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 May 13, 2026, 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 May 13, 2026, 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 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: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain self-closing doors in three instances, affecting one of fourteen smoke compartments.

Findings include:

1. Observation on May 13, 2026, revealed the following self-closing door deficiencies:

a) 10:00 a.m., the door to mechanical room 237 failed to latch when tested;
b) 10:40 a.m., the door to vending area failed to latch when tested;
c) 11:00 a.m., the center door in the laundry room failed to latch when tested.

Interview with the Director of Nursing and Maintenance Director on May 13, 2026, at 2:00 p.m., confirmed the above listed self-closing door deficiencies.

Plan of Correction - To be completed: 06/15/2026

The mechanical room 237 door in the main kitchen, the Vending area door, and the Center laundry room door were all immediately adjusted to ensure the door is self-closing and latches to maintain the smoke compartment. The Maintenance Director will educate the maintenance staff that all doors must close and latch at all times. The maintenance director will audit 3 doors once a month for the next three months and report his findings to the QA committee.

NFPA 101 STANDARD Exit Signage:

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed to maintain exit signage in one instance, affecting one of fourteen smoke compartments.

Findings Include:

1. Observation on May 13, 2026, at 11:20 a.m., revealed an exit sign on the second floor in the elevator lobby had a faulty or dead backup battery.

Interview with the Director of Nursing and Maintenance Director on May 13, 2026, at 2:00 p.m., confirmed the exit sign battery was not functioning.

Plan of Correction - To be completed: 06/15/2026

The facility immediately replaced the faulty battery backup exit sign on the second-floor elevator lobby with a new battery backup exit sign. Maintenance Director will reeducate maintenance staff during the monthly exit sign inspection that any exit signs that fail to light up during battery test will be replaced immediately and report his findings to the Maintenance Director. Maintenance Director will audit 3 exit signs once a month for the next three months and report his findings to the QA committee.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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 the automatic sprinkler system in two instances, affecting two of fourteen smoke compartments.

Findings include:

1. Observation on May 13, 2026, revealed the following automatic sprinkler deficiencies:

a) 10:15 a.m., there were multiple dirty/dusty sprinkler heads on 5 East Wing, near the elevator lobby;
b) 10:50 a.m., there was flexible electrical MC conduit supported by a sprinkler branch line, near the ceiling in Room 324.

Interview with the Director of Nursing and Maintenance Director on May 13, 2026, at 2:00 p.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 06/15/2026

The facility immediately cleaned the five sprinkler heads on the East Wing near the elevator lobby. Maintenance Director will educate maintenance staff that sprinkler heads cannot be dirty/dusty. Maintenance Director or designee will audit five sprinkler heads once a month for the next three months and report his findings to the QA committee.

The facility immediately removed the MC conduit from the sprinkler branch line near the ceiling in Room 324. Maintenance Director will reeducate maintenance staff that no wires can be supported or in contact with sprinkler branch lines. Maintenance Director or designee will audit one location for any wires on sprinkler branch line once a month for the next three months and report his findings to the QA committee.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform one of 12 required fire drills, affecting the entire facility.

Findings include:

1. Review of documentation on May 13, 2026, at 8:50 a.m., revealed the facility lacked documentation for a third shift fire drill, in the second quarter.

Interview with the Director of Nursing and Maintenance Director on May 13, 2026, at 2:00 p.m., confirmed the facility lacked documentation for the required fire drill in the last twelve months.

Plan of Correction - To be completed: 06/15/2026

On 5/14/26 the facility conducted a 3rd shift a fire drill at 3:00am. Maintenance Director will provide a fire drill schedule for the maintenance staff with dates and times when fire drills are to be conducted at various shifts and locations. Maintenance director will educate maintenance staff that fire drills must be completed as per schedule. Maintenance Director or designee will audit the fire drill logbook once a month for the next 6 months to ensure fire drills are being conducted once a month and every fire drill is being conducted on every shift per quarter and report his findings to the QA committee.

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