Pennsylvania Department of Health
TRANSITIONAL CARE UNIT AT NAZARETH HOSPITAL, THE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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TRANSITIONAL CARE UNIT AT NAZARETH HOSPITAL, THE - 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 17, 2026, at The Transitional Care Unit at Nazareth Hospital, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: ST JOSEPH'S BUILDING (TRANSITIONAL CARE UNIT) - Component: 01 - Tag: 0000
Facility ID# 400302Component 01St. Joseph's BuildingBased on a Medicare/Medicaid Recertification Survey completed on February 17, 2026, it was determined that The Transitional Care Unit at Nazareth Hospital - St Joseph's Building 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 seven-story, Type II (222), fire resistive building, with a ground floor, basement, and a penthouse, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD HVAC:

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.

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: ST JOSEPH'S BUILDING (TRANSITIONAL CARE UNIT) - Component: 01 - Tag: 0521 Based on document review and interview, it was determined the facility failed to maintain Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting one of seven levels. Based on document review and interview, it was determined the facility failed to maintain Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting one of seven levels. Findings include: 1. Document review on February 17, 2026, at 9:30 am, revealed February 2025, Fire Damper Inspection Report listed 8- dampers as deficient or inaccessible, evidence of corrective action and subsequent testing was not available at time of survey. Exit Interview with the Facilities Operations Manager on February 17, 2026, at 11:30 am, confirmed the missing documentation.

Plan of Correction - To be completed: 04/14/2026

*The fire dampers that were noted as deficient or inaccessible will be inspected by a 3rd party inspection agency at first available appointment time of 4/14/2026.
*All needed repaired will be completed by the 3rd party vendor
*all documentation will be provided to NHA at time of completion
*All future inspections will be monitored by work order and future quality meetings for review

NFPA 101 STANDARD Electrical Systems - Maintenance and Testing:

Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)

Observations:
Name: ST JOSEPH'S BUILDING (TRANSITIONAL CARE UNIT) - Component: 01 - Tag: 0914 Based on document review and interview it was determined the facility failed to provide annual receptacle testing in patient care rooms at bed locations within this facility. Findings include: 1. Document review on February 17, 2026, at 9:30 am, revealed the facility was unable to provide documentation showing annual receptacle testing at patient bed locations was performed during the prior 12-month period. Exit Interview with the Facilities Operations Manager on February 17, 2026, at 11:30 am, confirmed the missing documentation.

Plan of Correction - To be completed: 04/03/2026

*Electrical Systems maintenance and testing was completed and deficiencies corrected by 2/27/2026.
*This will be monitored via a preventative maintenance work order annually
*Receipt of this process will be provided to the administrator of the TCU at time of completion each year.
* This will be added to the Quarterly Quality meeting as an agenda item

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: ST JOSEPH'S BUILDING (TRANSITIONAL CARE UNIT) - Component: 01 - Tag: 0918 Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, affecting the entire facility. Findings include: 1. Document review on February 17, 2026, at 9:00 am, revealed the facility lacked documentation indicating performance of monthly testing and recording of battery conductance testing. (Refer to NFPA 110.8.3.7.1) Exit Interview with the Facilities Operations Manager on February 17, 2026, at 11:30 am, confirmed the missing documentation.

Plan of Correction - To be completed: 04/03/2026

0918
Electrical systems Essential Electric Systems Generator battery conductance testing will be completed by 3/31/26

In addition, this testing will be completed by the last day of the following months

This will be monitored by work order

Documentation will be provided to NHA

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