Pennsylvania Department of Health
HORSHAM CENTER FOR JEWISH LIFE
Building Inspection Results

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HORSHAM CENTER FOR JEWISH LIFE
Inspection Results For:

There are  47 surveys for this facility. Please select a date to view the survey results.

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HORSHAM CENTER FOR JEWISH LIFE - 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 April 2, 2024 at Horsham Center for Jewish Life 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 091302
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 2, 2024, it was determined that Horsham Center for Jewish Life was not in compliance with the following requirements of the Life Safety Code for an exisiting Nursing 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 Three story with a basement, Type II (222) protected non-combustible building, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Doors with Self-Closing Devices: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.
Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview facility failed to provide doors with self closing devices on two of four stories.

Findings include:

Observation on April 2, 2024, revealed the following deficiencies:
a. 9:40 a.m., the basement area inner door to elevator mechanical room propped open with a safety cone.
b. 9:42 a.m., the basement Nutritional services kitchen area door was propped open with a wooden wedge.
c. 9:57 a.m., the basement door to kitchen commissary held open with an unauthorized device secured to a local shelving rack.
d. 9:57 a.m., the same door also had a door clasp and pad lock on the door.
e. 11:13 a.m., the basement door #44 to housekeeping storage, the self closing device was broken and not in use.
f. 12:10 p.m., in C level the IT storage closet door was propped open with an unauthorized hold open device.
g. 12: 31 p.m., storage room in the kitchen area on A wing had an unauthorized hold open device.

Interview with Maintenance Director on April 2, 2024, at 2:30 p.m., confirmed the above deficiencies.



















 Plan of Correction - To be completed: 05/21/2024

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
The Facility has removed any objects that can used as props to inhibit doors from self closing.
a. The basement area inner door to the elevator mechanical room.
b. The basement Nutritional services kitchen area doors.
c. The basement door to the kitchen commissary and removed the door clasp and pad lock that was installed on the same kitchen commissary doors.
d. Repaired the self-closing device to basement door #44 to housekeeping storage.
e. Removed unauthorized hold open device in C level IT storage closet.
f. The storage room in the kitchen area on A wing.
The Maintenance Department will be in-serviced by the Administrator/Designee on the importance of self-closing doors working properly.
The Maintenance Director/ Designee will conduct random weekly audits x3 to ensure doors with self-closing devices are working properly. All findings will be reported to QAPI x3 months.

NFPA 101 STANDARD Alcohol Based Hand Rub Dispenser (ABHR):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.
Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0325


Based on observation and interview, the facility failed to provide a safe area to store Alcohol Based Hand Rub (ABHR) on one of the four floors.

Findings include:

Observation on April 2, 2024, at 10:17 a.m., the facility had over 10 gallons of ABHR stored in a storage room outside of a fire rated cabinet in the basement.

Interview with Maintenance Director on April 2, 2024, at 2:30 p.m., confirmed the storage of ABHR in the basement area.










 Plan of Correction - To be completed: 05/21/2024

The Facility is storing ABHR in a safe area.
The Materials Management Department will be in-serviced by the Maintenance Director/Designee about NFPA 30 requirements and the importance of storing it in a safe area.
The Maintenance Director/ Designee will complete weekly inspections x3 weeks to ensure that ABHR is being stored safely. All findings will be reported to QAPI x3 months.

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 facility failed to ensure sprinkler system would activate in a timely manner in one of four floors.

Findings include:

Observation on April 2, 2024, in the basement area revealed the following
A. April 2, 2024, Basement employee bathroom D wing at 10:34 a.m. had missing ceiling tile which would delay the activation of the sprinkler system.
B. On April 2, 2024, Basement Mechanical closet D wing) at 11:05 a.m. revealed the ceiling tiles and grid were removed during general maintance repair.
C. On April 2, 2024, Basement C Wing Basement had a recessed junction box in the ceiling that would let heat, fire, smoke around the junction box.
D. Observation made on April 2, 2024 at 10:50 a.m., revealed outside the elevators, above the suspended ceiling in the A/B Hallway link, there was a flexible HVAC duct laying on a sprinkler pipe.

Interview with Maintenance director confirmed the missing ceiling tiles and area around the junction box on April 2, 2024, at 2:30 p.m.






 Plan of Correction - To be completed: 05/21/2024

The Facility replaced the missing ceiling tile and grid in the employee bathroom and Mechanical closet in the D wing basement. Fire caulked the perimeter of the junction box in C wing basement with 3M Fire Barrier Sealant CP 25WB+ to ensure heat, fire, or smoke would not affect the junction box. Suspended the flexible HVAC duct to ensure it is no longer laying on the sprinkler pipe above the suspended ceiling in the A/B Hallway link.
The Maintenance Department will be in-serviced by the Administrator/ Designee on ensuring the sprinkler system will activate in a timely manner.
The Maintenance Director/ Designee will conduct random weekly audits x3 to ensure the sprinkler system will activate in a timely manner. All findings will be reported to QAPI x 3 months.

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 Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined that the facility failed to ensure that common fire walls were maintained free of unsealed penetrations and holes on two of three levels within this component.

Findings include:

Observations made on April 2, 2024, between 9:25 a.m. and 10:10 a.m., revealed unsealed penetrations and holes in common fire walls in the following locations:

a. 9:25 a.m., on the third floor, A/B Hallway link rated separation wall, above the closets, above the ceiling over the fire doors, one unsealed penetrations of the wall.
b. 10:10 a.m., on the second floor, A/B Hallway link rated separation wall, above the ceiling over the fire doors, one unsealed penetration around data cables.

Interview with Maintenance Director on April 2, 2024, at 2:30 p.m., confirmed the above doors, confirmed the unsealed penetrations in the above named locations.







 Plan of Correction - To be completed: 05/21/2024

The Facility has repaired the separations on the third floor A/B Hallway link and A/B second floor Hallway links with 3M Fire Barrier Sealant CP 25WB+.
The Maintenance Department will be in-serviced by the Administrator/ Designee on the importance of maintaining NFPA 101 standards in Smoke Barriers.
The Maintenance Director/ Designee will conduct random weekly audits x3 of the A/B hallway links (x4 floors) to ensure there are no unsealed penetrations or holes. All findings will be reported to QAPI x 3 months.

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, the facility failed to provide smoke barrier door that function as designed on one of four floors.

Findings include:

Observation on April 2, 2024, at 10:01 a.m., revealed the smoke doors in the A/B corridors the left side near the mechanical room had latching mechanism but did not latch in its frame.

Interview with Maintenance Director on April 2, 2024, at 2:30 p.m., confirmed the door did not latch.







 Plan of Correction - To be completed: 05/21/2024

The Facility adjusted the latching mechanism on the A/B Corridor left side near the mechanical room so that the door latches functions correctly.
The Maintenance Department will be in-serviced by the Administrator/ Designee on the importance of smoke barrier doors functioning as designed.
The Maintenance Director/ Designee will conduct random weekly audits of the A/B hallway links (x4 floors) to ensure smoke barrier doors function as designed. All findings will be reported to QAPI x 3 months.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0541


Based on observation and interview facility failed to ensure the fire rating and self closing devices on one of four floors for the linen chute area.

Findings include:

1. Observation on April 2, 2024, at 12:30 p.m., revealed the Chute access door had paper stuffed into the latching mechanism prevent the chute room door from latching in its frame and the chute door itself had a bag of laundry stuck in it preventing the chute door from self latching in its frame.

2. Observation on April 2, 2024, at 11:05 a.m., revealed the trash chute door not latching inside A1 soiled linen room, A Building, on the first floor.

3. Observation on April 2, 2024, at 1:00 p.m. , revealed the trash chute door not latching inside C1 soiled linen room, C Building, on the first floor.


Interview with Maintenance Director on April 2, 2024, at 2:30 p.m. confirmed the the above doors.





















 Plan of Correction - To be completed: 05/21/2024

The Facility removed the paper stuffed into the latching mechanism that prevented the chute room door from latching and removed the bag of laundry that was preventing the chute door from latching to its frame on Pod D3. The facility adjusted the trash chute door latch's to correctly function at A pod first floor and C pod first floor soiled linen rooms.
The Maintenance Department will be in-serviced by the Administrator/ Designee on the importance of trash and linen chutes latching properly to ensure fire rating.
The Maintenance Director/ Designee will conduct random weekly audits x3 to ensure trash and linen chutes are latching properly to ensure fire rating. All findings will be reported to QAPI x3 months.

NFPA 101 STANDARD Electrical Systems - Other: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 - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to provide proper protection for electrical equipment in accordance with NFPA 70 314.28 (C), affecting two of three smoke zones in the component.

Findings include:

1. Observation made on April 2, 2024, at 10:00 a.m., revealed an open junction box missing cover in the ceiling above B3 Fire Doors, in B Building third floor.

2. Observation made on April 2, 2024, at 11:27 a.m., revealed open splices and unsecured wiring above the ceiling at near stairtower 3, of B1 right cluster, in A Building on the first floor.

Interview with Maintenance Director on April 2, 2024, at 2:30 p.m., confirmed the lack of protection for electrical equipment.





 Plan of Correction - To be completed: 05/21/2024

The facility has replaced the missing cover plate in the ceiling above B3 Fire Doors and removed the open spliced wire and connected the unsecured wiring above the ceiling near the stair tower of B1 Right Cluster.
The Maintenance Department will be in-serviced by the Administrator/ Designee on the importance of maintaining proper electrical protection in smoke zones in accordance with NFPA 70 314.28(C)
The Maintenance Director/ Designee will conduct random weekly audit x3 of to ensure that we are maintaining proper electrical protection in smoke zones. Findings will be reported to QAPI x3 months.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain the Helium cylinders to be secured, affecting one of four floors.

Findings include:

Observation on April 2, 2024, at 10:30 a.m., revealed an unsecured Helium tank, on the second floor, in the storage room, A/B hallway.

Interview with Maintenance Director on April 2, 2024, at 2:30 p.m., confirmed there was an unsecured Helium tank.





 Plan of Correction - To be completed: 05/21/2024

The Facility has removed the unsecured Helium tank from the storage room on the A/B hallway.
The Recreation Department will be in-serviced by the Administrator/ Designee on the importance of securing Helium tanks when not in use.
The Maintenance Director/ Designee will conduct random audits weekly x3 to ensure there are no unsecured Helium Tanks. Findings will be reported to QAPI x3 months.


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