Pennsylvania Department of Health
BRETHREN VILLAGE
Building Inspection Results

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BRETHREN VILLAGE
Inspection Results For:

There are  29 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
BRETHREN VILLAGE - 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 February 6, 2024, at Brethren Village, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: NEW BUILDING - Component: 04 - Tag: 0000


Facility ID #282602
Component 04
New Building

Based on a Medicare/Medicaid Recertification Survey completed on February 6, 2024, it was determined that Brethren 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 (111), protected noncombustible structure, 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: NEW BUILDING - Component: 04 - Tag: 0353
Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler protection system in a continuously reliable operating condition, affecting one of seven smoke compartments within the component.

Findings include:

1. Observation on February 6, 2024, at 11:44 AM, revealed the thermal vial of the sprinkler head protecting the 2nd floor Medical Suite Mechanical Room was wrapped in protective shipping material.

Interview with the Vice President of Facilities on February 6, 2024, at 11:44 AM, confirmed the sprinkler head was encased in protective material.




 Plan of Correction - To be completed: 02/19/2024

Commonwealth Fire Protection contacted, came onsite and removed protective shipping material from sprinkler head.

Commonwealth Fire Protection performed annual inspection of all sprinkler heads and noted no issues.

Results reported to QAPI.
NFPA 101 STANDARD Corridor - Doors: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.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Name: NEW BUILDING - Component: 04 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain the positive latching of corridor doors, affecting one of seven smoke compartments within the component.

Findings include:

1. Observation on February 6, 2024, at 12:15 PM, revealed the door to the 1st floor Elevator Machine Room failed to positively latch within the door frame due to an obstruction placed over the strike plate.

Interview with the Vice President of Facilities on February 6, 2024, at 12:15 PM, confirmed the corridor door did not positively latch within the door frame.


 Plan of Correction - To be completed: 03/18/2024

Obstruction over strike plate removed.

Education provided to Elevator Maintenance Company regarding not using obstructions on door strike plates

Audit of all corridor doors x 4 weeks.

Results to be reported to QAPI

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