Pennsylvania Department of Health
CHAPEL MANOR
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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CHAPEL MANOR - 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 June 30, 2026, at Chapel Manor, 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# 031602

Component 01

Based on a Medicare/Medicaid Recertification Survey completed on June 30, 2026, it was determined that Chapel Manor was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 (222), fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

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, affecting two of three levels within the facility. Findings include: 1. Observation on June 30, 2026, between 10:30 a.m., and 1:15 p.m., revealed: a) Basement laundry room door, failed to positively latch when tested. b) Basement large storage room (old gym) had two doors to corridor, that are not equipped with door closures. c) Second floor Soiled Linen room door across from nurses' station did not latch when closed due to paper towels stuffed into the strike plate. d) Second floor, C-Wing soiled utility room door did not latch when tested. e) Second floor, D-Wing storage room door, did not latch when closed due to paper towels stuffed into the strike plate. f) Second floor, D- Wing, environmental services closet door, did not latch when closed due to paper towels stuffed into the strike plate. g) Second floor, D-Wing Soiled linen room door, did not latch automatically when closed, due to a digital combination pad lock installed where the door handle hardware was removed. Exit interview with the Administrator and Maintenance Supervisor on June 30, 2026 at 1:30 p.m., confirmed the doors failed to latch.

Plan of Correction - To be completed: 08/12/2026

CHAPEL MANOR HAS REQUESTED A TIME LIMITED WAIVOR FOR BASEMENT LAUNDRY ROOM DOOR WITH A COMPLETION DATE OF 12/29/2026

1.Basement laundry room door (TLW REQUESTED), C wing - Soiled Utility Room doors,D wing - Storage Room, Environmental storage closet and Soiled linen room doors have been repaired to ensure the doors close and latch as designed. Self-closing hardware was installed in the basement storage room doors.
2.NHA will educate the Maintenance department on ensuring that all hazardous area doors close and latch, and have proper hardware installed.
3.NHA/designee will complete random weekly audits x 3 weeks and monthly x 1 monthly to ensure that hazardous area doors close and latch.
4.Maintenance Director will report audit findings to the QAPI Committee x 3 months for review.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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 ensure the automatic sprinkler system and its components were maintained, affecting the entire facility. Findings include: Observation made on June 30, 2026, at 10:40 a.m., revealed inside the sprinkler room, the sprinkler gauges were dated 2020 with indicated that the gauges were not within their 5-year calibration compliance. Exit interview with the Administrator and Maintenance Supervisor on June 30, 2026, at 1:30 p.m., confirmed the sprinkler gauges were dated 2020.

Plan of Correction - To be completed: 08/12/2026

1.A sprinkler gauge inspection has been scheduled.
2.NHA will educate the Maintenance department to ensure the automatic sprinkler system components are properly inspected and maintained.
3.NHA/designee will complete random weekly audits x 3 weeks and monthly x 1 month to ensure that the sprinkler system components are maintained and inspected.
4.Maintenance Director will report audit findings to the QAPI Committee x 3 months for review.

NFPA 101 STANDARD Corridor - Doors:

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 ensure there were noimpediments to the closing and latching of the corridor doors on two of three levels within the facility. Findings include: 1. Observations on June 30, 2026, revealed: a) 11:30 a.m., second floor resident room C205, failed to latch. b) 10:45 a.m., basement kitchen door's hardware was damaged and did not latch. Exit interview with the Administrator and Maintenance Supervisor on June 30, 2026, at 1:30 p.m., confirmed the door did not latch.

Plan of Correction - To be completed: 08/12/2026

1.Room C205 and basement kitchen doors have been repaired to ensure the door properly closes and latches.
2.NHA will educate the Maintenance department to ensure all corridor doors close and latch as designed.
3.NHA/designee will complete random weekly audits x 3 weeks and monthly x 1 month to ensure that all corridor doors close and latch as designed.
4.Maintenance Director will report audit findings to the QAPI Committee x 3 months for review.

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