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

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PAVILION AT SAINT LUKE VILLAGE, THE
Inspection Results For:

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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 24, 2024, 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 24, 2024, 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 24, 2024, at 11:00 a.m., 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 24, 2024, at 11:20 a.m., confirmed the building construction deficiency.



 Plan of Correction - To be completed: 08/27/2024

1. The facility has requested a Fire Safety Evaluation System (FSES) inspection for this citation.
2. There is only one requirement for the maximum allowable story height for this type of construction, therefore no additional reviews were needed.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Building Construction Type and Height specific to the maximum allowable story height for this type of construction, and will continue to monitor in accordance with NFPA standards.
4. Any findings will be reported to the monthly QAPI Committee for further review.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain one exit stair tower, affecting three of three floors.

Findings include:

1. Observation on July 24, 2024, at 10:29 a.m., revealed a PPE cart, located within the third floor portion of the B Wing stair tower.

Exit interview with the Executive Director and the Maintenance Director on July 24, 2024, at 11:20 a.m., confirmed the stair tower enclosure deficiency.



 Plan of Correction - To be completed: 08/27/2024

1. The improperly stored PPE cart, noted within the third floor portion of the B Wing stair tower, was removed on-site.
2. Additional stair towers will be reviewed for improper storage.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Stairways and Smokeproof Enclosures specific to maintaining stair towers free of improper storage, and will continue to monitor in accordance with NFPA standards.
4. Any findings will be reported to the monthly QAPI Committee for further review.

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

Based on observation and interview, it was determined the facility failed to maintain two hazardous area enclosure, affecting one of three floors.

Findings include:

1. Observation on July 24, 2024, between 10:33 a.m., and 10:37 a.m., revealed the following:

a. 10:33 a.m., the third floor, Multi-Purpose Room housed combustible materials. The door lacked a self-closing device.
b. 10:37 a.m., the third floor Supply Room door required adjustment to fully latch.

Exit interview with the Executive Director and the Maintenance Director on July 24, 2024, at 11:20 a.m., confirmed the hazardous area enclosure deficiencies.



 Plan of Correction - To be completed: 08/27/2024

1. The combustible materials noted in the Multi-Purpose Room on the third floor were removed, and the third floor Supply Room door was repaired to fully latch.
2. Additional hazard rooms will be reviewed for improper combustible storage and properly latching doors.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Hazardous Areas- Enclosure specific to, and will continue to monitor in accordance with NFPA standards.
4. Any findings will be reported to the monthly QAPI Committee for further review.

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, it was determined the facility failed to maintain the automatic sprinkler system three instances, affecting two of three floors.

Findings include:

1. Observation on July 24, 2024, between 9:42 a.m., and 10:50 a.m., revealed the following:

a. 9:42 a.m., a ceiling tile was missing within the first floor Maintenance Shop.
b. 9:44 a.m., multiple penetrations of the first floor Maintenance Shop ceiling.
c. 10:50 a.m., a missing escutcheon plate, located at the second floor, elevator doors.

Exit interview with the Executive Director and the Maintenance Director on July 24, 2024, at 11:20 a.m., confirmed the automatic sprinkler deficiencies.



 Plan of Correction - To be completed: 08/27/2024

1. The missing ceiling tile noted in the first floor Maintenance Shop was replaced, the penetrations noted in the first floor Maintenance Shop ceiling were properly sealed with a listed and rated fire stopping material, and the missing escutcheon plate noted at the second floor elevator doors was replaced.
2. Additional areas will be reviewed for missing ceiling tiles, improperly sealed penetrations, and missing escutcheon plates.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Sprinkler System- Maintenance and Testing specific to properly maintaining the facility ceiling tiles, barrier penetrations, and escutcheon plates, and will continue to monitor in accordance with NFPA standards.
4. Any findings will be reported to the monthly QAPI Committee for further review.

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, it was determined the facility failed to maintain one set of smoke barrier separation doors, affecting one of three floors.

Findings include:

1. Observation on July 24, 2024, at 10:22 a.m., revealed the third floor, smoke barrier separation doors did not fully close.

Exit interview with the Executive Director and the Maintenance Director on July 24, 2024, at 11:20 a.m., confirmed the smoke barrier separation door deficiency.



 Plan of Correction - To be completed: 08/27/2024

1. The smoke barrier separation doors noted on the third floor were repaired to fully close.
2. Additional smoke barrier separation doors were reviewed for fully closing.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Subdivision of Building Spaces- Smoke Barrier Doors specific to maintaining smoke barrier separation doors to fully close, and will continue to monitor in accordance with NFPA standards.
4. Any findings will be reported to the monthly QAPI Committee for further review.


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