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1001 STERIGERE STREET

NORRISTOWN, PA 19401

No Description Available

Tag No.: K0017

Based on observation and interview, it was determined the facility failed to maintain the corridor smoke separation in six of eleven smoke zones.

Findings include:

Observation on March 10, 2015 between 10:07 am and 1:15 pm, revealed penetrations of the corridor walls in the following locations:

a. 10:07 am, second floor, inside room 1A2-2057, copper pipe penetration above the corridor door.
b. 10:12 am, second floor, inside room 1A2-2056, thermacell wire penetration above the corridor door.
c. 10:30 am, second floor, above the corridor ceiling at 1A2-2041 above the strobe, gap between the wall edges from just above the ceiling grid to the deck.
d. 10:56 am, second floor, above the door of 1A2-2017, on the right hand side, data wire penetration.
e. 11:15 am, second floor, in the corridor by 1A2-2011, there was a metal grate in the ceiling.
f. 11:41 am, second floor, in the corridor at room 1C2-2126, there was a data wire penetration above the ceiling grid.
g. 1:15 pm, first floor, inside of chase 1C1-1094, above the corridor door, there was a white wire penetration.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015 at 11:15 am, confirmed the corridor separation was not smoke tight.

No Description Available

Tag No.: K0018

Based on observation and interview, it was determined the facility failed to ensure the corridor doors positively latched into the door frame such that the doors remained closed in the frames on one of three floors.

Findings include:

1. Obsevation made on March 10, 2015 between 9:45 am and 10:20 am, revealed that the following corridor doors failed to positively latched when tested.

a. 9:45 am, second floor A wing day hall room.
b. 10:20 am, second floor medical records room.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015 at 11:15 am, confirmed the doors failed to latch.

No Description Available

Tag No.: K0018

Based on observation and interview, it was determined the facility failed to ensure that exit corridors were protected by doors capable of positively latching shut, on one of four levels within this component.

Findings include:

1. Observation on March 10, 2015, at 9:48 am revealed on the second floor, the corridor door to resident room #2118 was missing door latching hardware and was unable to be shut latch tight.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015, at 11:15 am, confirmed the door was missing latching hardware.

2. Observation on March 10, 2015, at 10:00 am revealed on the second floor, there were no corridor doors installed at rooms #2095, #2096, and #2098.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015, at 11:15 am, confirmed the missing corridor doors.

No Description Available

Tag No.: K0025

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of the smoke barrier walls on one of three floors.

Findings include:

Observation made on March 10, 2015 at 11:45 am, revealed that the first floor A wing smoke barrier wall had an unsealed penetration around a bundle of blue data wiring.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015 at 11:15 am, confirmed the unsealed penetration.

No Description Available

Tag No.: K0025

Based on observation and interview, it was determined the facility failed to maintain the fire rating of the smoke barrier walls in five of eleven smoke zones.

Findings include:

Observation on March 10, 2015 between 9:50 am and 11:50 am, revealed penetrations of the smoke barrier walls at the following locations:

a. 9:50 am, second floor, at 1A2-2065, there was a bx armored cable penetration above the smoke barrier doors.
b. 10:20 am, second floor, at 1A2-2056, there was a partially sealed conduit penetration above the smoke barrier doors.
c. 11:50 am, first floor, at 1A1-1070, there was a data wire bundle that was partially sealed above the smoke barrier doors.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015 at 11:15 am, confirmed there were penetrations.

No Description Available

Tag No.: K0025

Based on observation and interview, it was determined that the facility failed to ensure that smoke barrier walls were maintained to provide a minimum of a half hour fire resistance rating, in two of seven smoke compartments within this component.

Findings include:

Observation on March 10, 2015, at 11:05 am revealed on the first floor, above the smoke barrier door located outside of the court room, there were two unsealed penetrations through the smoke barrier wall where gray security camera wiring had been installed.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015, at 11:15 am, confirmed the unsealed penetrations.

No Description Available

Tag No.: K0027

Based upon observation and interview, it was determined that the facility failed to ensure the smoke barrier doors remain smoke tight in the closed position on one of three floors.

Findings Include:

Observation made on March 10, 2015 at 1:00 pm, revealed that basement center hall smoke barrier doors by the nurse storage room failed to close smoke tight and requires an adjustment to the door coordinator.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015 at 11:15 am, confirmed the doors failed to close smoke tight.

No Description Available

Tag No.: K0033

Based on observation and interview, it was determined that the facility failed to maintain the fire resistance rating in one of six stair towers.

Findings include:

Observation made on March 10, 2015 at 10:25 am, at the second floor center stair tower by room #205, revealed that there was an unsealed penetration of the stair tower wall around a bundle of gray data wiring.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015 at 11:15 am, confirmed the unsealed penetration.

No Description Available

Tag No.: K0034

Based on observation and interview, it determined the facility failed to ensure that exit stair towers were kept free and clear of trash and debris, in one of five exit stair towers within this component.

Findings include:

Observation on March 10, 2015, at 10:46 am revealed inside of exit stair S41 there was a build up of trash, leaves and cigarette butts inside the stairway at the discharge level.
There were cigarette butts also observed at the first floor landing, and on the stairs between the first floor and the discharge level.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015, at 11:15 am, confirmed the trash, leaves and cigarette butts inside the exit stair tower.

No Description Available

Tag No.: K0038

Based on observation and interview, it was determined that the facility failed to ensure that exits were readily accessible at all times and that exit access is not impeded, on one of two levels within this component.

Findings include:

Observations on March 10, 2015 between 1:20 pm and 2:05 pm revealed impediments to exit access at the following locations:

a. 1:20 pm, Upper level, outside of Exit door #1098 in the CF wing, the concrete ramp had multiple cracks and areas where the concrete was uneven or had broken away.
b. 2:05 pm, Upper level, Exit door #1048, at the Center CR emergency exit, was in disrepair and extremely rusted at the of the bottom, creating a hazard where the door could become unusable in an emergency.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015 at 11:15 am, confirmed the impediments to Exit access at the above named locations.

No Description Available

Tag No.: K0047

Based on observation and interview, it was determined that the facility failed to ensure that exit signage was continuously illuminated on one of four levels within this component.

Findings include:

Observation on March 10, 2015, at 9:46 am revealed on the second floor, the EXIT sign inside of room 2110 was not illuminated.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015, at 11:15 am, confirmed the EXIT sign was not illuminated.

No Description Available

Tag No.: K0052

Based on observation, interview and document review, it was determined that the facility failed to properly inspect fire alarm system components throughout this component.

Findings include:

1. Document review on March 11, 2015, at 9:30 am, revealed the facility failed to document a semi-annual visual inspection six months apart from the last annual inspection, which was conducted June 2, 2014.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015, at 11:15 am, confirmed the facility did not have documentation of the semi-annual visual inspection performed in December.

2. Document review on March 11, 2015, at 10:00 am revealed the facility could not provide documentation of having the smoke detectors sensitivity testing completed.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015, at 11:15 am, confirmed there was no documentation for the smoke detector sensitivity testing.

No Description Available

Tag No.: K0067

Based on documentation review and interview, it was determined the facility failed to maintain the heating, ventilating and air conditioning (HVAC) system within this facility component.

Findings include:

Review of documents on March 11, 2015 at 9:30 am, revealed that fire damper report dated June 14, 2011 had noted deficiencies. Documentation was not available indicating that all work had been corrected and the dampers inspected/tested.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015 at 11:15 am, confirmed the facility did not have documentation.

No Description Available

Tag No.: K0071

Based on observation and interview, it was determined the facility failed to maintain rubbish chutes, incinerators and laundry chutes enclosures in two locations within this facility

Findings include:

1. Observation made on March 10, 2015 at 1:30 pm and 1:55 pm, revealed that the following laundry chute discharge rooms had unsealed penetrations with either armored MC cables and/or data wiring.

a. 1:30 pm, basement laundry chute room #42.
b. 1:55 pm, basement laundry chute room #48.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015 at 11:15 am, confirmed the unsealed penetrations.

No Description Available

Tag No.: K0076

Based on observation and interview, it was determined that the facility failed to ensure that medical gas cylinders were properly stored, on one of two levels within this component.

Findings include:

Observation on March 10, 2015, at 1:50 pm, revealed there were two unsecured freestanding oxygen cylinders sitting on the floor, inside of the first floor CR nurses station.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015, at 11:15 am, confirmed the oxygen cylinders were not secure.

No Description Available

Tag No.: K0144

Based on document review and interview, it was determined the facility failed to perform the required testing on the generator, which supplies emergency power to the entire building.

Findings include:

Document review on March 11, 2015 at 10:00 am, revealed the facility performed a battery electrolyte test during the monthly load test. The facility did not have documentation that a weekly visual and battery electrolyte test was being performed on a weekly basis.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015 at 11:15 am, confirmed the facility did not have documentation of the weekly visual and battery electrolyte test.

No Description Available

Tag No.: K0144

Based on document review and interview, it was determined the facility failed to perform the required testing on one of one emergency power generator.
Findings include:

Document review on March 11, 2015, at 10:00 am, revealed the facility performed a battery electrolyte test during the monthly load test. The facility did not have documentation that a weekly visual, and battery electrolyte level and electrolyte specific gravity test was being performed on a weekly basis.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015, at 11:15 am, confirmed the facility did not have documentation of the weekly visual and battery electrolyte specific gravity test.

No Description Available

Tag No.: K0144

Based on document review and interview, it was determined the facility failed to perform the required testing on the generator, which supplies emergency power to the entire building.
Findings include:

Document review on March 11, 2015, at 10:00 am, revealed the facility performed a battery electrolyte test during the monthly load test. The facility did not have documentation that a weekly visual, and battery electrolyte level and electrolyte specific gravity test was being performed on a weekly basis.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015, at 11:15 am, confirmed the facility did not have documentation of the weekly visual and battery electrolyte specific gravity test.

No Description Available

Tag No.: K0147

Based on observation and interview, it was determined that the facility failed to ensure that electrical equipment was inspected and maintained, on one of two levels within this component.

Findings include:

Observation on March 10, 2015, at 2:45 pm, revealed inside the basement level electrical transformer room, there was a metal access panel that was secured to two wooden 2x4's, approximately 3 feet long, on the back of the electrical switch gear and not secured directly on the switch gear.

There was a gap of approximately 1.5-2 inches between the protective panel and the switch gear, through which the cabling/wiring for an outdoor temporary generator was passing into the switch, exposing the inner wiring and connections of the switch gear.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015, at 11:15 am, confirmed the protective cover was not properly installed on the electrical switch gear.

No Description Available

Tag No.: K0147

Based on observation and interview, it was determined that the facility failed to maintain electrical system components, on two of four levels within this component.

Findings include:

1. Observation on March 10, 2015, at 9:50 am revealed on the second floor, the electrical panel inside of mechanical room #2104 lacked a circuit directory.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015, at 11:15 am, confirmed the electrical panel did not have a directory.

2. Observation on March 10, 2015, at 10:25 am revealed in the mechanical penthouse, the protective covers for the electrical disconnect boxes labeled EX6 and EX7 were not installed and were found to laying on the floor.

Interview at the time of the exit conference with the Chief Executive Officer and the Chief Operating Officer on March 11, 2015, at 11:15 am, confirmed the protective cover panels were not installed.