Pennsylvania Department of Health
THORNWALD HOME
Building Inspection Results

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THORNWALD HOME
Inspection Results For:

There are  46 surveys for this facility. Please select a date to view the survey results.

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THORNWALD HOME - 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 January 29, 2024, at Thornwald Home, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000


Facility ID #082802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 29, 2024, it was determined that Thornwald Home 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 one-story, Type II (000), unprotected noncombustible structure, with a basement, which is fully sprinklered.



 Plan of Correction:


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 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler piping system to be free of extraneous weight, affecting two of nine smoke compartments within the component.

Findings include:

1. Observation on January 29, 2024, between 11:30 AM and 11:45 AM, revealed items were being supported by the sprinkler piping system, at the following locations:

a. 11:30 AM, Main Corridor, above ceiling, by Service Hall, various wires, insulated pipes and pull lines;
b. 11:40 AM, Main Corridor, above ceiling, by Therapy, flex conduit and wires;
c. 11:45 AM, F Hall, above ceiling, by smoke doors, various rigid pipes and wires.

Interview at the time of the exit conference with the Administrator and Director of Environmental Services on January 29, 2024, at 1:45 PM, confirmed various items laying across sprinkler pipes.


 Plan of Correction - To be completed: 03/29/2024

The facility is bringing in its contracted construction partner to perform a survey and remediation of items laying on or touching/adding weight to the sprinkler system lines. Removal of said wires and items will be performed in the areas of the main corridor and the F hallway. This procedure will also be incorporated for the building as part of the HVAC renovation already in progress.

The facilities maintenance program will conduct quarterly inspections/audits throughout the building. Inspections and audits discrepancies will be reported to the QAPI committee for review and recommendation.


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