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 May 18, 2026, 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 May 18, 2026, 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 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 three instances, in three of 25 smoke compartments.

Findings include:

1. Observation on May 18, 2026, revealed the following automatic sprinkler system deficiencies:

a) 9:50 a.m., there was data cable supported by the sprinkler lines in the basement near the smoke doors next to the linen closet;
b) 10:10 a.m., there was a gap greater than 1/8 inch in the ceiling tile next to the kitchen fire suppression system, which would allow the passage of heat and smoke and may affect operation of the automatic sprinkler system;
c) 11:30 a.m., there was insulation supported by the sprinkler lines in the 3 South D hallway.

Interview with the Facility Commandant and Maintenance Director on May 18, 2026, at 2:00 p.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 06/18/2026

The gap greater than 1/8 inch next to the ceiling fires suppression system was sealed with 4 hour UL rated fire caulk. The data cable on the sprinkler pipe in the basement and the insulation on the sprinkler pipe in the 3S D hallway were secured and removed from the sprinkler pipe.

The Facility and Grounds Director and Institutional Fire and Safety Specialist will be educated on K0353- Sprinkler System Maintenance and Testing by the Deputy Commandant/designee.

The Facility and Grounds Director/IFSS/designee will conduct facility wide random inspections monthly x3. These documented inspections will include penetrations greater than 1/8" gap and maintenance of the automated sprinkler and standpipe systems. 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 Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors with smoke tight resistance in three instances, affecting five of twenty five smoke compartments.

Findings include:

1. Observation on May 18, 2026, revealed the following smoke barrier door deficiencies:

a) 10:10 a.m., the smoke doors at the entry to the PC Dining Room had a gap greater than 3/4 inch at the bottom when closed;
b) 11:00 a.m., the smoke doors leading to the F Hall on 2 North had a gap greater than 3/4 inch at the bottom when closed;
c) 11:35 a.m., the smoke doors to the A Hall on the first floor had a gap greater than 3/4 inch at the bottom when closed.

Interview with the Facility Commandant and Maintenance Director on May 18, 2026, at 2:00 p.m., confirmed the smoke barrier door deficiencies.

Plan of Correction - To be completed: 06/18/2026

The gaps of greater than � inch at the bottom of the PCD dining room door, smoke doors to the F hall on 2 North, and smoke doors to the A hall on the first floor was corrected by ordering approved panels and adding them to the bottom of each door at a height less than � inch from the floor. The Facility and Grounds Director/designee will audit other smoke doors to ensure there are no gaps greater than � inch at the bottom.

The Facility and Grounds Director and Institutional Fire and Safety Specialist will be educated on K0374 � Smoke Barrier Doors by the Deputy Commandant/designee.

The Facility and Grounds Director/IFSS/designee will conduct facility wide random inspections monthly x 3. These inspections will include ensuring smoke barrier doors do not have a gap of greater than � inches at the bottom. Any and all repairs/findings will be discussed at the quality assurance meetings. All corrections will be in accordance with all applicable NFPA codes.

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 wiring in one instance, in one of 25 smoke compartments. Installation shall be in accordance with NFPA 70, National Electric Code. 19.5.1.1, NFPA 101 (2012).

Findings include:

1. Observation on May 18, 2026, at 1:17 p.m., revealed an open electrical junction box above the ceiling in the Elevator 2 lobby.

Interview with the Facility Commandant and Maintenance Director on May 18, 2026, at 2:00 p.m.,confirmed the open electrical junction box.

Plan of Correction - To be completed: 06/18/2026

The open electrical junction box above the ceiling in the elevator 2 lobby was corrected by adding junction box cover to the open box.

The Facility and Grounds Director and Institutional Fire and Safety Specialist will be educated on K911- Electrical Systems � Other by the Deputy Commandant/designee
.
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.

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