Pennsylvania Department of Health
ST. JOSEPH'S MANOR (A D/B/A ENTITY OF HRHS)
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ST. JOSEPH'S MANOR (A D/B/A ENTITY OF HRHS)
Inspection Results For:

There are  59 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.
ST. JOSEPH'S MANOR (A D/B/A ENTITY OF HRHS) - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: BUILDING 01 (1936 BUILDING) - Component: 01 - Tag: 0000


Facility ID# 451002
Component 01
1936 Building

Based on a Medicare/Medicaid Recertification Survey completed on February 21, 2024, it was determined that St. Joseph's Manor - 1936 Building was not in compliance with the following requirements of the Life Safety Code for an existing 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 four-story, Type III (211), protected ordinary building, with unused attic spaces, 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: BUILDING 01 (1936 BUILDING) - Component: 01 - Tag: 0161

Based on document review, observation, and interview, it was determined the facility failed to maintain building construction requirements, affecting six of six smoke compartments within this component.

Findings include:

Document review and observation on February 21, 2024, between 8:30 a.m. and 11:00 a.m., revealed this component was a four-story building, Type III (211), protected ordinary construction. The story height exceeds the maximum allowed for this construction type.

Exit interview with the Director of Facilities on February 21, 2024, at 12:15 p.m., confirmed the building construction and height.





 Plan of Correction - To be completed: 04/15/2024

The facility is in agreement with the deficiency of the (building construction/building story height deficiency). An FSES to cover this deficiency was completed by our Director of Engineering & Maintenance who carries a CHFM designation from AHA.
NFPA 101 STANDARD Vertical Openings - Enclosure: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.
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: BUILDING 01 (1936 BUILDING) - Component: 01 - Tag: 0311

Based on observation, document review, and interview, it was determined the facility failed to maintain the required fire resistive rating of stairways, affecting four of six smoke compartments within this component.

Findings include:

1. Observation and interview on February 21, 2024, between 8:30 a.m. and 11:00 a.m., revealed the stair tower enclosures lacked the required fire resistive integrity due to non-rated door hardware, sheet metal plates within the lower portion of door assemblies, excessively sized wired glass openings in the communicating stairway, and lack of fire resistive labeling on doors and door frame assemblies.

Exit interview with the Director of Facilities on February 21, 2024, at 12:15 p.m., confirmed the exit stairways lacked the fire resistive rated construction.

2. Observation on February 21, 2024, at 9:40 a.m., revealed, on the fourth floor at the PC Specialist Office, the rated access door to the mechanical shaft failed to self-close and latch when tested.

Exit interview with the Director of Facilities on February 21, 2024, at 12:15 p.m., confirmed the shaft door deficiency.











 Plan of Correction - To be completed: 04/15/2024

# 1
The facility is in agreement with the deficiency of the (stair tower enclosures lack fire resistive integrity due to non-rated door hardware, sheet metal plates within the lower portion door assemblies, excessive sized wired glass openings, and lack of fire resistive labeling on both doors and door frame assemblies). An FSES to cover this deficiency was completed by our Director of Engineering & Maintenance who carries a CHFM designation from AHA.

#2 The shaft door has been adjusted to insure proper closing and latching operation. We will monitor for these conditions on this and all other shaft doors during our monthly environmental rounds to insure continued compliance. The Director of Maintenance will be responsible for maintaining compliance of this inspection.

NFPA 101 STANDARD Smoke Detection: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.
Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2
Observations:
Name: BUILDING 01 (1936 BUILDING) - Component: 01 - Tag: 0347

Based upon observation and interview, it was determined the facility failed to maintain smoke detectors, affecting one of four levels.

Findings include:

Observation on February 21, 2024, at 10:30 a.m., revealed, a smoke detector detached from its housing, on the first floor, at IT department closet.

Exit interview with the Director of Facilities on February 21, 2024, at 12:15 p.m., confirmed the detached smoke detector.




 Plan of Correction - To be completed: 04/15/2024

The smoke detector will be re-attached to its base to insure proper operation. We will continue to inspect for these conditions on our monthly environmental rounds for compliance. The Director of Maintenance will be responsible for maintaining compliance of this inspection.
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: BUILDING 01 (1936 BUILDING) - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain sprinkler system components, affecting one of four levels.

Observation on February 21, 2024, at 10:20 a.m., revealed, on the first floor, in the soiled utility room, the sprinkler was recessed into the ceiling tile, which could obstruct the spray pattern of the sprinkler.

Exit interview with the Director of Facilities on February 21, 2024, at 12:15 p.m., confirmed the obstructed sprinkler.




 Plan of Correction - To be completed: 04/15/2024

The sprinkler head will be adjusted to properly align with the Plane of the ceiling to meet Code compliance. Staff will be instructed to inspect the sprinkler heads for mis-alignment and to report it to the Maintenance department for resolution. We will monitor for these conditions during our monthly environmental rounds for compliance. The Director of Maintenance will be responsible for maintaining compliance of this inspection.
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: BUILDING 01 (1936 BUILDING) - Component: 01 - Tag: 0911

Based on observation and interview, it was determined that the facility failed to ensure that junction boxes were properly sealed within this facility, affecting 1 of 3 levels.

Findings include:

Observation made on February 21, 11:04 a.m., revealed an open junction box above the ceiling, outside of the smoke doors in the center hallway.

Exit interview with the Director of Facilities on February 21, 2024, at 12:15 p.m., confirmed the open junction box.







 Plan of Correction - To be completed: 04/15/2024

The missing plate was installed. Staff will be educated in meeting proper code compliance for this deficiency and documented. We will monitor for these conditions during our monthly environmental rounds for compliance. The Director of Maintenance will be responsible for maintaining compliance of this inspection.
Initial comments:Name: BUILDING 02 (1976 BUILDING) - Component: 02 - Tag: 0000


Facility ID# 451002
Component 02
1976 Building

Based on a Medicare/Medicaid Recertification Survey completed on February 21, 2024, it was determined that St. Joseph's Manor - 1976 Building was not in compliance with the following requirements of the Life Safety Code for an existing 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 four-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.




 Plan of Correction:


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: BUILDING 02 (1976 BUILDING) - Component: 02 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain that fire barrier walls were free of unsealed penetrations, affecting 1 of 4 zones within the component.

Findings include:

Observation made on February 21, 2024, at 9:40 a.m., on the second floor, revealed an unsealed wall penetration around electrical cables above the fire barrier double doors, in the corridor between buildings 36 and 76, above the ceiling.

Exit interview with the Director of Facilities on February 21, 2024, at 12:15 p.m., confirmed the open penetration.









 Plan of Correction - To be completed: 04/15/2024

The penetration will be sealed with a UL approved through penetration fire stop system (Hilti figure # W-L-1464 to maintain the fire and smoke resistance rating of the wall. Maintenance staff and the contractors involved will be re-educated on the proper procedure for sealing all fire/smoke rated penetrations and documented. Construction / renovation projects will be monitored on a continual basis for compliance also. Holy Redeemer Health System has implemented a Fire & Smoke Barrier Penetration Policy in 2012 that provides a comprehensive means of verifying that above ceiling work within Holy Redeemer Health System is accomplished in accordance with applicable building codes, standards, and related hospital policies. This policy applies to any work done in the buildings owned and or rented by the Holy Redeemer Health System. Permit forms are available in the Engineering & Maintenance office. All Smoke and Fire barriers will be inspected Quarterly for compliance as part of our preventative maintenance program and policy. The Director of Maintenance will be responsible for maintaining compliance of this inspection
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: BUILDING 02 (1976 BUILDING) - Component: 02 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain the resistance of smoke barrier doors, affecting 2 of 4 levels in the facility.

Findings include:

1. Observation on February 21, 2024, at 9:45 a.m., revealed on the fourth floor of the 76 building, the hatch door in the P.C. Sales office is missing a self closing latch.
2. Observation on February 21, 2024, at 10:15 a.m., revealed on the second floor of the 76 building, smoke doors in the hallway outside room 2603 not positively latching.

Exit interview with the Director of Facilities on February 21, 2024, at 12:15 p.m., confirmed the doors failed to positively latch.





 Plan of Correction - To be completed: 04/15/2024

#1 The shaft door will be adjusted to insure proper closing and latching operation. We will monitor for these conditions during our monthly environmental rounds for compliance. The Director of Maintenance will be responsible for maintaining compliance of this inspection.

#2 The doors and door hardware will be adjusted so the door will positively latch into the frame and maintain a gap of less than " to maintain a smoke tight compartment. We will continue to inspect for these conditions on our monthly environmental rounds for compliance. The Director of Maintenance will be responsible for maintaining compliance of this inspection.
NFPA 101 STANDARD HVAC: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.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: BUILDING 02 (1976 BUILDING) - Component: 02 - Tag: 0521

Based on document review and interview, it was determined the facility failed to maintain Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting three of five levels.

Findings include:

Document review on February 21, 2024, at 9:30 a.m., revealed six deficient dampers on the August 2023, fire damper inspection report. Documentation of subsequent repairs was not available at time of survey.

Exit interview with the Director of Facilities on February 21, 2024, at 12:15 p.m., confirmed the missing documentation.





 Plan of Correction - To be completed: 04/15/2024

The fire and Smoke damper was completed, but due to a delay in getting required parts to repair several identified deficiencies, at the time of inspection the repairs had not been completed although the work has been assigned and Purchase Orders have been issued. The work was scheduled for the week of 3/4/24. We will continue to inspect for these conditions on our monthly environmental rounds for compliance. The Director of Maintenance will be responsible for maintaining compliance of this inspection.
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: BUILDING 02 (1976 BUILDING) - Component: 02 - Tag: 0911

Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting one of five levels.

Findings include:

Observation on February 21, 2024, at 11:45 a.m., revealed in basement laundry sorting room, a duplex receptacle with a broken ground pole.

Exit interview with the Director of Facilities on February 21, 2024, at 12:15 p.m., confirmed the damaged receptacle.

~Refer to NFPA 70, National Electric Code, and NFPA 99, 6.3.2.1.





 Plan of Correction - To be completed: 04/15/2024

The broken receptacle will be replaced. We will monitor for these conditions during our monthly environmental rounds and during all future construction projects for Code compliance. The Director of Maintenance will be responsible for maintaining compliance of this inspection.
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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 - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: BUILDING 02 (1976 BUILDING) - Component: 02 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of electrical devices affecting one of five levels.

Findings include:

Observations on February 21, 2024, revealed the following electrical deficiencies:

a. 11:30 a.m., basement HVAC shop, microwave into surge protector.
b. 11:32 a.m., basement HVAC shop, extension cord powering a microwave.

Exit interview with the Director of Facilities on February 21, 2024, at 12:15 p.m., confirmed the unauthorized electrical devices.




 Plan of Correction - To be completed: 04/15/2024

1a The extension cord was immediately removed and the equipment was removed. Staff/contractors will be educated on the proper use of extension cords. We will monitor for these conditions during our monthly environmental rounds for compliance. The Director of Maintenance will be responsible for maintaining compliance of this inspection.

1b The cord was immediately removed and plugged directly into a receptacle . Staff/contractors will be educated on the proper use of surge protectors. We will monitor for these conditions during our monthly environmental rounds for compliance. The Director of Maintenance will be responsible for maintaining compliance of this inspection.
Initial comments:Name: BUILDING 03 (1998 BRIDGE LINK BUILDING) - Component: 03 - Tag: 0000


Facility ID# 451002
Component 03
Bridge Link Building

Based on a Medicare/Medicaid Recertification Survey completed on February 21, 2024, it was determined that St. Joseph's Manor - Bridge Link Building was not in compliance with the following requirements of the Life Safety Code for an existing 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 four-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.





 Plan of Correction:


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: BUILDING 03 (1998 BRIDGE LINK BUILDING) - Component: 03 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of stairwell, affecting one of five levels in the facility.

Findings include:

Observation on February 21, 2024, at 9:51 a.m., revealed, in the exit stairwell in the back of the basement Electric Substation, storage under the stairs.

Exit interview with the Director of Facilities on February 21, 2024, at 12:15 p.m., confirmed the storage under the stairs.





 Plan of Correction - To be completed: 04/15/2024

The storage was immediately removed. Staff will be educated on the code compliance of not storing anything in exit stairwells and documented. We will monitor for these conditions during our monthly environmental rounds for compliance. The Director of Maintenance will be responsible for maintaining compliance of this inspection.

NFPA 101 STANDARD Hazardous Areas - 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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: BUILDING 03 (1998 BRIDGE LINK BUILDING) - Component: 03 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of hazardous area enclosures, affecting one of five level in the facility.

Findings include:

Observation on February 21, 2024, between 9:45 a.m. and 9:48 a.m., revealed, in the basement, open penetrations in the following locations:

a. 9:45 a.m., Electrical Storage Room, by data wires to the right of the door into the room;
b. 9:48 a.m., Data Closet, by a return duct above the door to the room.

Exit interview with the Director of Facilities on February 21, 2024, at 12:15 p.m., confirmed the open penetrations.





 Plan of Correction - To be completed: 04/15/2024

# 1a, 1b
The penetrations will both be sealed with a UL approved through penetration fire stop system (Hilti figure # W-L-1464 to maintain the fire and smoke resistance rating of the wall. Maintenance staff and the contractors involved will be re-educated on the proper procedure for sealing all fire/smoke rated penetrations and documented. Construction / renovation projects will be monitored on a continual basis for compliance also. Holy Redeemer Health System has implemented a Fire & Smoke Barrier Penetration Policy in 2012 that provides a comprehensive means of verifying that above ceiling work within Holy Redeemer Health System is accomplished in accordance with applicable building codes, standards, and related hospital policies. This policy applies to any work done in the buildings owned and or rented by the Holy Redeemer Health System. Permit forms are available in the Engineering & Maintenance office. All Smoke and Fire barriers will be inspected Quarterly for compliance as part of our preventative maintenance program and policy. The Director of Maintenance will be responsible for maintaining compliance of this inspection

NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: BUILDING 03 (1998 BRIDGE LINK BUILDING) - Component: 03 - Tag: 0324

Based on observation and interview, it was determined the facility failed to maintain kitchen hood suppression systems, affecting one of five levels in the facility.

Findings include:

Observation on February 21, 2024, at 9:34 a.m., revealed, in the basement kitchen, the kitchen hood suppression system next to the steam table was missing monthly inspections.

Exit interview with the Director of Facilities on February 21, 2024, at 12:15 p.m., confirmed the missing monthly inspections.



 Plan of Correction - To be completed: 04/15/2024

The monthly checks are completed during the Fire Extinguisher inspection rounds. Staff responsible for this inspection will be trained to insure this is also being signed off. We will monitor the reports for these conditions during our quarterly compliance reviews. The Director of Maintenance will be responsible for maintaining compliance of this inspection.
NFPA 101 STANDARD Portable Fire Extinguishers: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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: BUILDING 03 (1998 BRIDGE LINK BUILDING) - Component: 03 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers, affecting one of five levels in the facility.

Findings include:

Observation on February 21, 2024, at 9:39 a.m., revealed, in the basement Mechanical Room, the portable fire extinguisher was blocked by a tool cart.

Exit interview with the Director of Facilities on February 21, 2024, at 12:15 p.m., confirmed the blocked portable fire extinguisher.




 Plan of Correction - To be completed: 04/15/2024

The cart was removed during survey and staff will be educated on the importance of not blocking fire safety features of the building. We will monitor for these conditions during our monthly environmental rounds for compliance. The Director of Maintenance will be responsible for maintaining compliance of this inspection.
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: BUILDING 03 (1998 BRIDGE LINK BUILDING) - Component: 03 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain the resistance of smoke barrier doors, affecting one of five levels in the facility.

Findings include:

Observation on February 21, 2024, at 10:32 a.m., revealed, on the second floor, the smoke barrier doors next to resident room 2527 failed to close together.

Exit interview with the Director of Facilities on February 21, 2024, at 12:15 p.m., confirmed the doors failed to close together.




 Plan of Correction - To be completed: 04/15/2024

The doors and door hardware will be adjusted so the door will positively latch into the frame and maintain a gap of less than " to maintain a smoke tight compartment. We will continue to inspect for these conditions on our monthly environmental rounds for compliance. The Director of Maintenance will be responsible for maintaining compliance of this inspection.
NFPA 101 STANDARD Utilities - Gas and Electric: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.
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2




Observations:
Name: BUILDING 03 (1998 BRIDGE LINK BUILDING) - Component: 03 - Tag: 0511

Based on observation, the facility failed to comply with NFPA 70, National Electric Code, for the electrical wiring and equipment affecting one of five levels in the facility.

Findings include:

Observation on February 21, 2024, at 10:28 a.m., revealed, in the basement, an open junction box above the near resident room 2530.

Exit interview with the Director of Facilities on February 21, 2024, at 12:15 p.m., confirmed the open junction box.





 Plan of Correction - To be completed: 04/15/2024

A junction box cover will be installed and properly secured to meet code compliance and maintenance staff will be educated on proper code compliance of this deficiency and documented. We will monitor for these conditions during our monthly environmental rounds and during all future construction projects for Code compliance. The Director of Maintenance will be responsible for maintaining compliance of this inspection.

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