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

There are 45 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 May 2, 2024, 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 May 2, 2024, 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 construction, that is fully sprinklered.

Plan of Correction:

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, Section 210.8(B)5, for electrical wiring and equipment, affecting one of three levels.

Findings include:

Observation on May 2, 2024, at 11:40 a.m., revealed, on the second floor, in Activities, a non-GFCI outlet located within 6 feet of a sink.

Exit interview with the Administrator and Maintenance Director on May 2, 2024, at 12:30 p.m., confirmed the outlet.

Plan of Correction - To be completed: 05/24/2024

1. Work Order #88088 description: have an electrician change out the outlets to Hospital Grade GFCI outlets. Outlets inspected, tested completed, on 5/7/2024. Maintenance staff education on the requirements of Hospital Grade GFCI outlets.

2. Maintenance Director or designee will continue quarterly inspections, document and report any items found in the monthly QAPI meeting x's 3 months.

NFPA 101 STANDARD Fire Drills:

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on observation and interview, it was determined the facility failed to ensure fire drills were conducted as required, and at unexpected times, affecting four of twelve drills.

Findings include:

1. Document review on May 2, 2024, at 10:10 a.m., revealed all second shift fire drills in were all conducted in the 11:00 p.m. hour.

Exit interview with the Administrator and Maintenance Director on May 2, 2024, at 12:30 p.m., confirmed the above listed fire drills were not held at unexpected times.

2. Document review on May 2, 2024, at 10:15 a.m., revealed the facility could not provide documentation that a fire drill was conducted, third shift, second quarter.

Exit interview with the Administrator and Maintenance Director on May 2, 2024, at 12:30 p.m., confirmed the missing drill.

Plan of Correction - To be completed: 05/24/2024

1. Fire drill will be conducted an alternate shift and documented appropriately. Fire drills continue to be conducted as scheduled per regulation.
Security Manager will educate staff on Fire Drill rules and regulations including quarterly inspections requirements of the fire drills and required documentation.

2. Security Manager or designee will continue quarterly inspections of the fire drills and documentation, document and report any items found in the monthly QAPI meeting.

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, it was determined the facility failed to maintain the emergency generator, affecting the entire facility.

Findings include:

Document review on May 2, 2024, at 10:35 a.m., revealed the January 15, 2024, Annual Fuel Quality Report indicated the following: "Analysis indicates abnormal fuel conditions! Sulphur content is HIGH. " Proof of corrective action was not available at time of survey.

Exit interview with the Administrator and Maintenance Director on May 2, 2024, at 12:30 p.m., confirmed the fuel quality issue.

Plan of Correction - To be completed: 05/24/2024

1. Contractor recovered the high sulfur diesel fuel and refill with ULSD (ultra low sulfur diesel) on 5/17/24. Currently awaiting GenServ to revisit and test sulfur levels. Maintenance staff educated on procedure and requirements for sulfur diesel fuel, refill and fuel analysis requirements.

2. Maintenance Director or designee will coordinate an additional fuel analysis. report any items found in the monthly QAPI meeting.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of electrical devices affecting one of three levels.

Findings include:

Observation on May 2, 2024, at 11:15 a.m., revealed a fridge plugged into a surge protector, on the first floor, in Nursing office.

Exit interview with the Administrator and Maintenance Director on May 2, 2024, at 12:30 p.m., confirmed the unauthorized electrical device.

Plan of Correction - To be completed: 05/24/2024

1. Refrigerator plug corrected at the time of the survey. All refrigerators in facility audited, all devices are plugged correctly in the appropriate outlets.
All staff education on the appropriate outlet usage for voltage and motor devices.

2. Maintenance Director or designee will continue quarterly inspections, document and report any items found in the monthly QAPI meeting.

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