Pennsylvania Department of Health
 KIRKLAND VILLAGE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
KIRKLAND VILLAGE
Inspection Results For:

There are  48 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
KIRKLAND VILLAGE - 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 August 20, 2025, at Kirkland Village, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.
 Plan of Correction:


Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000
Facility ID# 055402Component 01Main BuildingBased on a Medicare/Medicaid Recertification Survey completed on August 20, 2025, it was determined that Kirkland Village 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 two story, Type II (000), unprotected, noncombustible building, with a basement, that is fully sprinklered.
 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies: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.
Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain three common walls in five locations, affecting three of three floors.

Findings include:
Observation on August 20, 2025, between 11:12 a.m., and 12:04 p.m., revealed the following:
a. 11:12 a.m., holes within the first floor, common wall doors with the Apartment Building.
b. 11:13 a.m., the first floor, common wall doors with the Apartment Building required adjustment to fully latch.
c. 11:14 a.m., the first floor, single common wall door with the Apartment Building required adjustment to fully latch.
d. 11:41 a.m., the second floor, common wall, Dietary door did not latch.
e. 12:04 p.m., the basement-level, common wall doors with the Apartment Building (located within Dietary) required adjustment to fully latch.
Exit interview on August 20, 2025, between 12:45 p.m., and 1:00 p.m., with the Executive Director, the Administrator, and the Facilities Manager, confirmed the common wall deficiencies.





 Plan of Correction - To be completed: 09/15/2025

a. Holes in doors will be filled with 3M fire Rated caulk. (Auditorium Hallway).
Completed by 9/15/2025

b. Doors will be adjusted to provide positive latching. (Auditorium Hallway).
Completed by 9/15/2025

c. Doors will be adjusted to provide positive latching. (Auditorium door).
Completed by 9/15/2025

d. Lockset on door will be replaced, and the doors will be adjusted to provide positive latching. (3rd floor Kitchen).
Completed by 9/15/2025

e. Doors will be adjusted to provide positive latching. (Market Place to Main Kitchen)
Completed by 9/15/2025
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 01 - Component: 01 - Tag: 0211 Based on observation and interview, it was determined the facility failed to maintain means of egress in one location, affecting one of three floors. Findings include: Observation on August 20, 2025, at 12:11 p.m., revealed the basement-level, exit access corridor system housed skids, carts, boxes, shelving units, etc...Exit interview on August 20, 2025, between 12:45 p.m., and 1:00 p.m., with the Executive Director, the Administrator, and the Facilities Manager, confirmed the confirmed the means of egress deficiency.
 Plan of Correction - To be completed: 09/15/2025

Items stored in Hallway have been cleared to provide a clear pathway to the exit.
Completed 9/5/2025
NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
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 01 - Component: 01 - Tag: 0225 Based on observation and interview, it was determined the facility failed to maintain one exit stair tower in one location, affecting one of three floors. Findings include: Observation on August 20, 2025, at 11:20 a.m., revealed the vision panel of first floor portion of the "H" stair tower enclosure was lacking two screws.Exit interview on August 20, 2025, between 12:45 p.m., and 1:00 p.m., with the Executive Director, the Administrator and the Facilities Manager, confirmed the stair tower enclosure deficiency.
 Plan of Correction - To be completed: 09/15/2025

Missing screws in the vision panel of the door have been replaced.
Completed 8/27/2025
NFPA 101 STANDARD Emergency Lighting: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.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291 Based on observation and interview, it was determined the facility failed to maintain emergency lighting fixtures, affecting three of three floors. Findings include: Observation on August 20, 2025, at 12:25 p.m., revealed the facility lacked annual, ninety-minute bleed, or drain testing data of the emergency lighting fixtures.Exit interview on August 20, 2025, between 12:45 p.m., and 1:00 p.m., with the Executive Director, the Administrator and the Facilities Manager, confirmed the emergency lighting deficiency.
 Plan of Correction - To be completed: 09/30/2025

A preventive maintenance card will be written, and the task of inspecting all battery pack lighting is tested monthly and an annual 90 min duration test will be conducted.

To be completed by 9/30/2025.
NFPA 101 STANDARD Vertical Openings - Enclosure: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.
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:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain vertical openings in one location, affecting two of three floors.

Findings include:
Observation on August 20, 2025, at 12:00 p.m., revealed a penetration of the floor slab assembly, located with the second floor, Electric Room (conduit).Exit interview on August 20, 2025, between 12:45 p.m., and 1:00 p.m., with the Executive Director, the Administrator and the Facilities Manager, confirmed the vertical opening deficiency.





 Plan of Correction - To be completed: 09/15/2025

Conduits in the Electrical room have been filled with fire rated 3M caulk.
Completed 8/27/2025.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 01 - Component: 01 - Tag: 0353 Based on observation and interview, and documentation review, it was determined the facility failed to maintain the automatic sprinkler system in three instances, affecting three of three floors. Findings include: Observation on August 20, 2025, between 11:03 a.m., and 12:20 p.m., revealed the following: a. 11:03 a.m., a "loaded" sprinkler head assembly, located within the Main Lobby area. b. 12:02 p.m., a missing escutcheon plate, located within the second floor Pantry. c. 12:20 p.m., the facility lacked five-year internal valve, five-year internal pipe, and five year sprinkler gauge testing, inspection and inspection data. Exit interview on August 20, 2025, between 12:45 p.m., and 1:00 p.m., with the Executive Director, Administrator, and Facilities Manager, confirmed the automatic sprinkler system maintenance deficiencies.
 Plan of Correction - To be completed: 09/30/2025

Fire Sprinkler system was last tested on 9/2/20245. The report is available upon request. Fire Sprinkler system was inspected by Anchor Fire Protection. Kirkland's water source is the City of Bethlehem.

a. Sprinkler head was cleaned.
Completed 8/27/2025.

b. Escutcheon plate was replaced. Completed by 8/27/2025.

c. Sprinkler pipe internal test and gauge replacement is being conducted starting 9/2/2025. To be Completed by 9/26/2025.

NFPA 101 STANDARD Corridor - Doors: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.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363 Based on observation and interview, it was determined the facility failed to maintain four corridor openings, affecting three of three floors. Findings include: Observation on August 20, 2025, between 11:22 a.m., and 12:04 p.m., revealed the following:a. 11:22 a.m., holes within the first floor, Rosewood Clean Linen Room door. b. 11:43 a.m., the second floor Pantry door required adjustment to fully latch. c. 11:52 a.m., the basement-level, Dry Storage Room door required adjustment to fully latch. d. 12:04 p.m., the basement-level, Staff Lounge door required adjustment to fully latch. Exit interview on August 20, 2025, between 12:45 p.m., and 1:00 p.m., with the Executive Director, the Administrator, and the Facilities Manager, confirmed the corridor opening deficiencies.
 Plan of Correction - To be completed: 09/30/2025

a. The hole in the Rosewood Clean Linen door will be filled with a fire rated caulk.
Completion by 9/26/2025.

b. The 2nd floor pantry door will be adjusted to properly latch.
Completion by 9/26/2025.

c. Dry Storage room door closer will be replaced to provide positive latching.
Completed by 9/26/2025.

d. The door to the staff lounge will be adjusted to positively latch.
Completed by 9/26/2025.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374 Based on observation and interview, it was determined the facility failed to maintain one set of smoke barrier separation doors, affecting one of three floors. Findings include: Observation on August 20, 2025, at 11:39 a.m., revealed the smoke barrier separation doors, located closest to Resident Room 130, required adjustment to fully latch.Exit interview on August 20, 2025, between 12:45 p.m., and 1:00 p.m., with the Executive Director, the Administrator, and the Facilities Manager, confirmed the smoke barrier separation door deficiency.
 Plan of Correction - To be completed: 09/15/2025

The resident room door for room 130 was adjusted to latch.
Completed 8/27/2025.
NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761 Based on observation and interview, it was determined the facility failed to maintain fire doors in multiple locations, affecting three of three floors. Findings include: Observation on August 20, 2025, at 12:15 p.m., revealed the facility lacked annual fire door functional and visual testing data.Exit interview on August 20, 2025, between 12:45 p.m., and 1:00 p.m., with the Executive Director, the Administrator and the Facilities Manager, confirmed the fire door deficiencies.
 Plan of Correction - To be completed: 09/15/2025

A Preventive Maintenance work order was developed and will be implemented to inspect and service all fire rated doors.
Completed 8/27/2025.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918 Based on observation and interview, it was determined the facility failed to maintain the generator sets (2) in two locations, affecting three of three floors. Findings include: Observation on August 20, 2025, at 12:22 p.m., revealed the facility lacked annual, ninety -minute load bank testing, as well as three year, four-hour load testing data for both generator sets.Exit interview on August 20, 2025, between 12:45 p.m., and 1:00 p.m., with the Executive Director, the Administrator and the Facilities Manager, confirmed the generator set deficiency.
 Plan of Correction - To be completed: 09/30/2025

A load back test and a 4-hour continuous run test will be conducted by a certified contractor.
To be completed by 9/30/2025.
NFPA 101 STANDARD Electrical Equipment - Testing and Maintenanc: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.
Electrical Equipment - Testing and Maintenance Requirements
The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training.
10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0921 Based on observation and interview, it was determined the facility failed to maintain electrical components in one location, affecting one of three floors. Findings include: Observation on August 20, 2025, at 12:06 p.m., revealed a damaged electrical receptacle cover, located at the basement-level, Equipment Room entrance.Exit interview on August 20, 2025, between 12:45 p.m., and 1:00 p.m., with the Executive Director, the Administrator, and the Facilities Manager, confirmed the electrical systems deficiency.
 Plan of Correction - To be completed: 09/15/2025

Electrical cover plate was replaced.
Completed 8/27/2025.
Initial comments:Name: FITNESS/AQUATIC CTR - Component: 12 - Tag: 0000
Facility ID# 055402Component 12Aquatics/Fitness CenterBased on a Medicare/Medicaid Recertification Survey completed on August 20, 2025, it was determined that Kirkland Village was in substantial compliance with 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 building, that is fully sprinklered.
 Plan of Correction:



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