Pennsylvania Department of Health
PROVIDENCE POINT HEALTHCARE RESIDENCE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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PROVIDENCE POINT HEALTHCARE RESIDENCE - 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 6, 2026, at Providence Point Healthcare Residence, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: NCF - Component: 01 - Tag: 0000

Facility ID #21600201
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on July 6, 2026, it was determined that Providence Point Healthcare Residence 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 (111), protected, non-combustible building, with a basement and attic, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Doors with Self-Closing Devices:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: NCF - Component: 01 - Tag: 0223

Based on observation and interview, the facility failed to maintain self-closing doors in one instance, affecting one of 15 smoke compartments.

Findings include:

Observation on July 6, 2026, at 9:45 a.m., revealed the self-closing door was removed in the IT room on the third floor.

Interview with the facility administrator and maintenance staff on July 6, 2026, at 1:00 p.m., confirmed the self-closing door deficiency.

Plan of Correction - To be completed: 07/31/2026

1. Self-Closing Mechanism on the IT room on the third floor was fixed and put pack into place on 7/6/2026.
2. 5 random doors with self-closing mechanisms will be audited each week for 8 weeks to ensure properly functioning.
3. Results of audits will be reported at quarterly QA meetings.
4. EVS Director will be responsible for this plan of correction.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: NCF - Component: 01 - Tag: 0321

Based on observation and interview, the facility failed to maintain hazardous area enclosures in one instance, affecting one of fifteen smoke compartments.

Findings include:

Observation on July 6, 2026, at 11:00 a.m., revealed an unsealed MC conduit/wire penetration through the wall near the ceiling in the basement transfer switch room.

Interview with the facility administrator and maintenance staff on July 6, 2026, at 1:00 p.m., confirmed the hazardous area enclosure deficiency.

Plan of Correction - To be completed: 07/31/2026

1. Penetration in transfer switch room was appropriately sealed on 7/6/2026.
2. All hazardous rooms will be audited each week for 8 weeks to ensure all penetrations are properly sealed.
3. Results of audits will be reported at quarterly QA meetings.
4. EVS Director will be responsible for this plan of correction.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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.

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: NCF - Component: 01 - Tag: 0374

Based on observation and interview, the facility failed to maintain smoke barrier doors in one instance, affecting two of fifteen smoke compartments.

Findings include:

Observation on July 6, 2026, at 10:20 a.m., revealed the basement smoke barrier doors near the soiled laundry room had an excessive gap measuring greater than 3/4 inch at the bottom of the doors, which would allow smoke passage.

Interview with the facility administrator and director of maintenance on July 6, 2026, at 1:00 p.m., confirmed the smoke barrier doors had an excessive gap at the bottom of the doors that would allow smoke passage.

Plan of Correction - To be completed: 07/31/2026

1. Door sweep installed on 7/16/2026 on basement smoke barrier doors to reduce gap to less than � inch.
2. Smoke barrier doors will audited each week for 8 weeks to ensure there are no excessive gaps measuring more than � inch.
3. Results of audits will be reported at quarterly QA meetings.
4. EVS Director will be responsible for this plan of correction.

NFPA 101 STANDARD Fire Drills:

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.

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: NCF - Component: 01 - Tag: 0712

Based on documentation review and interview, the facility failed to perform one of twelve required fire drills.

Findings include:

Review of fire drill reports on July 6, 2026, at 9:40 a.m., revealed the facility lacked documentation for a third shift, first quarter fire drill.

Interview with the facility administrator and maintenance director on July 6, 2026, at 1:00 p.m., confirmed the missing fire drill documentation.

Plan of Correction - To be completed: 07/31/2026

1. Unable to correct past non-compliance as it relates to fire drills. A Fire drill will be conducted on 3rd shift in July of 2026. A schedule has been created in advance to ensure that a fire drill will be conducted on each shift during each of the remaining two quarters in 2026 and then ongoing.
2. Fire Drills will be audited monthly X 3 months and then monthly thereafter to ensure a fire drill is held on each shift each quarter.
3. Results of audits will be reported at quarterly QA meetings.
4. EVS Director will be responsible for this plan of correction.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

This is a less serious (but not lowest level) 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 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.

Electrical Systems - Essential Electric System Alarm Annunciator
A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator.
6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)

Observations:
Name: NCF - Component: 01 - Tag: 0916

Based on observation and interview, the facility failed to maintain the essential electrical system alarm annunciators in one instance, affecting the entire facility.

Findings include:

Observation on July 6, 2026, at 10:45 a.m., revealed the emergency generator remote annunciator panel was disconnected.

Interview with the facility administrator and maintenance staff on July 6, 2026 at 1:00 p.m., confirmed the remote annunciator deficiency.

Plan of Correction - To be completed: 07/31/2026

1. Generator Remote Annunciator panel was reconnected and operational on 7/15/2026.
2. Generator Remote Annunciator Panel will audited each week for 8 weeks to ensure proper functioning.
3. Results of audits will be reported at quarterly QA meetings.
4. EVS Director will be responsible for this plan of correction.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: NCF - Component: 01 - Tag: 0923

Based on observation and interview, the facility failed to properly store oxygen cylinders in two instances, affecting two of 15 smoke compartments.

Findings include:

Observation on July 6, 2026, revealed the following oxygen cylinder storage deficiencies:

a) 10:13 a.m., There was an oxygen cylinder stored in the clean utility room on C Pod third floor. This room did not have a sign indicating oxygen storage;
b) 11:03 a.m., There was an oxygen cylinder stored in the clean utility room on C Pod second floor. This room did not have a sign indicating oxygen storage.

Interview with the facility administrator and maintenance staff on July 6, 2026, at 1:00 p.m., confirmed the doors did not have the proper signage.

Plan of Correction - To be completed: 07/31/2026

1. Signs were placed on Utility rooms containing Oxygen on 7/6/2026.
2. Utility and Storage Rooms in Skilled Nursing will audited each week for 8 weeks to proper signage is in place if any oxygen is being stored in those rooms.
3. Results of audits will be reported at quarterly QA meetings.
4. EVS Director will be responsible for this plan of correction.

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