Pennsylvania Department of Health
CATHEDRAL VILLAGE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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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 February 24, 2026, 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# 030402Component 01Bishop White Lodge Based on a Medicare/Medicaid Recertification Survey completed on February 24, 2026, 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 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 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 documentation review and interview, it was determined the following item(s) did not 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, affecting the entire facility. Findings include: 1. Document review on February 24, 2026, at 9:30 a.m., revealed the facility did not have approved Department of Health drawings/plans available for a new Fire Alarm Panel and annunciator panels that had been installed. Exit interview with the Executive Director and the Director of Environmental Services on February 24, 2026, at 12:15 p.m. confirmed the facility failed to obtain Department-approved plans prior to installation. 28 Pa Code 51.3. Notification (d)

Plan of Correction - To be completed: 03/25/2026

Email sent on 3/10/2026 to RA-DSI@pa.gov to obtain SharePoint Online Library Account. Fire Panel updgrade plans will then be submitted for review. Once Fire Panel upgrade plans have been approved, facility will complete an online Occupancy Request Form for final inspection.
Environmental Service Director and Maintenance Manager have been educated on submitting upgrades for Fire Panel to Department of Health Plan and Review for approval.
Environmental Service Director or designee will conduct monthly audits x 3 months to ensure proper documentation is on file for Fire Panel Upgrades, then quarterly x 3 quarters.
Audits will be forwarded to the Safety Committee for further guidance if indicated.

NFPA 101 STANDARD Means of Egress - General:

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.

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 01 - Component: 01 - Tag: 0211 Based on observations and interview, it was determined the facility failed to ensure there were no obstructions to egress, affecting one of three stories. Findings include: 1. Observation on February 24, 2026, at 11:50 a.m., revealed a door leading to an enclosed patio could be mistaken for an exit and lacked signage indicating "Not an Exit", Third Floor South Wing next to stair tower. Exit interview with the Executive Director and the Director of Environmental Services on February 24, 2026, at 12:15 p.m. confirmed the missing signage.

Plan of Correction - To be completed: 03/18/2026

Appropriate "Not an Exit" signs have been installed at Third Floor South Wing next to Stair Tower Door.
Maintenance Staff have been educated on appropriate signage needed at stairtower doors.
Environmental Service Director or designee will conduct weekly audits x 3 months of stairtower doors to ensure signage remains in place then monthly x 3 months.
audits will be forwarded to the Safety Committee for further guidance if indicated.

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 01 - Component: 01 - Tag: 0353 Based on document review and interview, it was determined the facility failed to maintain and inspect the sprinkler system, affecting one of three sprinkler systems. Findings include: 1. Document review on February 24, 2026, at 9:30 a.m., revealed the facility could not provide documentation of the Annual Anit-Freeze Solution sprinkler system. Exit interview with the Executive Director and the Director of Environmental Services on February 24, 2026, at 12:15 p.m. confirmed the missing documentation.

Plan of Correction - To be completed: 03/18/2026

Documentation of Annuyal Anti Freeze Solution has been received and is on file.
Environmental Service Director and Maintenance Manager have been educated on ensuring Annual Sprinkler Inspection records are kept up to date and filed.
Environmental Service Director or designee will conduct monthly audits x 3 months to ensure proper documentation of Sprinker Inspections are on file, then quarterly x 3 quarters.
Audits will be forwarded to the Safety Committee for further guidance if indicated.

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