Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on February 26, 2026, at St. Joseph's Center Swoyersville, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.
Plan of Correction:
Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID# 45581100
Component 01
Main Building
Based on a Medicaid Recertification Survey completed on February 26, 2026, it was determined that St. Joseph's Center Swoyersville 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 one story, Type V (000), unprotected wood frame building, that is fully sprinklered.
State plans approved as Impractical.
Plan of Correction:
NFPA 101 STANDARD
General Requirements - Other
Name - MAIN BUILDING 01 Component - 01
General Requirements - Other
2012 EXISTING
List in the REMARKS section any LSC Section 33.1 or 33.2 General 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.
Observations:
Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers, affecting two of two floors.
Findings include:
1. Observation on February 26, 2026, at 10:33 a.m., revealed portable fire extinguishers were checked on a quarterly basis, and not monthly, as required.
Exit interview on February 26, 2026, between 10:55 a.m., and 11:00 a.m., with the Facilities Manager, confirmed the portable fire extinguisher deficiencies.
Plan of Correction:the extinguishers going forward will be checked by maintenance staff monthly.documentation will be provided
NFPA 101 STANDARD
Building Construction Type and Height
Name - MAIN BUILDING 01 Component - 01
Building Construction Type and Height
2012 EXISTING (Prompt)
In Prompt Evacuation Capability facilities, there are no construction requirements.
Observations:
Based on observation and interview, it was determined the facility failed to maintain building construction requirements in one location, affecting one of two floors.
Findings include:
1. Observation on February 26, 2026, at 10:43 a.m., revealed a penetration of the monolithic portion of the ceiling assembly, located within the rear bedroom.
Exit interview on February 26, 2026, between 10:55 a.m., and 11:00 a.m., with the Facilities Manager, confirmed the building construction deficiency.
Plan of Correction:the penetration has been repaired and secured with new fasteners.Staff will be checking these rooms on a mothly basis
NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing
Name - MAIN BUILDING 01 Component - 01
Sprinkler System - Maintenance and Testing
2012 EXISTING (Prompt)
NFPA 13 and 13R Systems
All sprinkler systems installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, and NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies Up To and Including Four Stories in Height, are inspected, tested and maintained in accordance with NFPA 25, Standard for Inspection, Testing and Maintenance of Water Based Fire Protection System.
NFPA 13D Systems
Sprinkler systems installed in accordance with NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, are inspected, tested and maintained in accordance with the following requirements of NFPA 25:
1. Control valves inspected monthly (NFPA 25, section 13.3.2).
2. Gauges inspected monthly (NFPA 25, section 13.2.71).
3. Alarm devices inspected quarterly (NFPA 25, section 5.2.6).
4. Alarm devices tested semiannually (NFPA 25, section 5.3.3).
5. Valve supervisory switches tested semiannually (NFPA 25, section 13.3.3.5).
6. Visible sprinklers inspected annually ((NFPA 25, section 5.2.1).
7. Visible pipe inspected annually (NFPA 25, section 5.2.2).
8. Visible pipe hangers inspected annually (NFPA 25, section 5.2.3).
9. Buildings inspected annually prior to freezing weather for adequate heat for water filled piping (NFPA 25, section 5.2.5).
10. A representative sample of fast response sprinklers are tested at 20 years (NFPA 25, section 5.3.1.1.1.2).
11. A representative sample of dry pendant sprinklers are tested at 10 years (NFPA 25, section 5.3.1.1.15).
12. Antifreeze solutions are tested annually (NFPA 25, section 5.3.4).
13. Control valves are operated through their full range and returned to normal annually (NFPA 25, section 13.3.3.1).
14. Operating stems of OS&Y valves are lubricated annually (NFPA 25, section 13.3.4).
15. Dry pipe systems extending into unheated portions of the building are inspected, tested and maintained (NFPA 25, section 13.4.4).
A. Date sprinkler system last checked and necessary maintenance provided. __________________________
B. Show who provided the service. _________________________
C. Note the source of the water supply for the automatic sprinkler system. __________________________________
(Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.)
33.2.3.5.3, 33.2.3.5.8, 9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Based on documentation review, observation, and interview, it was determined the facility failed to maintain the automatic sprinkler system, affecting two of two floors.
Findings include:
1. Observation on February 26, 2026, between 10:20 a.m., and 10:42 a.m., revealed the following:
a. 10:20 a.m.-10:24 a.m., automatic sprinkler system documentation lacked evidence of annual dry system trip test, a three year, full flow trip test, five year, internal valve inspection and five year, internal pipe inspection.
b. 10:42 a.m., a loaded sprinkler head assembly, located within the rear bedroom.
Exit interview on February 26, 2026, between 10:55 a.m., and 11:00 a.m., with the Facilities Manager, confirmed the automatic sprinkler system deficiencies.
Plan of Correction:our vendor is scheduled to do the 5 year pipe inspection this week ,also due to a new computer system they were using ,the annual dump test was done ,but was not documented. as soon as i get the updated documents.they will be availible shortly. this will be monitored closley weekly and monthly
NFPA 101 STANDARD
Building Services - Other
Name - MAIN BUILDING 01 Component - 01
Building Services - Other
List in the REMARKS section any LSC Section 32.2.5 and 33.2.5 Building Services 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.
Observations:
Based on documentation review, observation, and interview, it was determined the facility failed to maintain building services in several instances, affecting two of two floors.
Findings include:
1. Observation on February 26, 2026, between 10:10 a.m., and 10:14 a.m., revealed the following generator set deficiencies:
a. 10:10 a.m., a natural gas reliability letter.
b. 10:11 a.m., evidence of weekly inspection data.
c. 10:12 a.m., weekly battery voltage data.
d. 10:13 a.m., a record of monthly load testing data with respect to the generator sets' hour meter.
e. 10:14 a.m., three-year, four hour load testing data.
Exit interview on February 26, 2026, between 10:55 a.m., and 11:00 a.m., with the Facilities Manager, confirmed the generator set deficiencies.
Plan of Correction:the required document for the natural gas supplier has been obtained and a copy has been sent to the proper addresses.
a hard hard copy has also been placed in the fire manual at the properties
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