Pennsylvania Department of Health
 CATHEDRAL VILLAGE
Building Inspection Results

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CATHEDRAL VILLAGE
Inspection Results For:

There are  49 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.
CATHEDRAL 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 July 21, 2025, at Cathedral Village, 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# 030402
Component 01
Bishop White Lodge

Based on a Medicare/Medicaid Recertification Survey completed on July 21, 2025, it was determined that Cathedral Village 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 three story, Type II (222), fire resistive building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to maintain Fire Alarm components, affecting two of three levels.

Findings include:

Document review on July 21, 2025, at 9:40 a.m., revealed, the June 2025 Annual Fire Alarm Inspection Report noted the following deficiencies:

a. Elevator recall inoperable.
b. Relay trouble at panel.

These conditions were not corrected at time of survey.

Exit Interview with the Administrator and Maintenance Director on July 21, 2025, at 12:15 p.m., confirmed the listed deficiencies remained uncorrected at time of survey.





 Plan of Correction - To be completed: 08/13/2025

K 0345:
Oliver Fire Protection & Security repaired and tested the elevator recall and replaced the relay on 7/23/2025.
Maintenance staff education on Fire Alarm System Maintenance and Testing on 8/11/2025-8/13/2025.
The Environmental Services Director or Designee will continue to monitor weekly for 4 weeks, along with quarterly inspections, document and report any items found in the Monthly Safety meetings x's 3 months.

NFPA 101 STANDARD Utilities - Gas and Electric: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.
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting one of three levels.

Findings include:

Observation on July 21, 2025, at 9:40 a.m., revealed, non-GFCI outlet, located within 6 feet of the sink, powering an ice machine, Nourishment area on the third floor. Per NFPA 70 210.8(B)5, a GFCI outlet is required where receptacles are installed within 6ft of the outside edge of the sink.

Exit Interview with the Administrator and Maintenance Director on July 21, 2025, at 12:15 p.m., confirmed the unprotected outlet.







 Plan of Correction - To be completed: 08/13/2025

K 0511:
Maintenance staff installed a GFCI breaker for the ice machine located at the Nourishment area on the third floor.
Maintenance staff education on Utilities - Gas and Electric on 8/11/2025-8/13/2025.
The Environmental Services Director or Designee will continue to monitor weekly for 4 weeks, along with quarterly inspections, document and report any items found in the Monthly Safety meetings x's 3 months


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