Pennsylvania Department of Health
SOUTHMONT OF PRESBYTERIAN SENIORCARE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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SOUTHMONT OF PRESBYTERIAN SENIORCARE - 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 April 29, 2025, at Southmont of Presbyterian Senior Care, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

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

Facility ID# 422902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 29, 2025, it was determined that Southmont of Presbyterian Seniorcare 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 four-story, Type II (222), fire resistive building, with a basement, that 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 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.

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 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain a smoke resistant ceiling for proper operation of the automatic sprinkler and fire detection devices mounted on the ceiling, in one instance, affecting one of over 50 rooms inspected.

Findings include:

1. Observation on April 29, 2025, at 10:10 a.m., revealed a hanging escutcheon in the dietary closet in the kitchen, which created an opening in the ceiling.

Interview with the Facility Administrator and Maintenance Staff on April 29, 2025, at 12:30 p.m., confirmed the hanging escutcheon.

Plan of Correction - To be completed: 05/27/2025

Escutcheon in the dietary closet in the kitchen has been adjusted to close the opening in the ceiling. An audit of the rest of the kitchen will be completed to check for any escutcheons that are not flush with the ceiling. Maintenance employees will be reeducated that escutcheons must be flush with the ceiling so that an opening in the ceiling is not created. Audits will be completed of 5 rooms weekly times 4 and monthly times 3. Results will be brought to QAPI to determine if further audits are necessary.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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.

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 01 - Component: 01 - Tag: 0918

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

Findings include:

1. Review of documentation on April 29, 2025, at 8:30 a.m., revealed the facility could not produce documentation for the weekly inspections of battery electrolyte levels or battery voltage.

Interview with the Facility Administrator and Maintenance Staff on April 29, 2025, at 12:30 p.m., confirmed the lack of documentation at the time of the survey.

Plan of Correction - To be completed: 05/27/2025

Documentation of the weekly inspections of the generator battery electrolyte levels will be started. Maintenance employees will be reeducated that the generator battery electrolyte levels must be checked weekly. Audits will be completed weekly times 4 and monthly times 3 by maintenance director or designee. Results will be brought to QAPI to determine if further audits are necessary.

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