Pennsylvania Department of Health
FRIENDSHIP VILLAGE OF SOUTH HILLS
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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FRIENDSHIP VILLAGE OF SOUTH HILLS - 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 September 24, 2025, at Friendship Village of the South Hills, 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# 320102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on September 24, 2025, it was determined that Friendship Village of the South Hills 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 one-story, Type II (000), unprotected noncombustible building, without a basement, that is fully sprinklered.

Plan of Correction:

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, affecting one of five smoke compartments.

Findings include:

1. Observation on September 24, 2025, at 10:35 a.m., revealed part of the ceiling was cut out in the soiled utility room in Dogwood.

Interview with the Facility Administrator and Director of Maintenance on September 24, 2025, at 1:00 p.m., confirmed the above listed deficiency.

Plan of Correction - To be completed: 10/20/2025

The ceiling in the Dogwood utility room was repaired.
Plant Operations will educate the Maintenance department on maintaining vertical
openings.
Random Audits of Utility areas will be completed by maintenance/designee to ensure
vertical openings are maintained weekly x 4 weeks, then monthly x2. Results will be
reported to QAPI for review.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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.

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on documentation review and interview, it was determined the facility failed to perform the required semi-annual automatic fire alarm system test, affecting the entire facility.

Findings Include:

1. Review of documentation and interview on September 24, 2025, at 9:10 a.m., revealed the facility failed to perform the required semi-annual fire alarm system testing.

Interview with the Facility Administrator and Maintenance Director on September 24, 2025, at 1:00 p.m., confirmed the semi-annual fire alarm system testing deficiency.

Plan of Correction - To be completed: 10/20/2025

A Visual testing of the fire system will be completed by maintenance; Johnson Controls has
been scheduled for testing of the fire alarm on 11/4/25. This testing will be scheduled
annually and semiannually.
Plant operations will educate Maintenance on ensuring the fire alarm testing is scheduled
annually and semiannually. Results will be reported to QAPI for review.

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 observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting one of five smoke compartments.

Findings include:

1. Observation on September 24, 2025, at 11:15 a.m., revealed a dirty/dusty-covered sprinkler head in the Dining/Activity room, which may affect operation of the automatic sprinkler system.

Interview with the Facility Administrator and Maintenance Director on September 24, 2025, at 1:00 p.m., confirmed the automatic sprinkler system deficiency.

Plan of Correction - To be completed: 10/20/2025

The sprinkler head was cleaned for dust and debris.
A comprehensive audit of sprinkler heads was conducted to ensure all sprinkler heads are
free of dust.
Plant Operations will educate the maintenance department on maintaining sprinkler
heads.
Random audits of sprinkler heads to ensure they are free of dust will be completed by
maintenance/designee x4 weeks, then monthly x 2. The results will be reported to QAPI for
review.

NFPA 101 STANDARD Corridor - Doors:

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.

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 corridor doors in one instance, for one of more than 65 corridor doors inspected in the facility.

Findings include:

1. Observation on September 24, 2025, at 9:50 a.m., revealed the door to Resident Room 1, in the Special Care Unit was propped open with a garbage can.

Interview with the Facility Administrator and Maintenance Director on September 24, 2025, at 1:00 p.m.., confirmed the corridor door deficiency.

Plan of Correction - To be completed: 10/20/2025

The garbage can was removed immediately from door, removing impediment.
Plant operations/designee will educate staff on maintaining corridor doors from items
impeding closure
A comprehensive audit of doors was completed to ensure there is no impediment to the
closure of door
Random audits will be conducted by maintenance/designee to ensure corridor doors are
maintained with no impediments to closure weekly x4, then monthly x2. Findings will be
reported to QAPI for review

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