Pennsylvania Department of Health
CARING PLACE, THE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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CARING PLACE, THE - 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 July 7, 2026, at The Caring Place, 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 017102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on July 7, 2026, it was determined that The Caring Place was not in compliance with the following 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 basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

Least serious 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 has the potential for causing no more than a minor negative impact on the resident.

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 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.

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

Based on document review, observation, and interview, the facility failed to maintain portable floor plans that outlined designated rated partitions, affecting the entire facility.

Findings include:

1. Document review on July 7, 2026, at 1:00 p.m., revealed the facility failed to provide a set of accurate, portable floor plans. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site, to be used during the Life Safety Code Survey.

The Life Safety Code Floor Plan shall include the following:
a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls (1-2 hour walls);
c. Horizontal exits;
d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls.

Interview with the maintenance director on July 7, 2026, at 1:00 p.m., confirmed the Life Safety Code Floor Plan provided during the survey failed to accurately contain the listed items.

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Based on document review and interview, the facility failed to test and clean carbon monoxide detectors throughout the building, per PA Act #45.

Findings include:

2. Document review on July 7, 2026, at 11:15 a.m., revealed the facility lacked documentation that the carbon monoxide detectors were cleaned and tested within the previous twelve months.

Interview with the maintenance supervisor on July 7, 2026, at 11:15 a.m., confirmed the facility lacked the carbon monoxide detector documentation.

Plan of Correction - To be completed: 08/03/2026

Facility to maintain a portable and accurate floor plan to be used during the Life Safety Inspection
Carbon Monoxide detector documentation will be on record. Information will include Date of observation, battery change dates when applicable, noted cleaned. Education on Carbon Monoxide detectors review will be completed by maintenance department.
Audits for completeness of Carbon Monoxide Detector weekly reviews and Completeness of facility map will be completed by Maintenance Director/designee.
Results of audits will be reviewed at monthly Quality Assurance Performance Improvement meetings.

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 01 - Component: 01 - Tag: 0291

Based on document review and interview, the facility failed to provide documentation of functional tests of the battery-powered emergency lighting for one of one emergency light.

Findings include:

Document review on July 7, 2026, at 11:00 a.m., revealed the facility lacked documentation for the monthly 30-second and the annual 90-minute tests.

Interview with the administrator and maintenance supervisor on July 7, 2026, at 11:00 a.m., confirmed the facility could not provide documentation that the tests had been conducted.

Plan of Correction - To be completed: 08/03/2026

Facility will keep on filing all emergency lighting requiring testing for the annual 90 minute and monthly 30 second testing.
Inservice will be completed with all maintenance personal to complete audits by Nursing Home Administrator.
Maintenance director/designee will review for completeness of monthly emergency lighting testing.
Results of audits will be reviewed at monthly Quality Assurance Performance Improvement meetings.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

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 01 - Component: 01 - Tag: 0353

Based on observation and interview, the facility failed to meet sprinkler system requirements on one of three building levels.

Findings include:

Observation on July 7, 2026, between 1:23 p.m. and 1:30 p.m., revealed the sprinkler pipe had wires attached to it in the following locations:

A. (1:23 p.m.) Basement vending machine room had data cable on pipe;
B. (1:30 p.m.,) Basement laundry room thermostat wire zip-tied to pipe.

Interview with the administrator and maintenance supervisor on July 7, 2026, at 1:30 p.m., confirmed the sprinkler system deficiencies.

Plan of Correction - To be completed: 07/20/2026

The facility will remove A. Data cable from the vending machine room; B. Basement laundry room with non-operational thermostat wire.
Maintenance Director/designee will educate maintenance assistants that no wires are to touch sprinkler system.
Maintenance Director/designee has completed a walkthrough of the facility and removed any areas out of compliance with regulation.
Facility review will be reviewed at monthly Quality Assurance Performance Improvement meetings.

NFPA 101 STANDARD HVAC:

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.

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 01 - Component: 01 - Tag: 0521

Based on document review and interview, the facility failed to maintain heating, ventilating, and air conditioning (HVAC) equipment, affecting the entire facility.

Findings include:

Document review on July 7, 2026, at 10:44 a.m., revealed the fire damper inspection report, dated January 1, 2024, listed 5 of 17 dampers as deficient. Corrections had not been completed at the time of this inspection.

Interview with the administrator and maintenance supervisor on July 7, 2026, at 10:44 a.m., confirmed corrected documentation was unavailable at the time of the survey.

Plan of Correction - To be completed: 08/03/2026

Fire Dampers will be reviewed by third party vendor. Third Party vendor will provide documentation confirming that all dampers are functioning per regulatory requirements.
Maintenance Director will complete education with maintenance assistants on requirements for fire damper testing per regulation.
Maintenance director will review completeness of heating, ventilating, and air conditioning (HVAC) equipment per regulations at Monthly Quality Assurance Performance Improvement Meeting.

NFPA 101 STANDARD Electrical Systems - Other:

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: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, on one of three building levels.

Findings include:

Observation on July 7, 2026, at 1:29 p.m., revealed the basement laundry room had exposed electrical wires behind the dryers.

Reference: NFPA 70-406.6

Interview with the administrator and maintenance supervisor on July 7, 2026, at 1:29 p.m., confirmed the electrical system deficiency.

Plan of Correction - To be completed: 07/20/2026

Exposed electrical wiring will be removed or properly capped as applicable per regulations from behind the laundry dryer.
Maintenance Director will educate maintenance assistants that no exposed wire is to be left exposed. Preventative measures must be taken to ensure the safety of the facility.
The facility will review any findings of exposed wiring at the monthly Quality Assurance Performance Improvement meeting and the steps taken to remove the fault.

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, readily identifiable, and separate from normal power circuits. 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 01 - Component: 01 - Tag: 0918

Based on document review and interview, the facility failed to maintain the emergency generator, affecting the entire facility.

Findings include:

Document review on July 7, 2026, at 11:00 a.m., revealed the facility failed to provide documentation for the following tests:

A. (Weekly) Battery voltage or electrolyte levels;
B. (Monthly) Specific gravity or conductance;
C. (Monthly) 30-minute run under load;
D. (Monthly) Operation of transfer switch;
E. (Annual) 90-minute load bank;
F. (Three-year) 4-hour load.

Interview with the administrator and maintenance supervisor on July 7, 2026, at 11:00 a.m., confirmed the documents were unavailable at the time of the survey.

Plan of Correction - To be completed: 08/03/2026

The facility will have on record completion in the following areas of concern:
A.(Weekly) Battery voltage or electrolyte levels
B.(Monthly) Specific gravity or conductance
C.(Monthly)30 minute run under load
D.(Monthly) Operation of transfer Switch
E.(Annual) 90 minute load bank
F.(Three Year) 4 hour load
Maintenance Director will review the regulation requirements of 0918 with maintenance assistants. Maintenance Director/designee will review that the facility has completed its weekly/monthly/and yearly obligations to maintain regulatory compliance with tag 0918 at monthly Quality Assurance Performance Improvement.

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