within the component.

Findings include:

1. Observation on January 4, 2022, at 11:50 AM revealed the 1st floor Supply Room Doors 144 and 145 lacked closures.

Interview with the Fire Marshall on January 4, 2022, at 11:50 AM confirmed the doors lacked self-closing hardware.

2. Observation on January 4, 2022, between 12:10 PM and 12:40 PM, revealed rated hazardous area doors had gaps exceeding 3/16th of an inch, at the following locations:

a. 12:10 PM, basement, Soiled-Linen Room Door 003;
b. 12:40 PM, basement, Storage Room Door 10.

Interview with the Fire Marshall on January 4, 2022, at 12:40 PM confirmed the hazardous area doors exceeded the allowed gap margins.


3. Observation on January 4, 2022, at 12:55 PM revealed a 4-inch PVC pipe penetrating the basement Elevator Equipment Room had.

Interview with the Fire Marshall on January 4, 2022, at 12:55 PM confirmed there was a penetration.

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors to self-close and latch, in two of ten smoke zones within the component.

Findings include:

1. Observation on January 4, 2022, between 10:30 AM and 11:12 AM revealed hazardous area doors failed to self-close, at the following locations:

a. 10:30 AM, ground floor, Mortuary Door, Room #24;
b. 10:45 AM, ground floor, Computer Room #5;
c. 11:05 AM, ground floor, Mechanical Room Door #02;
d. 11:07 AM, ground floor, Mechanical Room Door #03;
e. 11:12 AM, ground floor, House Keeping Storage Door.

Interview at the time of the exit conference with the Director of Maintenance, COO and Fire Marshall on January 4, 2022, at 2:00 PM confirmed the doors failed to self-close.

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors to be within allowed gap margins, and to positively latch, on two of four floors.

Findings include:

1. Observation on January 3, 2022, between 12:20 PM and 12:45 PM, revealed rated hazardous area doors exceeded the allowed gap margins, at the following locations:

a. 12:20 PM, basement, Electrical Room, in the Center Stairtower, gaps exceeded 3/16th of an inch;
b. 12:35 PM, basement, Soiled Laundry Room #21, gaps exceeded 3/16th of an inch;
c. 12:35 PM, second floor, Supply Room Door #256, gap exceeded 3/16th of an inch;
d. 12:40 PM, basement, Storage Room #17 gaps= exceed3d 3/16th of an inch;
e. 12:45 PM, basement, Soiled Laundry Room, gaps exceeded 3/16th of an inch. and lacked a closure in the basement.

Interview with the Fire Marshall on January 3, 2022, at 12:45 PM confirmed the door exceeded the allowed gap margin and the lack of a closure.


2. Observation on January 3, 2022, between 12:38 PM and 12:42 PM, revealed hazardous area doors failed to positively latch, at the following locations:

a. 12:38 PM, second floor, Vertical Access Fire Rated Door, in Supply Room #256;
b. 12:42 PM, basement, Storage Room #16.

Interview with the Fire Marshall on January 3, 2022, at 12:42 PM confirmed the doors did not positively latch in the frame.


3. Observation on January 3, 2022, at 12:45 PM, revealed the door to the basement Soiled Laundry Room did not self-close.

Interview with the Fire Marshall on January 3, 2022, at 12:45 PM confirmed the door did not self-close.

Based on observation and interview, it was determined the facility failed to monitor the placement of alcohol based hand rub dispensers, affecting one of four floors within the component.

Findings include:

1. Observation on January 3, 2022, at 1:38 PM revealed an alcohol based hand rub dispenser installed above a light switch within the 3rd floor Day Room countertop alcove.

Interview with Facility Maintenance Manager 1 on January 3, 2022, at 1:38 PM confirmed the dispenser was located above an ignition source.

Based on observation and interview, it was determined the facility failed to maintain location signage of portable fire extinguishers, affecting one of four floors within the component.

Findings include:

1. Observation on January 3, 2022, at 1:31 PM revealed the flush-mount portable fire extinguisher located next to 3rd floor Room 340 lacked identifying signage.

Interview with Facility Maintenance Manager 1 on January 3, 2022, at 1:31 PM confirmed the lack of signage identifying the location of the extinguisher recessed into the corridor wall.

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

Findings include:

1. Observation on January 4, 2022, at 11:06 AM revealed two unprotected penetrations of the corridor wall, located beside 3rd floor Laundry Room 340.

Interview with Facility Maintenance Manager 1 on January 4, 2022, at 11:06 AM confirmed the unprotected penetrations.

Based on observation and interview, it was determined the facility failed to maintain rated corridor doors to positively latch, and be within the allowed gap margins, on the two of four floors within the component.

Findings include:

1. Observation on January 3, 2022, at 12:50 PM revealed the rated corridor double doors to the basement Dietary Storage would not close and latch in the fame.

Interview with the Fire Marshall on January 3, 2022, at 12:50 PM confirmed the double doors would not positively latch.


2. Observation on January 3, 2022, between 12:53 PM and 1:20 M, revealed rated corridor doors had gaps exceeding the allowed gap margins, at the following locations:

a. 12:53 PM, 1st floor, Room #184, greater than 1/4 inch, between the door and the door stop;
b. 1:05 PM, first floor, Office Storage Room Door #154;
c. 1:10 PM, first floor, Dietary Storage Door #152;
d. 1:20 PM, first floor, Dietary Storage double door, by the Loading Dock.

Interview with the Fire Marshall on January 3, 2022, at 1:20 PM confirmed the fire rated doors had gaps greater than 3/16 inch.

Based on observation and interview, it was determined the facility failed to maintain the rating of smoke barrier walls, affecting two of four smoke compartments within the component.

Findings include:

1. Observation on January 4, 2022, at 11:20 AM revealed the smoke barrier wall had a recessed wood TV cabinet installed and had a door removed in Room 134.

Interview with the Fire Marshall on January 4, 2022, at 11:20 AM confirmed the smoke barrier wall was incomplete.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors to be self-closing, and the viewing panel rating to match the door rating, affecting two of five smoke compartment within the component.

Findings include:


1. Observation on January 4, 2022, between 10:30 AM and 11:30 AM, revealed smoke barrier doors failed to self-close, at the following locations:

a. 10:30 AM, at Rooms 209, 210, 214 and 215;
b. 11:30 AM, at Room 134, 136 and 139.

Interview with the Fire Marshall on January 4, 2022, at 11:30 AM confirmed the doors lacked self-closing devices.


2. Observation on January 4, 2022, at 10:40 AM revealed the smoke barrier doors by Rooms 223 and 242 had plain vision glass installed.

Interview with the Fire Marshall on January 4, 2022, at 10:40 AM confirmed the doors lacked fire rated glass.

Based on observation and interview, it was determined the facility failed to maintain the smoke barrier doors to self-close, affecting one of five smoke compartments on the 3rd floor within the component.

Findings include:

1. Observation on January 3, 2022, at 1:40 PM revealed the smoke barrier corridor doors to Rooms 309, 210, 312, 313 and 314, lacked self-closing hardware.

Interview with the Fire Marshall on January 3, 2022, at 1:40 PM confirmed the doors lacked self-closing devices.

Based on observation and interview, it was determined the facility failed to maintain electrical junction boxes to be covered, affecting one of three smoke compartments within the component.

Findings include:

1. Observation on January 4, 2022, at 11:30 AM revealed three open electrical boxes located within Chase 108, in Room 107, on the 1st floor.

Interview with the Fire Marshall on January 4, 2022, at 11:30 AM confirmed the junction boxes lacked their cover plates.

Based on observation and interview, it was determined the facility failed to maintain the physical integrity of electrical receptacles, affecting one four floors within the component.

Findings include:

1. Observation on January 3, 2022, between 12:40 PM and 12:54 PM, revealed electrical receptacles were physically broken, at the following locations:

a. 12:40 PM, 1st floor, receptacle beneath the fire alarm strobe, within Dining Room 134;
b. 12:54 PM, 1st floor, receptacle within the Corridor, between Room 114 and Room 115.

Interview with the Facility Maintenance Manager 1 on January 3, 2022, at 12:54 PM confirmed the compromised physical integrity of the electrical receptacles.

Based on observation and interview, it was determined the facility failed to maintain the physical integrity of electrical receptacles, affecting one of five floors within the component.

Findings include:

1. Observation on January 4, 2022, at 11:43 AM revealed a receptacle in the 2nd floor Staff Lounge Room 240 was physically broken.

Interview with Facility Maintenance Manager 1 on January 4, 2022, at 11:43 AM confirmed the compromised physical integrity of the electrical receptacle.

Based on observation and interview, it was determined the facility failed to maintain the heating, ventilating and air conditioning system, affecting one of five floors within the component.

Findings include:

1. Observation on January 4, 2022, at 10:25 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 with Facility Maintenance Manager 1 on January 4, 2022, at 10:25 AM confirmed the corridor was used as a return air plenum.

Based on observation and interview, it was determined the facility failed to install a remote manual stop station for emergency generators servicing the facility, affecting the entire component.

Findings include:

1. Observation on January 3, 2022, at 12:00 PM revealed the facility lacked a remote manual stop station for the emergency generator servicing the component.

Interview with Facility Maintenance Manager 1 on January 3, 2022, at 12:00 PM confirmed the lack of a remote manual stop station for the emergency generator.

Based on observation and interview, it was determined the facility failed to install a remote manual stop station, for emergency generators, servicing the facility, affecting the entire component.

Findings include:

1. Observation on January 3, 2022, at 12:00 PM revealed the facility lacked a remote manual stop station for the emergency generator servicing the component.

Interview with Facility Maintenance Manager 1 on January 3, 2022, at 12:00 PM confirmed the lack of a remote manual stop station for the emergency generator.

Based on observation and interview, it was determined the facility failed to provide a remote manual stop station for the emergency generators servicing the facility, affecting the entire component.

Findings include:

1. Observation on January 3, 2022, at 12:00 PM revealed the facility lacked a remote manual stop station for the emergency generator servicing the component.

Interview with Facility Maintenance Manager 1 on January 3, 2022, at 12:00 PM confirmed the lack of a remote manual stop station for the emergency generator.

Based on observation and interview, the facility failed to monitor the use of electrical equipment, in one of five smoke compartments on the 2nd floor within the component.

Findings include:

1. Observation on January 4, 2022, at 10:50 AM revealed the use of a 3-way multiplier to supply power to surge suppressor in Activity Office #2451, on the 2nd floor.

Interview with the Fire Marshall on January 4, 2022, at 10:50 AM confirmed the use of a receptacle multiplier.


2. Observation on January 4, 2022, at 12:40 PM revealed the use of an extension cord in the basement Storage Room #10.

Interview with the Fire Marshall on January 4, 2022, at 12:40 PM confirmed the use of an extension cord.

Based on observation and interview, it was determined the facility failed to monitor the use of surge suppressors, affecting two of ten smoke compartments within the component.

Findings include:

1. Observation on January 4, 2022, between 12:30 PM and 12:40 PM, revealed surge suppressors supplying electric power to a refrigerator and microwave, at the following locations:

a. 12:30 PM, File Room #135, 1st floor;
b. 12:40 PM, Computer Room #146-03, 1st floor.

Interview at the time of the exit conference with the Director of Maintenance, COO and Fire Marshall on January 4, 2022, at 2:00 PM confirmed the refrigerator and microwave were plugged into surge suppressor cords.