Pennsylvania Department of Health
INN AT FREEDOM VILLAGE, THE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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INN AT FREEDOM VILLAGE, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Facility ID #105502
Component 01
Main Building

Based on a Relicensure Survey completed on November 4, 2025, it was determined that The Inn at Freedom Village was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a two-story, Type II (222), fire resistive structure, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided S-tags, but are deficient.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0100

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on document review, observation and interview, it was determined the facility failed to meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component.

Findings include:

1. Review of documentation on November 4, 2025, between 9:00 AM and 10:30 AM, revealed the facility lacked documentation, verifying the testing and inspection of installed Carbon Monoxide Alarms, per manufacture's instructions.

Interview at the time of the exit conference with the Administrator and Maintenance Director on November 4, 2025, at 2:00 PM, confirmed the lack of documentation for the installed alarms.

2. Observation and interview on November 4, 2025, between 9:00 AM and 10:30 AM, revealed the facility could not verify Carbon Monoxide Alarms could be heard by staff on duty, in accordance with the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act.

Interview at the time of the exit conference with the Administrator and Maintenance Director on November 4, 2025, at 2:00 PM, confirmed the facility could not verify Carbon Monoxide Alarms could be heard by staff on duty.

3. Review of documentation, observation and interview on November 4, 2025, between 9:00 AM and 10:30 AM, revealed the facility could not verify Carbon Monoxide Alarms were installed in proximity, but less than fifteen feet, from a fossil-burning device, in accordance with the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act.

Interview at the time of the exit conference with the Administrator and Maintenance Director on November 4, 2025, at 2:00 PM, confirmed the facility lacked documentation, verifying alarms were installed in proximity, but at least fifteen feet, of a fossil-burning device.

Plan of Correction - To be completed: 12/28/2025

The facility reached out to the vendor and acquired the documentation showing / verifying testing and inspections were completed on Carbon monoxide alarms. Testing's passed indicating that the alarms would sound should there be carbon monoxide leakage.

Training will be completed with maintenance staff on ensuring that the carbon monoxides are inspected and documentations are secured. Training will be completed by 12/15/25.

Deficiency and compliance requirements will be discussed in QAPI, and an audit will be completed monthly thereafter for functioning and compliance.

NFPA 101 STANDARD Means of Egress - General:

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain special locking arrangements, which lacked delayed egress signage, in one of six smoke zones within the component.

Findings include:

1. Observation on November 4, 2025, at 11:35 AM, revealed the exit discharge doors, to the service hall Memory Care, lacked delayed egress signage.

Interview at the time of the exit conference with the Administrator and Maintenance Director on November 4, 2025, at 2:00 PM, confirmed doors lacked delayed egress signage.

Plan of Correction - To be completed: 12/28/2025

The facility placed a signage above the door on 12/1/25 indicating a delayed egress to the service hall in memory care building.

Training will be completed with maintenance staff on delayed egress signage. Training will be completed by 12/15/25.

Deficiency and compliance requirements will be discussed in QAPI, and an audit will be completed after installation for two weeks and monthly thereafter for functioning and compliance.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the stairtower, to be of storage, on one of two floors within the component.

Findings include:

1. Observation on November 4, 2023, between 12:00 PM and 12:03 PM, revealed unauthorized storing, at the following locations:

a. 12:00 PM, 1st floor, Stairtower #3, obstructed with various items;
b. 12:03 PM, 2nd floor, Stairtower #3, obstructed with various items.

Interview at the time of the exit conference with the Administrator and Maintenance Director on November 4, 2025, at 2:00 PM, confirmed the stairtowers were obstructed with various storage items.

Plan of Correction - To be completed: 12/28/2025

The facility removed all the stored items in indicated stair tower areas on 11/25/2025.

The maintenance and housekeeping staff will be trained to ensure that no storage should be in those areas indicated. Training will be completed by 12/15/2025.

Deficiency and compliance requirements will be discussed in QAPI, and an audit will be completed weekly through the year.

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0291

Based on document review, observation and interview, it was determined the facility failed to maintain the installed battery back-up emergency lighting, at the emergency generator and transfer switch, affecting the entire component.

Findings include:

1. Observation on November 4, 2025, at 11:00 AM, revealed the installed battery back-up emergency lighting failed to illuminate, when tested, at the Transfer Switch/Emergency Generator Room.

Interview at the time of the exit conference with the Administrator and Maintenance Director on November 4, 2025, at 2:00 PM, confirmed the installed battery back-up emergency lighting failed to illuminate, when tested.

Plan of Correction - To be completed: 12/28/2025

The facility will fix the installed battery emergency light ensuring that it illuminates when tested. This will be completed by 12/15/25.

The maintenance staff will be trained to ensure that the emergency light battery backup is in operations and illuminates when tested. Training will be completed by 12/15/25.

Deficiency and compliance requirements will be discussed in QAPI, and an audit will be completed weekly through the year.

NFPA 101 STANDARD Exit Signage:

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0293

Based on document review and interview, it was determined the facility failed to provide documentation, verifying monthly visual inspections of exit signs had been performed, within the previous twelve months, affecting the entire component.

Findings include:

1. Review of documentation on November 4, 2025, between 9:00 AM and 10:30 AM, revealed the facility failed to provide documentation, verifying monthly visual inspections of exit signs had been performed, within the previous twelve months.

Interview at the time of the exit conference with the Administrator and Maintenance Director on November 4, 2025, at 2:00 PM, confirmed the lack of documentation, verifying monthly visual inspections of exit signs had been performed, within the previous twelve months.

Plan of Correction - To be completed: 12/28/2025

The facility was not able to retroactively correct the visual audits since they are in the past.

The maintenance staff will be trained to ensure the completions of visual exit signs audits monthly. This training will be completed by 12/15/25.

Deficiency and compliance requirements will be discussed in QAPI, and an audit will be completed monthly through the year starting with December 2025.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 document review, observation and interview, it was determined the facility failed to provide quarterly and five-year sprinkler maintenance documentation, maintain the automatic sprinkler system to be free of obstructions and to be free of extraneous weight, in six of six smoke compartments within the component.

Findings include:

1. Review of documentation on November 4, 2025, between 9:15 AM and 9:20 AM, revealed the facility lacked documentation, for the following:

a. 9:15 AM, wet system, semi-annual, Valve Supervisory Switches and Pressure Switch Waterflow Alarms;
b. 9:18 AM, 3rd quarter, wet system inspections:
c. 9:20 AM, 5-year, wet system, internal pipe/valve inspections.

Interview at the time of the exit conference with the Administrator and Maintenance Director on November 4, 2025, at 2:00 PM, confirmed the facility lacked documentation for the installed sprinkler system.

2. Observation on November 4, 2025, between 11:10 AM and 11:15 AM, revealed sprinkler heads covered with debris, at the following locations:

a. 11:10 AM, 1st floor, Laundry Room, Washroom, 3 sprinkler heads;
b. 11:13 AM, 1st floor, Laundry Room, Dryer Chase Room 2 sprinkler heads;
b. 11:15 AM, 1st floor, Laundry Room, Dryer Room, 2 sprinkler heads.

Interview at the time of the exit conference with the Administrator and Maintenance Director on November 4, 2025, at 2:00 PM, confirmed debris was covering sprinkler heads.

3. Observation on November 4, 2025, between 11:32 AM and 12:35 PM, revealed items were being supported and attached to the sprinkler piping system, at the following locations:

a. 11:32 PM, 1st floor, service hall, above ceiling, above Laundry doors, various wires zip-tied to sprinkler bracket;
b. 12:20 PM, 2nd floor, Arbor, above ceiling, by Dining Room, various wires, and flex conduit;
c. 12:35 PM, 1st floor, above ceiling, by Nurses' Station, flex conduit and wires.

Interview at the time of the exit conference with the Administrator and Maintenance Director on November 4, 2025, at 2:00 PM, confirmed various items attached and laying across the installed sprinkler system.

Plan of Correction - To be completed: 12/28/2025

The facility acquired documentation from the vendor showing that the quarterlies were completed however the 5-year inspection will be completed by 12/5/2025.

Training will be completed with maintenance staff on ensuring that documentation and inspections are completed within required timeframes and documentation secured as record. This training will be completed by 12/15/2025.

Deficiency and compliance requirements will be discussed in QAPI, and an audit will be completed weekly for 3 months or until compliance is met then monthly thereafter for 6 months and randomly thereafter.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0355
Based on observation and interview, it was determined the facility failed to maintain monthly inspections of portable fire extinguishers, affecting one of six smoke compartments within the component.

Findings include:

1. Observation on November 4, 2025, at 10:55 AM, revealed the lack of monthly inspection tag, verifying fire extinguisher exterior break area was subjected to monthly inspections.

Interview at the time of the exit conference with the Administrator and Maintenance Director on November 4, 2025, at 2:00 PM, confirmed the fire extinguisher, exterior break area, had not been inspected, monthly, in the past year.

Plan of Correction - To be completed: 12/28/2025

The facility could not retroactively correct the inspection since it was in the past. However, the extinguisher will be inspected by 12/15/25 and monthly thereafter.

Training will be completed with maintenance staff on ensuring that extinguishers are inspected monthly and completed within required timeframes and documentation secured as record. This training will be completed by 12/15/2025.

Deficiency and compliance requirements will be discussed in QAPI, and an audit will be completed monthly for 12 months or until compliance.

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility lacked documentation that repairs were performed on the installed fire dampers, affecting the entire component.

Findings include:

1. Review of documentation on November 4, 2025, between 9:00 AM and 10:30 AM, revealed the facility failed to make repairs of the fire dampers, listed on a report from Clark, Inc., from the inspection on November 22, 2024, on the following dampers:

a. F-1FD-06, F-1-FD-09 and F2-FD-17 had a 1-inch gap, while in the closed position;
b. F2-FD-18 had a 2-inch gap and jammed, when closed.

Interview at the time of the exit conference with the Administrator and Maintenance Director on November 4, 2025, at 2:00 PM, confirmed the facility failed to make repairs to the deficient fire dampers.

Plan of Correction - To be completed: 12/28/2025

The facility will repair the fire dampers indicated by 12/15/2025.

Training will be completed with maintenance staff on ensuring that fire dampers should be repaired after each inspection ensuring compliance. This training will be completed by 12/15/2025.

Deficiency and compliance requirements will be discussed in QAPI, and an audit will be completed weekly for 3 months or until compliance is met then monthly thereafter for 6 months and randomly thereafter.

NFPA 101 STANDARD Operating Features - Other:

Operating Features - Other
List in the REMARKS section any LSC Section 18.7 and 19.7 Operating Features requirements that are not addressed by the provided S-tags, but are deficient.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0700

Based on document review and interview, it was determined the facility failed to provide documentation of the annual fire door inspection, in six of six smoke compartments within the component.

Findings include:

1. Review of documentation on November 4, 2025, between 9:00 AM and 10:30 AM, revealed the facility lacked documentation of the annual fire-rated door inspection.

Interview at the time of the exit conference with the Administrator and Maintenance Director on November 4, 2025, at 2:00 PM, confirmed the facility could not provide documentation of the annual fire door inspections.

Plan of Correction - To be completed: 12/28/2025

The facility reached out to the vendor and an annual / visual door inspection to the fire rated doors will be completed by 12/15/2025.

Training will be completed with maintenance staff on ensuring that there is an annual visual inspection to the fire rated doors and documentation acquired. This training will be completed by 12/15/2025.

Deficiency and compliance requirements will be discussed in QAPI, and an audit will be completed weekly for 3 months or until compliance is met then monthly thereafter for 6 months and randomly thereafter.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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 and readily identifiable. 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:
Name: MAIN BUILDING - Component: 01 - Tag: 0918

Based on document review, observation and interview, it was determined the facility failed to provide required maintenance and testing documentation, and lacked a remote emergency generator shut off switch, which serves the entire component.

Findings include:

1. Review of documentation on November 4, 2025, between 9:35 AM and 9:43 AM, revealed the facility lacked documentation, for the following:

a. 9:35 AM, one full year, weekly maintenance;
b. 9:40 AM, one full year, monthly maintenance, 30-minute load w/transfer switch;
c. 9:43 AM, annual, 90-minute load bank.

Interview at the time of the exit conference with the Administrator and Maintenance Director on November 4, 2025, at 2:00 PM, confirmed the lack of documentation for the emergency generator.

2. Observation on November 4, 2025, at 11:05 AM, revealed the emergency generator, lacked a remote shut off switch.

Interview at the time of the exit conference with the Administrator and Maintenance Director on November 4, 2025, at 2:00 PM, confirmed the emergency generator lacked a remote shut off switch.

Plan of Correction - To be completed: 12/28/2025

The facility generator has the switch located in the Personal Care Side of the building. Testing of the emergency generator shut off could not be retroactively corrected since it in the past however one will be completed by 12/15/25 then weekly testing following.

Training will be completed with maintenance director and other maintenance managers on ensuring that the paperwork to the generator emergency shut off testing is completed weekly, annually specifically 30-minute load testing monthly and 90-minute load bank testing annually. Training will be completed by 12/15/25.

Deficiency and compliance requirements will be discussed in QAPI, and an audit will be completed weekly after for the entire year.

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