Pennsylvania Department of Health
NURSING AND REHABILITATION AT THE MANSION
Building Inspection Results

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NURSING AND REHABILITATION AT THE MANSION
Inspection Results For:

There are  41 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.
NURSING AND REHABILITATION AT THE MANSION - 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 January 26, 2024, at Nursing and Rehabilitation at the Mansion, 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# 130502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 26, 2024, it was determined that Nursing and Rehabilitation at the Mansion 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 483.70(a).

This is a three story, Type V (000), unprotected, wood frame building, with a partial attic and a partial basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting five of five smoke compartments.

Findings include:

1. Observation on January 26, 2024, between 9:00 am and 11:00 am, revealed the building story height exceeds the maximum allowable by two stories.

Exit interview with the facility administrator and facility maintenance at 11:30 am, on January 26, 2024, confirmed the building story height exceeds the maximum allowable by two stories.




 Plan of Correction - To be completed: 03/13/2024

Nursing and Rehabilitation at the Mansion request to continue to use FSES regarding 0161
NFPA 101 STANDARD Number of Exits - Corridors: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.
Number of Exits - Corridors
Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies.
18.2.5.4, 19.2.5.4




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0252

Based on observation and interview, it was determined the facility failed to provide not less than two exits, remote from one another, affecting five of five smoke compartments.

Findings include:

1. Observation on January 26, 2024, between 10:35 am and 10:55 am, revealed the second and third floor lacked an acceptable, second means of egress.

Exit interview with the facility administrator and facility maintenance at 11:30 am, on January 26, 2024, confirmed the lack of an acceptable, second means of egress from the second and third floors.



 Plan of Correction - To be completed: 03/13/2024

Nursing and Rehabilitation at the Mansion request to continue to use FSES regarding 0252
NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain doors to hazardous areas on one of three floors.

Findings include:
1. Observation on January 26, 2024, at 10:30 am, revealed the door to the basement level laundry room was not tight fitting in the frame with gaps on the latch side exceeding allowable tolerances.
Exit interview with the facility administrator and facility maintenance at 11:30 am, on January 26, 2024, confirmed the door was not smoke tight in the frame.





 Plan of Correction - To be completed: 03/13/2024

The basement level laundry room door will be corrected to be tight fitting in the frame to ensure no gaps on the latch side.

We will audit 15% of doors monthly in building to ensure we are in compliance regarding frame door fittings in our TELS system. We will review monthly at QAIP X 3 months.
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 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors in one of five smoke compartments.

Findings include;

1. Observation on January 26, 2024, at 10:50 am, revealed the door to room 106 was not smoke tight when latched in the frame.

Exit interview with the facility administrator and facility maintenance at 11:30 am, on January 26, 2024, confirmed the door lacked smoke tight integrity.




 Plan of Correction - To be completed: 03/13/2024

The door on room 106 will be corrected to ensure when latched in the frame will be smoke tight.

We will audit 15% of doors monthly in building to ensure we are in compliance regarding smoke tight frames of doors in our TELS system. We will review monthly at QAIP X 3 months.
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of unauthorized power taps and and electrical devices.

Findings include;
1. Observation on January 26, 2024, between 10:45 am and 11:00 am, revealed the following:
a. At 10:45 am, an outlet multiplier was in use in room 203.
b. At 11:00 am, medical equipment was being powered by an extension cord in room 103.

Exit interview with the facility administrator and facility maintenance at 11:30 am, on January 26, 2024, confirmed the electrical devices were in use.




 Plan of Correction - To be completed: 03/13/2024

The outlet multiplier in use in room 203 and the extension cord in room 103 have been removed from use.

We will audit 15% of rooms to ensure we are not utilizing outlet multipliers or extension cords not appropriately in our TELS system. We will review monthly X 3 in QAIP

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