Pennsylvania Department of Health
 HOLY FAMILY HOME
Building Inspection Results

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HOLY FAMILY HOME
Inspection Results For:

There are  46 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.
HOLY FAMILY 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 April 6, 2026, at Holy Family Home, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.
 Plan of Correction:


Initial comments:Name: MAIN 01-DINING, COMMUNITY CENTER, CHAPEL, ENTRANCE - Component: 01 - Tag: 0000
Facility ID# 341602Component 01Health Care Building, Side-ADining, Community Center, Chapel, Shared EntranceBased on a Medicare/Medicaid Recertification Survey completed on April 6, 2026, at Holy Family Home - Main Building, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing Nursing 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, with a penthouse and basement level, that is fully sprinklered.
 Plan of Correction:


Initial comments:Name: SKILLED ADDITION - Component: 02 - Tag: 0000
Facility ID #341602Component 02Skilled AdditionBased on a Medicare/Medicaid Recertification Survey completed on April 6, 2026, it was determined that Holy Family Home - Skilled Addition was not in compliance with the following requirements of the Life Safety Code for a new Nursing 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, with a partial basement, that is fully sprinklered.
 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies: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.
Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
18.1.3.3, 42 CFR 482.41, 42 CFR 485.623
Observations:
Name: SKILLED ADDITION - Component: 02 - Tag: 0131 Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of common walls, affecting one of two floors. Findings include: 1.Observation on April 6, 2026, at 10:30 a.m., revealed on the first floor, above the common wall fire doors, separating skilled/main buildings, an unsealed penetration around a bundle of data cables through the wall. Exit Interview with the Executive Director, Administrator and Maintenance Director on April 6, 2026, at 1:30 p.m., confirmed the fire wall penetration.
 Plan of Correction - To be completed: 05/13/2026

1. The facility corrected the deficient penetrations by installing a UL-listed through-penetration firestop system (UL System No. W-L-3001), tested in accordance with UL 1479, appropriate for the construction of concrete wall and penetrating cable bundles. Installation was completed in accordance with the manufacturer's instructions and UL design specifications.

2. The Maintenance Director will ensure a full inspection of any work done where fire wall is penetrated to ensure penetration is properly sealed.

NFPA 101 STANDARD Vertical Openings - Enclosure: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.
Vertical Openings - Enclosure
2012 NEW
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 2 hours connecting four or more stories. (1 hour for single story building and buildings up to three stories in height.) An atrium may be used in accordance with 8.6.7.
18.3.1 through 18.3.1.5
Observations:
Name: SKILLED ADDITION - Component: 02 - Tag: 0311 Based on observation and interview, it was determined the facility failed to ensure vertical openings between floors were sealed to maintain the proper fire resistance rated construction, affecting one of two levels within the facility. Findings include: 1.Observation made on April 6, 2026, at 1:00 p.m., revealed unsealed rated ceiling deck slab penetrations inside the electrical room on the first floor. Exit Interview with the Executive Director, Administrator and Maintenance Director on April 6, 2026, at 1:30 p.m., confirmed the unsealed penetrations.
 Plan of Correction - To be completed: 05/13/2026

1.The facility will correct the deficient penetrations by installing a UL-listed through-penetration firestop system (UL System No. C-AJ-1353), tested in accordance with UL 1479, appropriate for the construction of ceiling deck slab with penetrating steel conduit. Installation was completed by the UL system design, including required backing materials and sealant depth, restoring the fire-resistance rating.

2. Maintenance staff completed an inspection of mechanical rooms to ensure vertical penetrations were sealed.

3. Penetration sealing requirements are now included in all construction, repair, and renovation work orders. Contractors must provide documentation of fire-rated materials used.

4. The Maintenance Director will review all ceiling penetration inspections and report findings to the Safety Committee.

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.
Doors protecting corridor openings shall be constructed to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have self-latching and 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 18.3.6.3.6 are permitted.

18.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatic closing devices, etc.
Observations:
Name: SKILLED ADDITION - Component: 02 - Tag: 0363 Based on observation and interview, it was determined the facility failed to ensure corridor doors positively latched into the door frame and resisted the passage of smoke, affecting one of two floors within the facility. Findings include: 1.Observation made on April 6, 2026, at 12:35 p.m., revealed on the first floor, the storage room 125, the double doors were not equipment with door latching hardware and lacked self-closing devices. Exit Interview with the Executive Director, Administrator and Maintenance Director on April 6, 2026, at 1:30 p.m., confirmed the doors were unequipped to latch and self close.
 Plan of Correction - To be completed: 05/13/2026

1. Approved latching hardware and self-closing devices were installed on both doors of Storage Room 125.

2. A door inspection audit was conducted on all corridors area doors.

3. Results will be documented and reviewed by the Safety Committee.

NFPA 101 STANDARD Electrical Systems - Other:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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.
Chapter 6 (NFPA 99)
Observations:
Name: SKILLED ADDITION - Component: 02 - Tag: 0911 Based on observation and interview, it was determined the facility failed to remove temporarywiring in accordance with NFPA 70 2011 Section 590.3 (D), affecting entire component. Findings include: 1. Observation made on April 6, 2026, between 10:30 a.m.,and 1:15 p.m., revealed abandoned temporary lighting above the ceiling, throughout component. Exit Interview with the Executive Director, Administrator and Maintenance Director on April 6, 2026, at 1:30 p.m., confirmed the abandoned temporary lighting.
 Plan of Correction - To be completed: 05/13/2026

1. All abandoned temporary lighting and wiring above ceiling spaces were removed.


2. The Maintenance Director will review electrical systems quarterly and document compliance with NFPA 70.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: SKILLED ADDITION - Component: 02 - Tag: 0923 Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of medical gas rooms, in sprinklered locations, affecting one of two levels. Findings include: 1.Observation on April 6, 2026, at 12:10 p.m., revealed on the first floor, Oxygen Storage Room door lacked a self-closing device. Exit Interview with the Executive Director, Administrator and Maintenance Director on April 6, 2026, at 1:30 p.m., confirmed the missing self-closer.
 Plan of Correction - To be completed: 05/13/2026


1. A self-closing device was installed on the oxygen storage room door.

2. Medical gas room inspection was added to the monthly Life Safety checklist.


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