Pennsylvania Department of Health
WHITEHALL BOROUGH POST ACUTE
Building Inspection Results

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WHITEHALL BOROUGH POST ACUTE
Inspection Results For:

There are  40 surveys for this facility. Please select a date to view the survey results.

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WHITEHALL BOROUGH POST ACUTE - 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 May 7, 2025, at Whitehall Borough Post Acute, 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 - Tag: 0000

Facility ID# 10230200
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 7, 2025, it was determined that Whitehall Borough Post Acute 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 two-story, Type II (111), protected non-combustible building, without a basement, that is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in one instance, affecting two of eleven smoke compartments.

Findings include:

1. Observation on May 7, 2025, at 10:30 a.m., revealed the smoke barrier in the Medbridge B hallway, had an gap exceeding 1/8 " between the meeting edges of the doors, which would not resist the passage of smoke.

Interview with the Facility Administrator and Maintenance Director on May 7, 2025, at 1:00 p.m., confirmed the smoke barrier doors had an excessive gap that would not resist the passage of smoke.







 Plan of Correction - To be completed: 06/03/2025

A compliant smoke-rated strip will be installed on the smoke barrier doors in the Medbridge B hallway on June 3, 2025, to eliminate the gap exceeding 1/8 inch between the meeting edges. This correction will ensure the doors resist the passage of smoke in accordance with NFPA 101. The Maintenance Director is responsible for overseeing the installation. To prevent recurrence, the Maintenance Department will conduct and document monthly inspections of all smoke barrier doors. Any identified gaps or deficiencies will be promptly corrected to maintain life safety compliance.

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