Pennsylvania Department of Health
VINCENTIAN HOME
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 42 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.


VINCENTIAN 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 June 3, 2024, at Vincentian Home, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: BUILDING 3 - 1957 - Component: 01 - Tag: 0000

Facility ID# 221002
Component 01
1959 Building

Based on a Medicare/Medicaid Recertification Survey completed on June 3-4, 2024, it was determined that Vincentian Home, 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 two-story, Type II (000), unprotected noncombustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Emergency Lighting:

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.

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: BUILDING 3 - 1957 - Component: 01 - Tag: 0291

Based on documentation review and interview, it was determined the facility failed to maintain emergency lighting in one instance, affecting the entire facility.

Findings Include:

1. Documention review on June 3, 2024, at 8:55 a.m., revealed the facility failed to provide documentation for the required annual 90 minute test for the emergency lighting..

Interview with the Director of Nursing and Maintenance Staff on June 4, 2024 at 1:30 p.m., confirmed the facility could not provide documentation for the annual test on the battery back up lighting.

Plan of Correction - To be completed: 08/01/2024

The battery back-up emergency task light will be tested for the 90-minute minimum test duration as required in the room where the transfer switchgear is located by June 10, 2024. This light will continue to be tested monthly and annually (90-minute duration) as required. The results of this inspection will be maintained along with the records of the other existing battery back-up lights located throughout the facility. These records will be maintained for review at the annual life safety survey

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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: BUILDING 3 - 1957 - Component: 01 - Tag: 0353

Based on documentation review, observation, and interview, it was determined the facility failed to maintain the automatic sprinkler system in four instances, affecting the entire facility.

Findings include:

1. Observation and document review on June 3, 2024 , revealed the following automatic sprinkler system deficiencies:

a) 8:30 a.m., the facility failed to perform the required 5 year obstruction test;
b) 8:45 a.m., the facility failed to perform the 3rd quarter sprinkler inspection;
c) 9:55 a.m., there was a gap greater than 1/8 inch around 4 and 2 inch pipes, to the left of the stairwell in the basement;
d) 10:01 a.m., there was a gap, greater than 1/8 inch around the electrical conduit, above an emergency strobe light in the basement.

Interview with the Director of Nursing and Maintenance Staff on June 4, 2024 at 1:30 p.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 08/01/2024

a)The 5-year obstruction test will be performed as required by August 1, 2024. Furthermore, the facility has initiated a calendar reminder for the 5-year inspection.
b)The facility will continue to perform the quarterly sprinkler inspections as required. Furthermore, the facility has initiated a calendar reminder for the quarterly inspections.
c)The facility filled the gaps found around both the 4 inch and 2 inch pipes with acceptable fire stop material. This work was completed no later than June 10, 2024. Audits of the area will be conducted weekly times 4 by the maintenance manager or his designee. Results of these audits will be presented at the Quality Assurance quarterly meeting.
d)The facility filled the gaps found around electrical conduit at the emergency strobe light in the basement with acceptable fire stop material. This work was completed no later than June 10, 2024. Audits of the area will be conducted weekly times 4 by the maintenance manager or his designee. Results of these audits will be presented at the Quality Assurance quarterly meeting.

NFPA 101 STANDARD Corridor - Doors:

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.

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: BUILDING 3 - 1957 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors in one instance, for one of over 20 corridor doors inspected.

Findings include:

1. Observation on June 3, 2024, at 9:45 a.m., revealed holes in the door to the kitchen were not filled in with an approved sealant after changing door hardware.

Interview with the Director of Nursing and Maintenance Staff on June 4, 2024 at 1:30 p.m., confirmed the door deficency.

Plan of Correction - To be completed: 08/01/2024

The facility sealed the holes in the kitchen door to restore the integrity of the door. This work was completed no later than June 10, 2024. Audits of the door will be conducted weekly times 4 by the maintenance manager or his designee. Results of these audits will be presented at the Quality Assurance quarterly 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: BUILDING 3 - 1957 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain the emergency generator in one instance affecting the entire facility.

Findings include:

1. Review of documentation on June 3, 2024 at 8:50 a.m., revealed the facility failed to provide documentation for the required annual fuel test for their diesel powered generators.

Interview with the Director of Nursing and Maintenance Staff on June 4, 2024 at 1:30 p.m., confirmed the facility did not have the documentation for the fuel sample at the time of survey.

Plan of Correction - To be completed: 08/01/2024

The required annual fuel test was completed on June 10, 2024. Furthermore, the facility has initiated a calendar reminder for the fuel inspection.

Initial comments:Name: BUILDING 4 - 1980 - Component: 02 - Tag: 0000

Facility ID# 221002
Component 02
1980 Building

Based on a Medicare/Medicaid Recertification Survey completed on June 3-4, 2024, it was determined that Vincentian Home, 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 two-story, Type II (III), protected noncombustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Observations:
Name: BUILDING 4 - 1980 - Component: 02 - Tag: 0353

Based on documentation review, observation, and interview, it was determined the facility failed to maintain the automatic sprinkler system in four instances, affecting the entire facility.

Findings include:

1. Documentation review on June 3, 2024, revealed the following automatic sprinkler system deficiencies:

a) 8:30 a.m., the facility failed to perform the required 5 year obstruction test;
b) 8:45 a.m., the facility failed to perform the 3rd quarter sprinkler inspection.

Interview with the Director of Nursing and Maintenance Staff on June 4, 2024 at 1:30 p.m., confirmed the missing documentation at the time of the survey.

2. Observation on June 3, 2024, revealed the following deficiencies that would prevent proper operation of the automatic sprinkler system:

a) 8:39 a.m., there was electrical flex tubing on the sprinkler line above the ceiling, in the second floor elevator lobby;
b) 8:46 a.m., there was electrical flex tubing on the sprinkler line above the ceiling, in the first floor elevator lobby.

Interview with the Director of Nursing and Maintenance Staff on June 4, 2024 at 1:30 p.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 08/01/2024

1.a)The 5-year obstruction test will be performed as required by August 1, 2024. Furthermore, the facility has initiated a calendar reminder for the 5-year inspection.
1.b)The facility will continue to perform the quarterly sprinkler inspections as required. Furthermore, the facility has initiated a calendar reminder for the quarterly inspections.
2.a)The facility will remove the flex tubing from the sprinkler line and inspect the remainder of the area above the ceiling in the second floor elevator lobby to ensure that no other material is in contact with the sprinkler pipes. Audits of the ceiling area will be conducted weekly times 4 by the maintenance manager or his designee. Results of these audits will be presented at the Quality Assurance quarterly meeting.
2.b)The facility will remove the flex tubing from the sprinkler line and inspect the remainder of the area above the ceiling in the first floor elevator lobby to ensure that no other material is in contact with the sprinkler pipes. Audits of the ceiling area will be conducted weekly times 4 by the maintenance manager or his designee. Results of these audits will be presented at the Quality Assurance quarterly meeting.

NFPA 101 STANDARD Corridor - Doors:

Observations:
Name: BUILDING 4 - 1980 - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors in one instance, for one of over 20 corridor doors inspected.

Findings include:

1. Observation on June 4, 2024, at 10:45 a.m., revealed the door to the fire panel room in the basement failed to latch when tested.

Interview with the Director of Nursing and Maintenance Staff on June 4, 2024 at 1:30 p.m., confirmed the door deficency.

Plan of Correction - To be completed: 08/01/2024

The facility immediately repaired the closing mechanism of the door to the fire panel room to ensure proper closing and latching. Audits of the door will be conducted weekly times 4 by the maintenance manager or his designee. Results of these audits will be presented at the Quality Assurance quarterly meeting.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: BUILDING 4 - 1980 - Component: 02 - Tag: 0918
Based on document review and interview, it was determined the facility failed to maintain the emergency generator in one instance affecting the entire facility.

Findings include:

1. Review of documentation on June 3, 2024 at 8:50 a.m., revealed the facility failed to provide documentation for the required annual fuel test for their diesel powered generators.

Interview with the Director of Nursing and Maintenance Staff on June 4, 2024 at 1:30 p.m., confirmed the facility did not have the documentation for the fuel sample at the time of survey.

Initial comments:Name: BUILDINGS 1-2 - 2000 - Component: 04 - Tag: 0000

Facility ID# 221002
Component 04
New Addition 2008

Based on a Medicare/Medicaid Recertification Survey completed on June 3-4, 2024, it was determined that Vincentian Home, 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 two-story, Type II (III), protected noncombustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Observations:
Name: BUILDINGS 1-2 - 2000 - Component: 04 - Tag: 0353

Based on documentation review, observation, and interview, it was determined the facility failed to maintain the automatic sprinkler system in three instances, affecting the entire facility.

Findings include:

1. Document review on June 3, 2024 , revealed the following automatic sprinkler system deficiencies:

a) 8:30 a.m., the facility failed to perform the required 5 year obstruction test;
b) 8:45 a.m., the facility failed to perform the 3rd quarter sprinkler inspection.

Interview with the Director of Nursing and Maintenance Staff on June 4, 2024 at 1:30 p.m., confirmed the missing documentation at the time of the survey.

2. Observation on June 4, 2024, at 10:10 a.m., revealed a ceiling tile with a 1/8 inch gap in the Medical Records room storage room in the basement.

Interview with the Director of Nursing and Maintenance Staff on June 4, 2024 at 1:30 p.m., confirmed the automatic sprinkler system deficiencies.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: BUILDINGS 1-2 - 2000 - Component: 04 - Tag: 0918
Based on document review and interview, it was determined the facility failed to maintain the emergency generator in one instance affecting the entire facility.

Findings include:

1. Review of documentation on June 3, 2024 at 8:50 a.m., revealed the facility failed to provide documentation for the required annual fuel test for their diesel powered generators.

Interview with the Director of Nursing and Maintenance Staff on June 4, 2024 at 1:30 p.m., confirmed the facility did not have the documentation for the fuel sample at the time of survey.

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