Pennsylvania Department of Health
HOLLIDAYSBURG VETERANS' HOME
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 62 surveys for this facility. Please select a date to view the survey results.

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HOLLIDAYSBURG VETERANS' 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 15, 16, and 17, 2024, it was determined that Hollidaysburg Veterans' Home, had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

482.15(e), 483.73(e), 485.542(e), 485.625(e) STANDARD Hospital CAH and LTC Emergency Power:

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.

§482.15(e) Condition for Participation:
(e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section.

§483.73(e), §485.625(e), §485.542(e)
(e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section.

§482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1)
Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated.

482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2)
Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code.

482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2)
Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates.

*[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):]
The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.
If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes.
(1) National Fire Protection Association, 1 Batterymarch Park,
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
(i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011.
(ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011.
(iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
(iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
(v) TIA 12-5 to NFPA 99, issued August 1, 2013.
(vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
(vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011.
(viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
(ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
(x) TIA 12-3 to NFPA 101, issued October 22, 2013.
(xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
(xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009..

Observations:
Name: - Component: -- - Tag: 0041

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

Findings include:

1. Review of documentation on July 15, 2024, at 11:00 a.m., revealed the facility failed to perform the required monthly conductance testing of the emergency generator batteries for twelve of the past twelve months.

Interview with the Facility Commandant, Maintenance Supervisor, and Facility Staff on July 17, 2024, at 11:30 a.m., confirmed the listed emergency generator testing deficiency.

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

Facility ID# 341402
Component 01
Eisenhower Building

Based on a Medicare/Medicaid Recertification Survey completed on July 15, 16, and 17, 2024, it was determined that Hollidaysburg Veterans Home was not in compliance with the following requirements of the Life Safety Code for an existing healthcare 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 structure, with a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Vertical Openings - Enclosure:

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.

Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain vertical opening enclosures in three instances, affecting eight of 18 smoke compartments.

Findings include:

1. Observation on July 16, 2024, revealed the following vertical opening enclosure deficiencies:

a) 9:43 a.m., there were unsealed pipe penetrations in the B-19 pipe chase on south two, the penetrations were in the bathroom wall side of the pipe chase;
b) 9:48 a.m., there were unsealed pipe penetrations in the B-22 pipe chase on south two, the penetrations were in the bathroom wall side of the pipe chase;
c) 10:03 a.m., there were unsealed pipe penetrations in the C-13 pipe chase on south two, the penetrations were in the bathroom wall side of the pipe chase.

Interview with the Facility Commandant, Maintenance Supervisor, and Facility Staff on July 17, 2024, at 11:30 a.m., confirmed the listed vertical opening enclosures deficiencies.

Plan of Correction - To be completed: 08/26/2024

Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted solely because of requirements under state and federal laws.
The unsealed pipe penetrations in the B-19 pipe chase on South 2 in the bathroom wall side, the unsealed pipe penetrations in the B-22 pip chase on South 2, in the bathroom wall side of the pipe chase and the unsealed pipe penetration in the C-13 pipe chase on south two, the penetrations were in the bathroom wall side of the pipe chase have been closed with a UL approved through stop penetration system to maintain integrity.
The Bureau of Veterans Homes policy regarding Above Ceiling Work Permit will be reviewed and revised as necessary. A permit will be completed at any time work is completed above the ceiling to ensure compliance with NFPA 101 & 99 fire penetration both vertical and horizontal.
The Facility Maintenance Manager/designee will conduct random monthly audits to ensure that no unsealed vertical opening enclosure penetrations are present. The Maintenance Department will continue random monthly checks throughout the buildings to ensure penetrations that are identified are corrected.
The results will be reported at the monthly Quality Improvement Committee meeting 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 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in three instances, affecting two of 18 smoke compartments.

Findings include:

1. Observation on July 16, 2024, revealed the following automatic sprinkler system deficiencies:

a) 9:38 a.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system there were multiple unsealed wire penetrations in the ceiling of South 2 custodial room B-17;
b) 9:55 a.m., the facility failed to maintain storage below the 18-inch horizontal sprinkler plane in the closet of South 2 treatment room B-26;
c) 10:19 a.m., observation above the ceiling, at the A-wing stairwell door on North 2, revealed data wires were lying on top of a sprinkler pipe.

Interview with the Facility Commandant, Maintenance Supervisor, and Facility Staff on July 17, 2024, at 11:30 a.m., confirmed the listed automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 08/26/2024

Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted solely because of requirements under state and federal laws.
The multiple unsealed wire penetrations in the ceiling of the South 2 custodial room B-17 have been repaired. The storage that was identified in the South 2 treatment room B-26 that was below the 18-inch horizontal sprinkler plane has been removed. The data wires that were lying on top of the sprinkler pipe has been removed. The Bureau of Veterans Home policy regarding Above ceiling work permit will be reviewed and revised if necessary. A permit will be completed any time that work is being completed above the ceiling to ensure compliance with NFPA 101 and 99 fire penetrations both vertical and horizontal.
The Facility Maintenance Manager/designee will conduct random monthly checks to ensure that no unsealed penetrations are present, that the sprinkler pipes are free of obstructions and that the storage is not within the 18-inch horizontal sprinkler planes. The Maintenance Department will continue random monthly checks throughout the buildings and any penetrations that are identified will be corrected.
The results of these random monthly checks will be reported at the Monthly Quality Improvement Committee meeting 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 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain electrical wiring in two instances, affecting two of 18 smoke compartments. Installation shall be in accordance with NFPA 70, National Electric Code...19.5.1.1, NFPA 101.

Findings include:

1. Observation above the ceiling on July 16, 2024, revealed open electrical junction boxes in the following locations:

a) 10:02 a.m., men's restroom C-12, on South 2 above the sinks;
b) 11:54 a.m., ground floor North, outside the Commandants office.

Interview with the Facility Commandant, Maintenance Supervisor, and Facility Staff on July 17, 2024, at 11:30 a.m., confirmed the listed electrical wiring deficiencies.

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 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 - Component: 01 - Tag: 0918

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

Findings include:

1. Review of documentation on July 15, 2024, at 11:00 a.m., revealed the facility failed to perform the required monthly conductance testing of the emergency generator batteries for twelve of the past twelve months.

Interview with the Facility Commandant, Maintenance Supervisor, and Facility Staff on July 17, 2024, at 11:30 a.m., confirmed the listed emergency generator testing deficiency.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

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.

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 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of 18 smoke compartments.

Findings include:

1. Observation on July 16, 2024, at 9:53 a.m., revealed there was a coffee maker, refrigerator, and microwave plugged into a power strip in the South 2 RNAC office.

Interview with the Facility Commandant, Maintenance Supervisor, and Facility Staff on July 17, 2024, at 11:30 a.m., confirmed the listed electrical wiring systems and equipment deficiency.

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

Facility ID# 341402
Component 02
Arnold Building

Based on a Medicare/Medicaid Recertification Survey completed on July 15, 16, and 17, 2024, it was determined that Hollidaysburg Veterans Home was not in compliance with the following requirements of the Life Safety Code for an existing healthcare 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 structure, with a basement, which is fully sprinklered. Facility ID# 341402

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: BUILDING 02 - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in one instance, affecting one of 14 smoke compartments.

Findings include:

1. Observation on July 15, 2024, at 1:44 p.m., revealed the facility failed to maintain the required one-hour fire rating, in the first-floor mechanical room C-101. There were multiple unsealed pipes and wires in the front wall above the entrance door.

Interview with the Facility Commandant, Maintenance Supervisor, and Facility Staff on July 17, 2024, at 11:30 a.m., confirmed the listed hazardous area enclosures deficiency.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in six instances, affecting four of 14 smoke compartments.

Findings include:

1. Observation on July 15, 2024, revealed the following automatic sprinkler system deficiencies:

a) 12.25 p.m., the facility failed to maintain storage below the 18-inch horizontal sprinkler plane in the East 2 supply room C-210;
b) 12:45 p.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. There were misaligned ceiling tiles in the ground floor pharmacy room E-G26;
c) 12:48 p.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. There were missing ceiling tiles in the ground floor central supply room E-G23;
d) 12:55, p.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. There were multiple unsealed pipe penetrations in the ceiling of the ground floor supply room E-G5;
e) 1:01 p.m., the facility failed to maintain storage below the 18-inch horizontal sprinkler plane in the ground floor supply room B-G15;
f) 1:14 p.m., the facility failed to maintain storage below the 18-inch horizontal sprinkler plane in the ground floor supply room A-G14.

Interview with the Facility Commandant, Maintenance Supervisor, and Facility Staff on July 17, 2024, at 11:30 a.m., confirmed the listed automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 08/26/2024

Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted solely because of requirements under state and federal laws.
The storage in the East 2 supply room C-210, the ground floor supply room B-G15 and the ground floor supply room A-G14 that was not below the 18-inch horizontal sprinkler plan was removed.
The ceiling tile that was misaligned in ground floor pharmacy room E-G26 and the missing ceiling tile in the ground floor central supply room E-G23 have been replaced.
The multiple unsealed wire penetrations in the ceiling of the ground floor supply room E-G5 have been repaired.
The Bureau of Veterans Home policy regarding Above ceiling work permit will be reviewed and revised if necessary. A permit will be completed any time that work is being completed above the ceiling to ensure compliance with NFPA 101 and 99 fire penetrations both vertical and horizontal.
The Facility Maintenance Manager/designee will conduct random monthly checks to ensure that no unsealed penetrations are present, that the sprinkler pipes are free of obstructions and that the storage is not within the 18-inch horizontal sprinkler planes. The Maintenance Department will continue random monthly checks throughout the buildings and any penetrations that are identified will be corrected.
The results of these random monthly checks will be reported at the Monthly Quality Improvement Committee meeting for three months.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0918

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

Findings include:

1. Review of documentation on July 15, 2024, at 11:00 a.m., revealed the facility failed to perform the required monthly conductance testing of the emergency generator batteries for twelve of the past twelve months.

Interview with the Facility Commandant, Maintenance Supervisor, and Facility Staff on July 17, 2024, at 11:30 a.m., confirmed the listed emergency generator testing deficiency.

NFPA 101 STANDARD Electrical Equipment - Other:

Electrical Equipment - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, 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 10 (NFPA 99)

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0919

Based on observation and interview, it was determined the facility failed to maintain electrical equipment in one instance, affecting one of 14 smoke compartments, per NFPA 99 2012 Edition, Chapter 10.1.1

Findings include:

1. Observation on July 15, 2024, at 1:12 p.m., revealed miscellaneous stored items in the ground floor exam room G-19, obstructed access to the electrical panels.

Interview with the Facility Commandant, Maintenance Supervisor, and Facility Staff on July 17, 2024, at 11:30 a.m., confirmed the listed electrical equipment deficiency.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of 14 smoke compartments.

Findings include:

1. Observation on July 15, 2024, at 1:22 p.m., revealed there was a coffee maker plugged into a power strip in the RN supervisor office E-120, on the first floor.

Interview with the Facility Commandant, Maintenance Supervisor, and Facility Staff on July 17, 2024, at 11:30 a.m., confirmed the listed electrical wiring systems and equipment deficiency.

Initial comments:Name: MAIN BUILDING - Component: 03 - Tag: 0000

Component 03
Main Building
(A Building)

On July 15, 2024, observation revealed that component three Main Building (A Building) is under construction and projected to be completed in September 2025.

Plan of Correction:

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