Pennsylvania Department of Health
VINCENTIAN HOME
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 44 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


VINCENTIAN HOME - 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 5-6, 2025, at Vincentian Home, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: BUILDING 3 - 1957 - Component: 01 - Tag: 0000

Facility ID# 221002
Component 01
1959 Building

Based on a Medicare/Medicaid Recertification Survey completed on May 5-6, 2025, it was determined that Vincentian Home, 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 (000), unprotected noncombustible 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: BUILDING 3 - 1957 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting one of four smoke compartments.

Findings include:

1. Observation on May 6, 2025, at 10:50 a.m., revealed there was a penetration in the ceiling greater than 1/8 inch, in the Transfer Switch room, which would allow the passage of heat and smoke, and may affect operation of the automatic sprinkler system.

Interview with the Facility Administrator, Safety Manager, and Maintenance Director on May 6, 2025, at 1:00 p.m., confirmed the automatic sprinkler system deficiency.

Plan of Correction - To be completed: 06/23/2025

The facility immediately patched the hole greater than 1/8 inch in transfer switch room with two hour "red" rated fire patch to stop the passage heat and smoke to maintain proper operation of the automatic sprinkler system. The maintenance manager will train all staff to inspect the area for any other open penetrations and correct any other instances when found. The maintenance manager/designee will inspect the transfer switch room for open penetrations once a month for the next three months and report their findings to the QA committee.

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: BUILDING 3 - 1957 - Component: 01 - Tag: 0918

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

Findings include:

1. Review of documentation on May 5, 2025, at 8:30 a.m., revealed the facility could not produce documentation for the following required emergency generator maintenance and testing:

a) weekly testing of battery electrolyte levels or battery voltage;
b) monthly electrolyte specific gravity or conductance tests;

Interview with the Facility Administrator, Maintenance Director, and Safety Manager on May 6, 2025, at 1:00 p.m., confirmed the lack of documentation at the time of the survey.

Plan of Correction - To be completed: 06/23/2025

The facility immediately conducted a voltage test and conductance test on all batteries on Building 3 emergency generator and documented in emergency generator maintenance and testing log. The maintenance manager will train staff on how to properly conduct a voltage/conductance test and properly log the data into maintenance/testing logbook. The maintenance manager/designee will inspect the batteries and report the testing results on Building 3 emergency generator once a month for the next three months and report their findings to the QA committee.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: BUILDING 3 - 1957 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of four smoke compartments.

Findings include:

1. Observation on May 6, 2025, at 10:35 a.m., revealed two electric toasters plugged into a multi-plug adapter in the Employee Lounge.

Interview with the Facility Administrator, Safety Manager, and Maintenance Director on May 6, 2025, at 1:00 p.m., confirmed the misuse of a multi-plug adapter being used to power two toasters.

Plan of Correction - To be completed: 06/23/2025

The facility immediately removed and disposed of the multiplug with 2 electric toasters plugged into to maintain a safe electrical wiring system. The maintenance manager will train staff to inspect the area for any other unapproved use of multi-plug outlets and correct any other instances when found. The maintenance manager/designee will inspect all offices for unapproved multiplugs once a month for the next three months and report their findings to the QA committee

Initial comments:Name: BUILDING 4 - 1980 - Component: 02 - Tag: 0000

Facility ID# 221002
Component 02
1980 Building

Based on a Medicare/Medicaid Recertification Survey completed on May 5-6, 2025, it was determined that Vincentian Home, 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 (III), protected noncombustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: BUILDING 4 - 1980 - Component: 02 - Tag: 0918

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

Findings include:

1. Review of documentation on May 5, 2025, at 8:30 a.m., revealed the facility could not produce documentation for the following required emergency generator maintenance and testing:

a) weekly testing of battery electrolyte levels or battery voltage;
b) monthly electrolyte specific gravity or conductance tests;

Interview with the Facility Administrator, Maintenance Director, and Safety Manager on May 6, 2025, at 1:00 p.m., confirmed the lack of documentation at the time of the survey.

Plan of Correction - To be completed: 06/23/2025

The facility immediately conducted a voltage test and conductance test on all batteries on Building 4 emergency generator and documented in emergency generator maintenance and testing log. The maintenance manager will train staff on how to properly conduct a voltage/conductance test and properly log the data into maintenance/testing logbook. The maintenance manager/designee will inspect the batteries on Building 4 emergency generator and report the testing results on Building 4 emergency generator once a month for the next three months and report their findings to the QA committee.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

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.

Observations:
Name: BUILDING 4 - 1980 - Component: 02 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of 10 smoke compartments.

Findings include:

1. Observation on May 5, 2025, at 11:35 a.m., revealed there was an electrical extension cord being used as a fixed power source for an electric air conditioner in the Activities Storage room in the basement.

Interview with the Facility Administrator, Maintenance Director, and Safety Manager on May 6, 2025, at 1:00 p.m., confirmed the listed electrical wiring systems deficiency.

Plan of Correction - To be completed: 06/23/2025

The facility immediately removed the electrical extension cord for the room air conditioner to maintain a safe electrical wiring system. The maintenance manager will train staff to inspect all storage rooms in the basement of Building 4 for any other unapproved use of extension cord and correct any other instances when found. The maintenance manager/designee will inspect all storage rooms in the basement of Building 4 for unapproved use of extension cords once a month for the next three months and report their findings to the QA committee.

Initial comments:Name: BUILDINGS 1-2 - 2000 - Component: 04 - Tag: 0000

Facility ID# 221002
Component 04
New Addition 2008

Based on a Medicare/Medicaid Recertification Survey completed on May 5-6, 2025, it was determined that Vincentian Home, 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 (III), protected noncombustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: BUILDINGS 1-2 - 2000 - Component: 04 - Tag: 0918

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

Findings include:

1. Review of documentation on May 5, 2025, at 8:30 a.m., revealed the facility could not produce documentation for the following required emergency generator maintenance and testing:

a) weekly testing of battery electrolyte levels or battery voltage;
b) monthly electrolyte specific gravity or conductance tests;

Interview with the Facility Administrator, Maintenance Director, and Safety Manager on May 6, 2025, at 1:00 p.m., confirmed the lack of documentation at the time of the survey.

Plan of Correction - To be completed: 06/23/2025

The facility immediately conducted a voltage test and conductance test on all batteries on Building 1-2 emergency generator and documented in emergency generator maintenance and testing log. The maintenance manager will train staff on how to properly conduct a voltage/conductance test and properly log the data into maintenance/testing logbook. The maintenance manager/designee will inspect the batteries and report the testing results on Building 1-2 emergency generator once a month for the next three months and report their findings to the QA committee.

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