Pennsylvania Department of Health
SOUTHWESTERN VETERANS CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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SOUTHWESTERN 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 April 28-29, 2025, at Southwestern 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 01 - Component: 01 - Tag: 0000

Facility ID# 068802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 28-29, 2025, it was determined that Southwestern 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 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 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.

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 several instances, affecting four of 25 smoke compartments.

Findings include:

1. Observation on April 28, 2025, at 10:55 a.m., revealed several self-closing devices removed from doors after change of occupancy. The changes were not indicated on the portable life safety drawings.

Interview with Maintenance Director and Security Manager on April 28, 2025, at 2:30 p.m.,confirmed the self-closing door deficiencies.

Plan of Correction - To be completed: 06/04/2025

The self-closing devices were reinstalled on the 2 South D Hall Office and 3 North B Hall Office doors on 4/24/2025.

The Facility and Grounds Director and Institutional Fire and Safety Specialist will be educated on K223- Doors with Self-Closing Devices.

The Facility and Grounds Director/IFSS/designee will conduct facility wide random inspections monthly x3. These documented inspections will include a random sample of doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous 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. Any repairs and findings will be discussed at the quality assurance meetings. All corrections will be in accordance with applicable NFPA Codes.

NFPA 101 STANDARD HVAC:

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.

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: MAIN BUILDING 01 - 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 the entire facility.

Findings include:

1. Document review on April 28, 2025, at 9:15 a.m., revealed the January 12, 2023, fire damper inspection report listed 14 smoke dampers failed inspection for being deficient or in need of repairs. Documentation of subsequent repairs was not available at time of survey.

Interview with the Commandant and Facility Staff on April 29, 2025, at 1:30 p.m., confirmed the missing smoke damper documentation.

Plan of Correction - To be completed: 06/04/2025

The 14 smoke dampers identified on the January 12, 2023 will be repaired by the contracted vendor.

The Facility and Grounds Director and Institutional Fire and Safety Specialist will be educated on K521- HVAC.

The Facility will maintain compliance with fire damper inspections by scheduling them according to the prescribed intervals and ensuring any identified deficiencies are remedied upon receipt of the report of deficiency.

NFPA 101 STANDARD Electrical Systems - Other:

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 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 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain electrical equipment in two instances, affecting two of 25 smoke compartments. Installation shall be in accordance with NFPA 70, National Electric Code. 19.5.1.1, NFPA 101

Findings include:

1. Observation on April 28, 2025, at 9:55 a.m., revealed that there was an open electrical junction box above the smoke doors in hallway "A".

Interview with the Commandant and Facility Staff on April 29, 2025, at 1:30 p.m., confirmed the open electrical junction box.

2. Observation on April 29, 2025, at 10:05 a.m., revealed a low voltage electrical junction box, possibly used for HVAC automation, was open with multiple low voltage wire sets exposed and hanging outside, above, and below the junction box.

Interview with the Commandant and Facility Staff on April 29, 2025, at 1:30 p.m., confirmed the open electrical junction box.

Plan of Correction - To be completed: 06/04/2025

The contracted vendor will ensure the junction boxes above the smoke doors in hallway "A" and the low voltage electrical junction boxes have cover plates installed.

The Facility and Grounds Director and Institutional Fire and Safety Specialist will be educated on K911- Electrical Systems � Other.

The Facility and Grounds Director/IFSS/designee will conduct facility wide random inspections monthly x3. These documented inspections will include a random audit of electrical junction boxes to ensure cover plates are on the junction box. Any repairs and findings will be discussed at the quality assurance meetings. All corrections will be in accordance with applicable NFPA Codes.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to properly store oxygen cylinders in several instances, affecting four of twenty five smoke compartments.

Findings include:

1. Observation on April 28, 2025, at 11:15 a.m., revealed several oxygen cylinders stored in unmarked rooms throughout the building.

Interview with Maintenance Director and Security Manager on April 28, 2025, at 2:30 p.m., confirmed the listed cylinder storage deficiencies.

Plan of Correction - To be completed: 06/04/2025

The rooms that contain the facility crash carts with an oxygen cylinder were marked precautionary sign.

The Facility and Grounds Director and Institutional Fire and Safety Specialist will be educated on K923 � Gas Equipment Cylinder and Container Storage.

The Facility and Grounds Director/IFSS/designee will conduct facility wide random inspections monthly x3. These documented inspections will include inspections of rooms containing oxygen to ensure precautionary signage is present. Any repairs and findings will be discussed at the quality assurance meetings. All corrections will be in accordance with applicable NFPA Codes.

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