Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on October 21, 2025, at St. Joseph's Center Scranton, 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
Facility ID#19891100
Component 01
Building 01
Residential Building
Based on a revisit to a Medicaid Recertification Survey completed on October 21, 2025, it was determined that St. Joseph's Center Scranton, was not in compliance with the following requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).
This is a four story, Type III (211), protected, ordinary building, with a basement and two unused attic spaces, that is fully sprinklered.
State plans approved as Impractical.
Plan of Correction:
NFPA 101 STANDARD
Electrical Systems - Essential Electric Syste
Name - MAIN BUILDING 01 Component - 01
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Based on document review and interview, it was determined the facility failed to provide documentation of emergency generator fuel sample quality results, affecting the entire component.
Findings include:
1. Review of documentation on October 21, 2025, between 10:00 am, and 11:15 am, revealed the facility failed to provide documentation, verifying the quality of the emergency fuel reserve, within the previous twelve months.
Exit interview with the Facilities Manager on October 21, 2025, at 1:15 pm, confirmed the lack of documentation.
Based on the revisit, dated 5/6/2026, it was determined the facility lacked documentation to verify the quality of the emergency fuel reserve within the previous twelve month period.
Plan of Correction:The generator fuel sample has been taken by vendor-Cleveland Brothers- we are still waiting for results , we will insure a sample will be taken annually
Initial Comments:
Name - BUILDING 02 Component - 02
Facility ID# 19891100
Component 02
Building 02
Program Building
Based on a revisit to a Medicaid Recertification Survey completed on October 21, 2025, it was determined that St. Joseph's Center Scranton, was in substantial compliance with the requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).
This is a one story, Type V (000), unprotected, wood frame building, that is fully sprinklered.
State plans approved as Impractical.
Plan of Correction:
Initial Comments:
Name - BUILDING 03 Component - 03
Facility ID#19891100
Component 03
Building 03
Pool/Therapy Building
Based on a revisit to a Medicaid Recertification Survey completed on October 21, 2025, it was determined that St. Joseph's Center Scranton, was in substantial compliance with the requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).
This is a two story, Type II (111), protected, noncombustible building, that is fully sprinklered.
State plans approved as Impractical.
Plan of Correction:
Initial Comments:
Name - 04 BUILDING Component - 04
Facility ID#19891100
Component 04
Building 04
Apartments Building
Based on a revisit to a Medicaid Recertification Survey completed on October 21, 2025, it was determined that St. Joseph's Center Scranton, was in substantial compliance with the requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).
This is a two story, Type V (111), protected, wood frame building, that is fully sprinklered.
State plans approved as Impractical.
Plan of Correction:
|