Pennsylvania Department of Health
 SOUTHEASTERN PENNSYLVANIA VETERANS' CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SOUTHEASTERN PENNSYLVANIA VETERANS' CENTER
Inspection Results For:

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SOUTHEASTERN PENNSYLVANIA VETERANS' CENTER - 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 21, 2025, at Southeastern Pennsylvania Veterans' Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


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


Facility ID #426002
Component 01
Main Building (Coates Hall)

Based on a Medicare/Medicaid Recertification Survey completed on May 21, 2025, it was determined that Southeastern Pennsylvania Veterans' Center 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 five-story, Type II (222), fire resistive structure, with a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING - COATES HALL - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain the means of egress as unobstructed and ready for full and instant use, affecting one of five floors within the component.

Findings include:

1. Observation on May 21, 2025, at 11:09 AM, revealed the 1st floor door to the East Stairtower Exit Enclosure, within the Volunteers' Office, was obstructed by two folding tables.

Interview with the Director of Facilities and Grounds on May 21, 2025, at 11:09 AM, confirmed the means of egress was obstructed.



 Plan of Correction - To be completed: 07/20/2025

1. Removed the 2 folding tables that obstructed the means of egress.
2. Audited current facility egress door list for accuracy and noted that Volunteer Office was not included in the list. Moved folding tables and added door to new audit tool.
3. The Audit of all egress door checks will be completed by maintenance staff monthly for 12 months. Maintenance Supervisor/designee will monitor for compliance. The audit results will be reported at the monthly QA Committee.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING - COATES HALL - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of exit stairtower enclosures, affecting two of five floors within the component.

Findings include:

1. Observation on May 21, 2025, at 9:34 AM, revealed the 3rd floor West Stairtower access panel did not automatically close and latch within the frame.

Interview with the Director of Facilities and Grounds on May 21, 2025, at 9:34 AM, confirmed the access panel did not automatically close and positively latch within the frame.


2. Observation on May 21, 2025, at 10:35 AM, revealed the 2nd floor West Stairtower access panel did not automatically close and latch within the frame.

Interview with the Director of Facilities and Grounds on May 21, 2025, at 10:35 AM, confirmed the access panel did not automatically close and positively latch within the frame.




 Plan of Correction - To be completed: 07/20/2025

1. The 2 West Stairtower access panel doors had their closing springs repaired so that they positively latched.
2. Created a monthly PM to check all the access panel doors.
3. The IFSS/ or designee will monitor for compliance and report to QA Committee monthly.


NFPA 101 STANDARD Exit Signage: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.
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 - COATES HALL - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed to maintain the illumination of emergency exit signage, affecting one of five floors within the component.

Findings include:

1. Observation on May 21, 2025, at 12:47 PM, revealed the 1st floor west end exit sign, within the Adult Learning Center, was equipped with integrated lighting which did not function.

Interview with the Director of Facilities and Grounds on May 21, 2025, at 12:47 PM, confirmed the internal illumination of the exit sign did not operate.


 Plan of Correction - To be completed: 07/20/2025

1. The defective "EXIT" sign was replaced
with a sign that met NFPA 101 standard.
2. The facility will monitor exit sign function during monthly PM inspections.
Report findings to monthly QA Committee meeting.
3. The Maintenace Supervisor/designee will monitor for compliance.

NFPA 101 STANDARD Corridor - Doors: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.
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: MAIN BUILDING - COATES HALL - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain the unobstructed closing of corridor doors, affecting one of five floors within the component.

Findings include:

1. Observation on May 21, 2025, at 10:05 AM, revealed the 3rd floor door to Resident Room 348 was obstructed from closing, by a gallon water jug.

Interview with the Director of Facilities and Grounds on May 21, 2025, at 10:05 AM, confirmed the obstructed corridor door.




 Plan of Correction - To be completed: 07/20/2025

1. Facility removed the obstruction.
2. Maintenance met with the resident in room 348 and discussed his door preferences.
3. Maintenance will mark the floor to indicate the door position as per resident preference.
4. Educate staff with resident request for door opening preference angle.
5. Maintenance staff will complete a facility wide audit of all corridor doors; Followed by completion of random door audits monthly. Maintenance Supervisor/designee will monitor for compliance.
6. Audit results will be reported at monthly QA Committee.

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


Facility ID #426002
Component 02
Building 02 - Tilghman Hall

Based on a Medicare/Medicaid Recertification Survey completed on May 21, 2025, it was determined that Southeastern Pennsylvania Veterans' Center 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 (111), protected noncombustible structure, without a basement, which 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 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: BUILDING 02 - TILGHMAN HALL - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system to be free from extraneous weight, affecting one of two floors within the component.

Findings include:

1. Observation on May 21, 2025, at 11:31 AM, revealed a conduit, zip-tied to sprinkler piping in the Entrance Lobby, by the double doors to Component 01, was used to support various wires.

Interview with the Director of Facilities and Grounds on May 21, 2025, at 11:31 AM, confirmed the conduit and wires were supported by the sprinkler system.




 Plan of Correction - To be completed: 07/20/2025

1. Facility maintenance that is located in the Entrance Lobby at Tilghman/Coates Hall. Staff freed the wires from their attachment to the wires and the conduit, so they are no longer weighted to sprinkler piping.
2. Maintenace Supervisor/Designee will inspect post construction areas that involved wiring for compliance of NFPA 101 standards.
3. Maintenance Supervisor/Designee will monitor for compliance. Department staff will audit monthly for 12 months, as construction occurs. Audit results will be reported to monthly QA Committee.
Initial comments:Name: COMMUNITY LIVING CENTER - NEW SKILLED CARE - Component: 03 - Tag: 0000


Facility ID #426002
Component 03
Community Living Center - New Skilled Care

Based on a Medicare/Medicaid Recertification Survey completed on May 21, 2025, it was determined that Southeastern Pennsylvania Veterans' Center 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 structure, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Alcohol Based Hand Rub Dispenser (ABHR):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.
Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Observations:
Name: COMMUNITY LIVING CENTER - NEW SKILLED CARE - Component: 03 - Tag: 0325

Based on observation and interview, it was determined the facility failed to monitor the installation of alcohol based hand rub dispensers, affecting one of four floors within the component.

Findings include:

1. Observation on May 20, 2025, at 1:17 PM, revealed an alcohol based hand rub dispenser located directly above an electrical receptacle, within 3rd floor Bath Room A347.

Interview with the Director of Facilities and Grounds on May 20, 2025, at 1:17 PM, confirmed the alcohol based hand rub dispenser was located above an ignition source.




 Plan of Correction - To be completed: 07/20/2025

1. Facility relocated the 3rd floor congregate bathroom alcohol-based hand sanitizer dispenser.
2. Facility audit was performed to find other dispensers out of compliance. Issues all corrected.
3. Maintenance will be the only department to install any alcohol-based sanitizer dispensers to ensure compliance.
4. Maintenance Supervisor will monitor for compliance using the electronic maintenance work order system. Audit results will be reported to the monthly QA Committee.









NFPA 101 STANDARD Corridor - Doors: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.
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: COMMUNITY LIVING CENTER - NEW SKILLED CARE - Component: 03 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain the positive latching of corridor doors, affecting one of four floors within the component.

Findings include:

1. Observation on May 20, 2025, at 12:20 PM, revealed the 4th floor door to Electrical Room A442 failed to positively latch within the door frame.

Interview with the Director of Facilities and Grounds on May 20, 2025, at 12:20 PM, confirmed the corridor door did not latch within the frame.


 Plan of Correction - To be completed: 07/20/2025

1. Facility adjusted the Electrical Room door A442 to positively latch.
2. Audit for monthly door checks for properly operation. Report to QA Committee monthly with results.
3. Maintenance Supervisor/designee will monitor for compliance.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: COMMUNITY LIVING CENTER - NEW SKILLED CARE - Component: 03 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of smoke barrier walls, affecting one of four floors within the component.

Findings include:

1. Observation on May 20, 2025, at 1:50 PM, revealed an unprotected penetration of the 2nd floor smoke barrier wall, located above the double doors by Equipment Storage Room A250, around white wires.

Interview with the Director of Facilities and Grounds on May 20, 2025, at 1:50 PM, confirmed the unprotected penetration of the smoke barrier wall.


 Plan of Correction - To be completed: 07/20/2025

 1. Facility maintenance staff filled penetration, located in 2nd floor smoke barrier wall at Equipment Storage Room A250, with approved through penetration fire stop system.

2. Maintenace Supervisor/Designee will inspect post construction areas that involved wiring for compliance of NFPA 101 standards. Facility will maintain the rating of the smoke barrier walls.

3. Maintenance Supervisor/Designee will monitor for compliance. Department staff will audit monthly for 12 months, as construction occurs. Audit results will be reported to the monthly QA Committee.


NFPA 101 STANDARD Gas Equipment - Precautions for Handling Oxyg: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.
Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds
Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99)
11.6.2 (NFPA 99)
Observations:
Name: COMMUNITY LIVING CENTER - NEW SKILLED CARE - Component: 03 - Tag: 0929

Based on observation and interview, it was determined the facility failed to secure portable oxygen cylinders, affecting one of four floors within the component.

Findings include:

1. Observation on May 20, 2025, at 2:33 PM, revealed an unsecured portable oxygen cylinder, located within 1st floor Mechanical Room C104.

Interview with the Director of Facilities and Grounds on May 20, 2025, at 2:33 PM, confirmed the portable oxygen cylinder was not secured.



 Plan of Correction - To be completed: 07/20/2025

1. Oxygen canister was removed from 1st floor Mechanical Room C104 and relocated to designated oxygen storage area.
2. Other Mechanical Storage rooms were checked to see if other rooms were in compliance and w/o oxygen.
3. IFSS will monitor for compliance. Added Mechanical room to monthly Safety Rounds
to audit compliance. Report will also be sent to the monthly QA Committee.

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