Pennsylvania Department of Health
HOLY FAMILY MANOR
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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HOLY FAMILY MANOR - 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 June 8, 2026, at Holy Family Manor, 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#082702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 8, 2026, it was determined that Holy Family Manor 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 four story, Type II (000), unprotected, noncombustible building, with unused attic spaces, and partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

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.

Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting nine of nine smoke compartments.

Findings include:

1. Observation on June 8, 2026, between 11:30 am, and 12:30 pm, revealed the facility exceeded the maximum allowable story height by two stories.

Exit interview with the facility administrator and the facilities manager on June 8, 2026, at 1:15 pm, confirmed the building construction requirement deficiency.

Plan of Correction - To be completed: 07/31/2026

1. Facility is working on obtaining a Time-Limited Waiver (TLW) for deficiency K0161. The letter was drafted and sent out for approval. Facility will look to have an FSES evaluation conducted.

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 two instances, affecting nine of nine smoke compartments.

Findings include:

1. Observation on June 8, 2026, between 11:30 am, and 12:30 pm, revealed vertical openings lacked required two-hour, fire resistive integrity. These enclosures consist of HVAC shafts, mechanical chases, wall cavities, soiled linen chutes, trash chutes, elevator enclosures, and stair tower enclosures.

Exit interview with the facility administrator and the facilities manager on June 8, 2026, at 1:15 pm, confirmed the vertical opening deficiencies.

2. Observation on June 8, 2026, at 11:54 am, 3rd floor, revealed the attic access hatch door was open, not secured into the frame.
Exit interview with the facility administrator and the facilities manager on June 8, 2026, at 1:15 pm, confirmed the attic access hatch door being open.

Plan of Correction - To be completed: 07/31/2026

1. Holy Family Manor is working with architects and engineers to develop a viable structural solution to achieve the required fire resistive integrity of the smoke compartment. In accordance with TLW already in place, the attic space would become an interstitial space of the 3rd floor and bring the building back to construction type II (222). Holy Family Manor will bring these plans to the Department of Health Plan Review prior to initiation of work. Facility requests continuation of the existing F.S.E.S. on file. The third-floor attic hatch door was immediately closed by the Maintenance Department.

2. The Maintenance Director/Designee will conduct random audits 2 times weekly to ensure all vertical openings are closed and hatch door secured to the frames. Findings will be reported during our QAPI meeting.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of four floors.

Findings include:

1. Observation on June 8, 2026, at 12:01 pm, 3rd floor, revealed a sprinkler head in the nurses' station lacked an escutcheon plate.

Exit interview with the facility administrator and the facilities manager on June 8, 2026, at 1:15 pm, confirmed the missing sprinkler escutcheon plate.

Plan of Correction - To be completed: 07/31/2026

1. The Escutcheon plate was immediately replaced at the third-floor nursing station by the Maintenance department.

2. The Maintenance Director/Designee will conduct random audits 2 times a week to ensure all Escutcheon plates are present and not missing. Findings will be reported during our QAPI meeting.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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 document review and interview, it was determined the facility failed to have the annual fuel quality sample performed for the emergency generator, affecting four of four floors.

Findings include:

1. Review of documentation on June 8, 2026, between 10:45 am, and 11:30 am, revealed the facility failed to verify the quality of the emergency fuel reserve, within the previous twelve months.

Exit interview with the facility administrator and the facilities manager on June 8, 2026, at 1:15 pm, confirmed the lack of fuel quality documentation.

Plan of Correction - To be completed: 07/31/2026

1. The emergency fuel reserve was verified and sampled by Albarell Electric Inc. on June 11th, 2026.

2. Maintenance Director/Designee will conduct random generator audits to ensure that generator is working properly. Findings will be reported during our QAPI meeting.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID#082702
Component 02
McShea Building

Based on a Medicare/Medicaid Recertification Survey completed on June 8, 2026, it was determined that Holy Family Manor 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, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0353

Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of two floors.

Findings include:

1. Observation on June 8, 2026, at 12:37 pm, 2nd floor, revealed three unsealed penetrations of the ceiling within the north elevator machine room.

Exit interview with the facility administrator and the facilities manager on June 8, 2026, at 1:15 pm, confirmed the unsealed penetrations.

Plan of Correction - To be completed: 07/31/2026

1. The unsealed penetrations have been sealed by the Maintenance Department.

2. Maintenance Director/Designee will conduct random audits to ensure all penetrations within the facility are sealed. Findings will be reported during our QAPI meeting.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0918

Based on document review, observation, and interview, it was determined the facility failed to maintain the emergency generator in two instances, affecting two of two floors

Findings include:

1. Review of documentation on June 8, 2026, between 10:45 am, and 11:30 am, revealed the facility failed to verify the quality of the emergency fuel reserve, within the previous twelve months.

Exit interview with the facility administrator and the facilities manager on June 8, 2026, at 1:15 pm, confirmed the lack of fuel quality documentation.

2.. Observation on June 8, 2026, at 12:42 pm, revealed the remote generator annunciator had a trouble light for generator Line Power.

Exit interview with the facility administrator and the facilities manager on June 8, 2026, at 1:15 pm, confirmed the line power generator light.

Plan of Correction - To be completed: 07/31/2026

1. The emergency fuel reserve was verified and sampled by Albarell Electric Inc. on June 11th, 2026. The remote generator annunciator was assessed by Albarell Electric Inc. and is working properly. Facility Maintenance will ensure this testing is completed annually.

2. Maintenance Director/Designee will conduct random generator and line power audits to ensure generator and line power are working properly. Findings will be reported during our QAPI meeting.

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