Pennsylvania Department of Health
LINDEN HALL
Building Inspection Results

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LINDEN HALL
Inspection Results For:

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LINDEN HALL - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000


Facility ID #908002
Component 01
Main Building

Based on a Relicensure Survey completed on April 29, 2025, it was determined that Linden Hall was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a one-story, Type II (000), unprotected noncombustible structure, with a partial basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:State only Deficiency.
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 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain hardware components of the automatic sprinkler protection system, affecting the entire component.

Findings include:

1. Observation on April 29, 2025, at 9:55 AM, revealed the sprinkler head protecting Resident Room 9, by the window, lacked an escutcheon.

Interview with the Building Systems Manager on April 29, 2025, at 9:55 AM, confirmed the sprinkler head lacked an escutcheon.



 Plan of Correction - To be completed: 05/29/2025

An escutcheon was installed on the sprinkler head in Room 9 by the window and a full house inspection will be done to determine if any other escutcheons are missing from sprinkler heads.

Monthly rounds will take place by the Director of Facilities/designee to ensure sprinkler heads have escutcheons. Results of the rounds will be reported to the Quality Assurance Performance Improvement Committee by the Director of Facilities/designee for review and further recommendation.


NFPA 101 STANDARD Portable Fire Extinguishers:State only Deficiency.
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: MAIN BUILDING - Component: 01 - Tag: 0355

Based on document review and interview, it was determined the facility failed to provide documentation verifying portable fire extinguishers had been subjected to monthly visual inspections, affecting the entire component.

Findings include:

1. Review of documentation on April 29, 2025, at 10:30 AM, revealed the facility lacked documentation verifying the basement fire extinguisher had been inspected since October, 2024.

Interview with the Building Systems Manager on April 29, 2025, at 10:30 AM, confirmed the lack of documentation verifying the portable fire extinguisher had been inspected, monthly, within the previous twelve months.



 Plan of Correction - To be completed: 05/29/2025

The basement fire extinguisher was inspected and verifying documentation recorded. A full house inspection will be done to verify documentation is in place that all fire extinguishers have been inspected monthly.

Monthly rounds will take place by the Director of Facilities/designee to verify monthly documented inspection of portable fire extinguishers has occurred. Results of the monthly rounds will be reported to the Quality Assurance Performance Improvement Committee for review and further recommendation.


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