Pennsylvania Department of Health
QUINCY RETIREMENT COMMUNITY
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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QUINCY RETIREMENT COMMUNITY - 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 19, 2025, at Quincy Retirement Community, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000

Facility ID #170202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 19, 2025, it was determined that Quincy Retirement Community was not in compliance with the following requirements of the Life Safety Code for an existing 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 (000), unprotected noncombustible structure, with a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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 - Component: 01 - Tag: 0353

Based on document review, observation and interview, it was determined the facility failed to provide pressurized water tank documentation, and the sprinkler piping system to be free of extraneous weight, affecting the entire component.

Findings include:

1. Review of documentation on February 19, 2025, between 9:55 AM and 9:59 AM, revealed the facility lacked documentation for required inspections of the municipality owned water tank:

a. 9:55 AM, wet system, 3-5 year internal tank inspection;
b. 9:59 AM. wet system, quarterly, exterior tank inspections.

Interview at the time of the exit conference with the Administrator, Director Environmental Services and Maintenance Manager on February 19, 2025, at 2:15 PM, confirmed the facility could not provide documentation of the municipality owned water tank internal and exterior inspections.

2. Observation on February 19, 2025, between 12:00 PM and 1:05 PM, revealed items were being supported by the sprinkler piping system, at the following locations:

a. 12:00 PM, basement, above ceiling, by elevator, various wires;
b. 12:40 PM, 1st floor, above ceiling, by Wheeler #1 Nurses' Station, wires;
c. 1:05 PM, 2nd floor, above ceiling, by Resident Room 229, rigid conduit.

Interview at the time of the exit conference with the Administrator, Director Environmental Services and Maintenance Manager on February 19, 2025, at 2:15 PM, confirmed various items supported by the sprinkler piping system.

Plan of Correction - To be completed: 03/10/2025

Obtained inspections from Township for the water tanks. The Director of Environmental Services or Designee will provide them with guidance for future inspections to be complaint. Items supported by sprinkler piping system were corrected. Maintenance Manager or designee will conduct recurring audit to check that we have proper documentation related to water tanks from township and audit to assure the sprinkler piping does not have items being supported. Random Quarterly Audits will be conducted to ensure there are no items supported by the sprinkler piping system. The results of the audits will be shared with QAPI.

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