Pennsylvania Department of Health
SURGERY CENTER AT CRANBERRY, THE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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SURGERY CENTER AT CRANBERRY, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID #16591501
Component 01
Main Building

Based on a Relicensure Survey completed on August 28, 2024, it was determined that The Surgery Center at Cranberry was not in compliance with the following requirements of the Life Safety Code for an existing ambulatory health care occupancy.

This is a two-story, Type II (000), unprotected, non-combustible building, that is fully sprinklered.

Plan of Correction:

28 Pa. Code § 569.2 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 document review and interview, the facility failed to meet sprinkler system requirements for one of two sprinkler systems.

Findings include:

Document review on August 28, 2024, at 10:00 a.m., revealed the facility failed to provide documentation for a recent three-year full flow trip test.

Interview with the administrator on August 28, 2024, at 10:00 a.m., confirmed the sprinkler system deficiency.

Plan of Correction - To be completed: 09/06/2024

The full flow trip test will be performed every three years. A contractor (S.A. Comunale) has been secured to perform a three-year full flow trip test. This test is scheduled for 9/6/2024.

A maintenance checklist will list "3 year Full Flow Trip Test". This checklist will be reviewed by the Facility Administrator monthly. A report will be addressed with the QA committee at the quarterly QA meeting.

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