Pennsylvania Department of Health
PAVILION AT SAINT LUKE VILLAGE, THE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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PAVILION AT SAINT LUKE VILLAGE, THE - 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 July 31, 2026, at The Pavilion at Saint Luke Village, 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# 455202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on July 31, 2026, it was determined that The Pavilion at Saint Luke Village 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 three story, Type II (000), unprotected, noncombustible building, 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 three of three floors.

Findings include:

1. Observation on July 31, 2026, between 9:30 am and 12:00 pm revealed the building exceeded the maximum allowable story height for this type of construction by one story.

Exit interview with the Executive Director and the Maintenance Director on July 31, 2026, at 12:30 pm, confirmed the building construction deficiency.

Plan of Correction - To be completed: 08/25/2026

1. Corrective action for the identified deficient practice:
Evaluation of applicable waiver TLW was submitted by the facility, and will not negatively impact resident health and safety.
2. Identification of other areas potentially affected:
The cited condition relates to the construction classification and height of the building as a whole and therefore TLW includes entire facility.
3. Systemic changes to prevent recurrence:
The facility will maintain current documentation regarding the building's construction classification, number of stories, sprinkler protection, and any approved waiver, equivalency, or other regulatory determination within the facility's Life Safety documentation.
4. Monitoring/Quality Assurance:
The Maintenance Director will verify the continued availability and accuracy of the facility's building construction and applicable Life Safety compliance documentation quarterly for two quarters and annually thereafter.

NFPA 101 STANDARD Means of Egress - General:

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.

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined that the facility failed to maintain egress doors at location on one of three floors.

Findings include;

1. Observation on July 31, 2026, at 12:02 pm, revealed the left side exit door near the beauty shop on the 1st floor required excess force to open.

Exit interview with the Executive Director and the Maintenance Director on July 31, 2026, at 12:30 pm, confirmed the door required more than expected force to open.

Plan of Correction - To be completed: 08/25/2026

1. Corrective action for the identified deficient practice:
The left-side exit door near the first-floor beauty shop was inspected and adjusted/repaired by Maintenance to ensure the door opens freely without excessive force and permits unobstructed use of the means of egress.
Following correction, the door was tested to verify proper operation.
2. Identification of other areas potentially affected:
Because other exit doors could potentially be affected by similar conditions, the Maintenance Director/designee completed an audit of facility exit doors on all three floors to verify that doors open appropriately and that the means of egress is maintained for full use.
Any deficient condition identified during the audit was corrected or entered for immediate corrective action.
3. Systemic changes to prevent recurrence:
A monthly Life Safety Exit Door Inspection will be implemented and completed by the Maintenance Director/designee.
Any identified deficiency affecting safe egress will be addressed immediately or appropriate interim safety measures will be implemented until correction is completed.
4. Monitoring/Quality Assurance:
The Executive Director/designee will audit completion of the monthly Life Safety Exit Door Inspection monthly for three months to verify inspections are completed and identified deficiencies are corrected.
Results will be reported to the QAPI Committee. The Committee will determine whether additional monitoring or corrective action is warranted based upon audit results.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined that the facility failed to maintain three hazardous areas on two of three floors.

Findings include:

1. Observation on July 31, 2026, between 11:12 am and 12:11 pm, revealed the following;

a. At 11:12 am, 3rd floor soiled utility room had missing ceiling tile.
b. At 12:06 pm, 1st floor mechanical room, two open penetrations in the wall near the fire alarm panel.
c. At 12:11 pm, 1st floor, Supply room near maintenance office failed to latch in the frame.

Exit interview with the Executive Director and the Maintenance Director on July 31, 2026, at 12:30 pm, confirmed the hazardous area deficiencies.

Plan of Correction - To be completed: 08/25/2026

1. Corrective action for the identified deficient practices:
The facility corrected the three identified hazardous-area deficiencies as follows: The missing ceiling tile in the third-floor soiled utility room was replaced, The two open penetrations in the first-floor mechanical room near the fire alarm panel were properly sealed using an appropriate fire/smoke-rated penetration system consistent with the required barrier assembly and The first-floor supply room door near the Maintenance office was adjusted/repaired to ensure the door properly closes and latches within the frame.
Following correction, the Maintenance Director/designee inspected each location to verify the identified condition was corrected.
2. Identification of other areas potentially affected:
The Maintenance Director/designee completed an audit of facility hazardous areas on all three floors, including soiled utility rooms, mechanical rooms, storage areas, and other applicable hazardous areas.
Any identified deficiency was corrected or placed into immediate corrective action.
3. Systemic changes to prevent recurrence:
The facility will implement a monthly Hazardous Area Life Safety Inspection.
The Maintenance Director/designee will inspect designated hazardous areas for continued integrity of required enclosures, including ceilings, walls, penetrations, doors, frames, closing devices, and latching hardware.
Maintenance staff will also be educated that any work creating or exposing a penetration in a rated or smoke-resisting assembly must be appropriately repaired/sealed following completion of the work.
4. Monitoring/Quality Assurance:
The Executive Director/designee will audit five hazardous areas monthly for three months to verify enclosure integrity and compliance with the facility's inspection process.
Audit findings will be reported to the QAPI Committee. Identified deficiencies will be corrected, and the Committee will determine whether additional monitoring is warranted.

NFPA 101 STANDARD Corridor - Doors:

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 that the facility failed to maintain one corridor door on one of three floors.

Findings include;

1. Observation on July 31, 2026, at 11:22 am, revealed the door to room 322 on the 3rd floor failed to latch in the frame when tested.

Exit interview with the Executive Director and the Maintenance Director on July 31, 2026, at 12:30 pm, confirmed the door lacked positive latching.

Plan of Correction - To be completed: 08/25/2026

1. Corrective action for the identified deficient practice:
The door to Room 322 was inspected and adjusted/repaired to ensure the door closes and positively latches within the frame.
Following correction, the door was tested by the Maintenance Director/designee to verify proper closure and positive latching.
2. Identification of other areas potentially affected:
Because other corridor doors could potentially be affected by similar conditions, Maintenance completed an audit of resident room and other applicable corridor doors throughout the facility to verify that doors close appropriately and positively latch within their frames.
Any deficient doors identified during the audit were adjusted/repaired.
3. Systemic changes to prevent recurrence:
Maintenance will conduct a monthly corridor door inspection.
Staff will be educated to submit a Maintenance request when a resident room or other corridor door is observed not closing or latching appropriately.
4. Monitoring/Quality Assurance:
The Executive Director/designee will randomly audit 10 corridor doors monthly for three months to verify proper closure and positive latching.
Results will be reported to the QAPI Committee. Any deficient condition will be corrected, and patterns or recurring concerns will result in additional corrective action and/or continued monitoring as determined by the Committee.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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, it was determined that the facility failed to maintain smoke barrier doors on one of three floors.

Findings include:
1. Observation on July 31, 2026, at 11:41 am, revealed the smoke barrier doors near room 209 on the second floor had a gap in excess of the required tolerance of 1/8 of an inch.

Exit interview with the Executive Director and the Maintenance Director on July 31, 2026, at 12:30 pm, confirmed the gap between the doors exceeded acceptable tolerance.

Plan of Correction - To be completed: 08/25/2026

1. Corrective action for the identified deficient practice:
The smoke barrier doors near Room 209 were inspected and adjusted/repaired to correct the excessive gap and restore the door assembly to the required tolerance.
Following correction, the Maintenance Director/designee verified the gap was within acceptable tolerance and the smoke barrier doors operated appropriately.
2. Identification of other areas potentially affected:
The Maintenance Director/designee completed an audit of smoke barrier door assemblies throughout the facility.
Any deficient condition identified was corrected or entered for immediate corrective action.
3. Systemic changes to prevent recurrence:
Smoke barrier door assemblies will be incorporated into the facility's monthly Life Safety inspection process.
The Maintenance Director/designee will inspect smoke barrier doors for proper alignment, acceptable clearances/gaps, closure, physical integrity, and proper operation.
A measuring device appropriate for verifying door clearances will be maintained by the Maintenance Department and utilized when a gap appears questionable.
4. Monitoring/Quality Assurance:
The Executive Director/designee will audit smoke barrier door assemblies monthly for three months to verify continued compliance.
Results will be reported to the QAPI Committee. Any deficient findings will receive corrective action, and the Committee will determine whether additional monitoring is warranted.

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