Pennsylvania Department of Health
GERMANTOWN HOME
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 51 surveys for this facility. Please select a date to view the survey results.

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GERMANTOWN 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 July 1, 2026, at Germantown Home, 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 #122702Component 01Health Care Building Based on a Medicare/Medicaid Recertification Survey completed on July 1, 2026, it was determined that Germantown Home 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 four-story, Type II (222), fire resistive building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Cooking Facilities:

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.

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324 Based on document review and interview, it was determined the facility failed to ensure the kitchen suppression system was inspected and serviced at required intervals, affecting one of two kitchen exhaust hood reports. Findings include: 1. Document review on July 1, 2026, at 9:00 a.m., revealed the facility could not produce documentation showing that a kitchen exhaust hood cleaning had been performed twice in the prior year. Exit interview with the Administrator and Maintenance Director on July 1, 2026, at 1:30 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 08/25/2026

The Maintenance Director and Food & Nutrition Director/ Designee will review the preventive maintenance schedule monthly to verify that all required inspections, testing, for required semiannual kitchen exhaust hood cleaning is current and supportive documentation is in place.
The Maintenance Director will implement a preventive maintenance schedule that includes the required semiannual kitchen exhaust hood cleaning. A tracking log and TELS calendar reminder will be maintained to ensure cleanings are scheduled and completed within the required timeframes. Education with Maintenance Director and Food & Nutrition Director on Kitchen Hood Cleaning schedule compliance will be done.
Maintenance Director will report on semi-annual inspections for 2 QAPI meetings reflective of semi-annual kitchen hood cleanings.

NFPA 101 STANDARD Fire Alarm System - Initiation:

Fire Alarm System - Initiation
Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200' travel distance is not exceeded.
18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0342 Based on observation and interview, it was determined the facility failed to maintain fire alarm initiating devices, affecting one of four levels. Findings include: 1. Observation on July 1, 2026, at 1:00 p.m., revealed a dislodged smoke detector, Second Floor Nurse Break Room. Exit interview with the Administrator and Maintenance Director on July 1, 2026, at 1:30 p.m., confirmed the smoke detector that was not securely mounted.

Plan of Correction - To be completed: 08/25/2026

The smoke detector was dislodged (hanging) from ceiling. The fire alarm reattached/corrected immediately.

All staff will be educated to report immediately any smoke detectors seen dislodged/hanging to the maintenance director, maintenance tech, or supervisor, for immediate repair. Three months of weekly audits of smoke detectors in 2nd floor break room will be done.

The Maintenance Director will review monthly audit findings in QAPI for three months.

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, observation and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting two of four levels. Findings include: 1. Document review on July 1, 2026, at 9:00 a.m., revealed the fire pump report dated June 5, 2026, listed deficiencies that stated: a. Diesel fire pump ran out of water for the 150%. b. Hit 100% but it ran out of water at 150%. Evidence of corrective action was not available at time of survey. Exit interview with the Administrator and Maintenance Director on July 1, 2026, at 1:30 p.m., confirmed the missing documentation. 2. Observation on July 1, 2026, between 12:20 p.m., revealed the sprinkler deficiencies at the following locations: a. 12:20 p.m., Boxes stored within 18 inches of a sprinkler, Ground Floor Central Supply Room. b. 12:35 p.m., Two gauges dated 2017 on the sprinkler riser, Ground Floor Sprinkler Riser / Fire Pump Room. c. 1:10 p.m., Sprinkler head covered by medicine/pill cup, Second Floor Back Dining Hall. Exit interview with the Administrator and Maintenance Director on July 1, 2026, at 1:30 p.m., confirmed the sprinkler deficiencies.

Plan of Correction - To be completed: 08/25/2026

1) In review of the annual inspection report it was identified the diesel fire pump/sprinkler system met the 100% but did not meet maximum capacity of 150%. Impact Fire was contacted and facility was referred to the Philadelphia Water Department (PWD). Impact identified it was not on the part of the facility but external factors with PWD. PWD was called and PWD has identified they have an obstructive valve box identified during inspection on July 2nd under the street and have an open ticket. Facility has informed PWD emergency department this has affected the diesel fire pump/sprinkler system and is not allowing the sprinkler system to meet the maximum of 150% capacity in case of a fire thus not meeting Life Safety NFPA standard. Facility has also informed PWD this is a nursing home with the capacity to house 180 seniors and employs 250+ staff.

Systemic Changes: All Fire Sprinkler vendor reports that are due quarterly, annually, and monthly will be reviewed with the administrator to ensure recommendations are addressed timely to meet compliance and provide support for 3 months.
The Maintenance Director will review monthly inspections and findings in QAPI monthly for 3 months.

2) Boxes stored with in 18 inches were removed immediately below 18 inches in central supply room.
- Education will be provided Central Supply coordinator on stocking guidelines within NFPA?18 inches and safety.

Systematic change: will include marking the walls to show representation of 18 inches stock level.

Maintenance Director/Designee will monitor weekly for 3 months and report in QAPI monthly for three months.

3) The two gauges dated 2017 on the sprinkler riser, Ground Floor Sprinkler Riser / Fire Pump Room were identified. Sprinkler company have been scheduled to inspect the sprinkler riser/fire pump and provide updated tags after inspection.

Systematic Change: Maintenance Director and Maintenance team will add the annual schedule to TELS maintenance system calendar for reminder to have annual sprinkler riser/fire pump inspection completed.

Maintenance Director /Designee will report in QAPI the completion of sprinkler riser/fire pump inspection for two months.

4) Observed sprinkler cap covered with a medicine cup and it was removed immediately at time of survey. No residents or staff were affected.

Systematic Changes: Maintenance Director/Designee will perform daily checks in back dining room/lounge area second floor daily for 1 month and weekly for 2 months to ensure sprinkler heads are not covered. Staff will be educated to report medicine cups obstructing sprinklers immediately to maintenance or supervisors.

- Maintenance Director will report findings in QAPI for three months.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu:

Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0541 Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of chute discharge rooms, affecting one of four levels. Findings include: 1. Observation on July 1, 2026, at 12:15 p.m., revealed the trash chute door failed to latch when tested, Ground Floor Trash Chute Room. Exit interview with the Administrator and Maintenance Director on July 1, 2026, at 1:30 p.m., confirmed the door failed to latch.

Plan of Correction - To be completed: 08/25/2026

During annual Life Safety Survey, the ground floor linen chute access room door did not positively latch. All linen/trash room doors were checked and all others positively latched during survey. Ground floor linen room access door has been scheduled to be repaired to positively latch.

Daily inspections of the ground floor linen access door will be added to the preventive maintenance inspections for one month. Weekly x 3 months to ensure continued compliance.

Maintenance Director will report in QAPI monthly inspection findings for three months.

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, it was determined the facility failed to maintain access to electrical panels, affecting one of four levels. Findings Include: 1. Observation on July 1, 2026, at 1:00 p.m., revealed an electrical panel that was blocked by salon equipment and chair, Second Floor Beauty Salon. Exit interview with the Administrator and Maintenance Director on July 1, 2026, at 1:30 p.m., confirmed the blocked electrical panel.

Plan of Correction - To be completed: 08/25/2026

During survey electrical panel was blocked by salon equipment and chair in the second-floor beauty salon. Items were immediately removed during survey.

A large sign will be placed in this area and hairdresser and housekeeping will be educated to not block this area and discuss the NFPA rule.

Maintenance Director/Designee will check weekly for three months.

Maintenance Director will report findings in QAPI meeting for three months.

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 and inspect the emergency generator, affecting one of nine generator reports. Findings include: 1. Document review on July 1, 2026, at 9:00 a.m., revealed the facility could not produce documentation of the Annual 90-minute load bank test. Exit interview with the Administrator and Maintenance Director on July 1, 2026, at 1:30 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 08/25/2026

During Life Safety Survey it was identified that one out of nine generator reports the Annual 90-minute load bank test documentation could not be identified as being completed. The maintenance director has scheduled the 90-minute load bank test to be completed.

Education with maintenance team on importance of generator testing and scheduling to be completed. Maintenance Director will place the annual 90-minute load bank test for the generator in the TEL's maintenance calendar as a reminder for maintenance team.

Maintenance Director will report in QAPI confirmed 90-minute load bank test for 1 month.
Corrective Action Date- 08/25/2026

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