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 September 23, 2025, it was determined that Chapel Manor had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:

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.

§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.

Observations:
Name: - Component: -- - Tag: 0004 Based on documentation review and interview, it was determined the facility failed to ensure Emergency Preparedness Plan policies and procedures were reviewed and updated at least annually, affecting the entire facility. Findings include: 1. Document review on September 23, 2025, at 8:30 a.m., revealed the Facility's Emergency Preparedness Plan had not been reviewed and updated at least annually. Exit interview with the Administrator, Regional Maintenance Director and Maintenance Director on September 23, 2025, at 12:15 p.m., confirmed the above deficiency.

Plan of Correction - To be completed: 01/07/2026

Emergency Preparedness Manual has been reviewed and updated for 2025-2026.

NHA will educate the Maintenance Department on ensuring that the Emergency
Preparedness Manual is reviewed and updated at least annually.

NHA/Maintenance Director will review the Emergency Preparedness Manual quarterly
and make necessary changes to the plan.

Maintenance Director will report any changes to the Emergency Preparedness manual quarterly to the QAPI/Safety Committee for review.

403.748(c)(2), 416.54(c)(2), 418.113(c)(2), 441.184(c)(2), 482.15(c)(2), 483.475(c)(2), 483.73(c)(2), 484.102(c)(2), 485.542(c)(2), 485.625(c)(2), 485.68(c)(2), 485.727(c)(2), 485.920(c)(2), 486.360(c)(2), 491.12(c)(2), 494.62(c)(2) STANDARD Emergency Officials Contact Information:

§403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2).

[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:

(2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.

*[For LTC Facilities at §483.73(c):] (2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) The State Licensing and Certification Agency.
(iii) The Office of the State Long-Term Care Ombudsman.
(iv) Other sources of assistance.

*[For ICF/IIDs at §483.475(c):] (2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.
(iii) The State Licensing and Certification Agency.
(iv) The State Protection and Advocacy Agency.

Observations:
Name: - Component: -- - Tag: 0031 Based on documentation review and interview, it was determined the facility failed to ensure the Emergency Preparedness Plan included all Emergency Officials Contact information, including Federal, State, tribal, regional, and local emergency preparedness staff affecting the entire facility. Findings include: 1. Document review on September 23, 2025, at 8:30 a.m., revealed the Facility's Emergency Preparedness Plan did not include federal, state, and regional contact information in the Emergency Officials Contact Information. Exit interview with the Administrator, Regional Maintenance Director and Maintenance Director on September 23, 2025, at 12:15 p.m., confirmed the above deficiency.

Plan of Correction - To be completed: 01/07/2026

The Emergency Preparedness Manual has been updated to include Emergency
Officials contact information to include Federal, State. Tribal, Regional and local Emergency Preparedness staff.

NHA will educate the Maintenance department to ensure all emergency contacts are included in the Emergency Preparedness Plan and updated as needed.

NHA/Maintenance Director will review the Emergency Preparedness Manual quarterly
and make necessary changes to emergency contacts in the plan.

Maintenance Director will report any changes to the Emergency Preparedness manual quarterly to the QAPI/Safety Committee for review.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000
Facility ID# 031602Component 01Based on a Medicare/Medicaid Recertification Survey completed on September 23, 2025, 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 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 ensure that doors to hazardous area enclosures are self-closing and positively latching, affecting one of three levels. Findings include: 1. Observation on September 23, 2025, revealed a magnetically held fire door device failed to release when tested, First Floor near room A-127. Exit interview with the Administrator, Regional Maintenance Director and Maintenance Director on September 23, 2025, at 12:15 p.m., confirmed the deficient maglock.

Plan of Correction - To be completed: 01/07/2026

Magnetically held fire door that failed to release when tested was repaired.

NHA will educate the Maintenance Department on ensuring magnetically held fire doors release as designed.

NHA/designee will complete random weekly audits x 3 weeks and monthly x 1 month to
ensure that magnetically held doors release.

Maintenance Director will report audit findings to the QAPI Committee x 3 months for review.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225 Based on observation and interview, it was determined the facility failed to ensure that exit stair tower enclosures maintained the fire resistive rating, affecting one of three levels. Findings include: 1. Observation made on September 23, 2025, from 10:20 a.m., to 11:00 a.m., revealed stair tower doors that failed to close and latch at the following locations: a. 10:20 a.m., East Stair Tower single door, Basement Business Office. b. 11:00 a.m., Middle Stair Tower double doors, Basement Corridor. Exit interview with the Administrator, Regional Maintenance Director and Maintenance Director on September 23, 2025, at 12:15 p.m., confirmed the doors failed to close and latch.

Plan of Correction - To be completed: 01/07/2026

East Stair Tower and Middle Stair Tower doors have been repaired to ensure the doors close and latch as designed.

NHA will educate the Maintenance department to ensure that fire rated doors close and latch as designed.

NHA/designee will complete random weekly audits x 3 weeks and monthly x 1 month to
ensure that fire rated doors close and latch as designed.

Maintenance Director will report audit findings to the QAPI Committee x 3 months for review.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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 a hazardous area enclosure on two of three levels of the facility. Findings include: 1. Observation on September 23, 2025, between 10:00 a.m., and 12:00 p.m., revealed: a) Basement Laundry room door failed to close and latch. b) Second floor, Soiled utility room next to room 217 failed to close and latch due to tape over the door strike. c) Second floor, Soiled utility across nursing station failed to close and latch due to gloves stuffed into door strike. Exit interview with the Administrator, Regional Maintenance Director and Maintenance Director on September 23, 2025, at 12:15 p.m., confirmed the above deficiencies.

Plan of Correction - To be completed: 01/07/2026

Basement laundry room door, and both 2nd Fl. soiled utility room doors have been
repaired to ensure the doors close and latch as designed.

NHA will educate all staff on ensuring that all hazardous area doors are not obstructed as to stop doors from not closing and latching.

NHA/designee will complete random weekly audits x 3 weeks and monthly x 1 monthly
to ensure that hazardous area doors close and latch.

Maintenance Director will report audit findings to the QAPI Committee x 3 months for review.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 components were properly installed, maintained, and free of external loads, affecting two of three levels of the facility. Findings Include: Observations on September 23, 2025, between 10:00 am, and 12:00 p.m., revealed the following sprinkler deficiencies: a) Inside the IT room located within the basement administration wing, revealed a zip tied conduit and electrical junction box tied to the sprinkler branch line; b) Inside the Kitchen, next to the cooler box revealed a zip tied conduit tied to the sprinkler branch line. c) Inside the Kitchen, next to the cooler box revealed an upright sprinkler pendent, pointing downwards. Exit interview with the Administrator, Regional Maintenance Director and Maintenance Director on September 23, 2025, at 12:15 p.m., confirmed the above sprinkler system deficiencies.

Plan of Correction - To be completed: 01/07/2026

IT room, Kitchen cooler and kitchen sprinkler heads were repaired to ensure the automatic sprinkler system components are maintained and free from external
loads.

NHA will educate the Maintenance department to ensure the automatic sprinkler system Components are properly installed, maintained and are free from external loads.

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 free from external loads.

Maintenance Director will report audit findings to the QAPI Committee x 3 months for review.

NFPA 101 STANDARD Corridors - Construction of Walls:

Corridors - Construction of Walls
2012 EXISTING
Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code.
Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames.
If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area.
19.3.6.2, 19.3.6.2.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0362 Based on observation and interview, it was determined the facility failed to maintain corridor walls smoke resistance rating, affecting one of three levels. Findings include: 1. Observation on September 23, 2025, at 10:30 a.m., revealed unsealed penetrations around duct work and alongside wall, Administration Office IT Room, Basement. Exit interview with the Administrator, Regional Maintenance Director and Maintenance Director on September 23, 2025, at 12:15 p.m., confirmed the penetrations.

Plan of Correction - To be completed: 01/07/2026

Unsealed penetrations around the duct work and alongside the wall in the IT room were sealed to ensure smoke resistance using 3M Fire Barrier Sealant CP 25WB+ (4 hrs).

NHA will educate the Maintenance department to ensure that unsealed penetrations throughout the facility are sealed to ensure smoke resistance.

NHA/designee will complete random weekly audits x 3 weeks and monthly x 1 month to
ensure that unsealed penetrations are sealed.

Maintenance Director will report audit findings to the QAPI Committee x 3 months for review.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372 Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting one of two levels. Findings include: 1. Observation on September 23, 2025, at 11:40 a.m., revealed above double smoke doors an unsealed penetration around data wires, First Floor Nurses Sation B-Wing. Exit interview with the Administrator, Regional Maintenance Director and Maintenance Director on September 23, 2025, at 12:15 p.m., confirmed the penetration.

Plan of Correction - To be completed: 01/07/2026

Unsealed penetrations above double doors on B-wing have been sealed to ensure
smoke barrier walls are free from penetration using 3M Fire Barrier Sealant CP 25WB+ (4 hrs).

NHA will educate the Maintenance department to ensure unsealed penetrations are sealed to maintain smoke barrier walls are free from penetration.

NHA/designee will complete random weekly audits x 3 weeks and monthly x 1 month to
ensure that unsealed penetrations are sealed

Maintenance Director will report audit findings to the QAPI Committee x 3 months for review.

NFPA 101 STANDARD Electrical Systems - Other:

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.

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 and inspect electrical system requirements, per NFPA 70 and NFPA 99, on three of three levels within the facility. Findings include: 1. Observation on September 23, 2025, between 10:00 a.m. and 12:00 p.m., revealed the following electrical deficiencies: a) Inside IT room within the basement administration wing, revealed free hanging exposed, uncapped, (1) three wire conduit and (1) uncapped Romex, free hanging in room; b) On the first floor, in corridor, next to room A115, an in-wall junction box without a cover plate; c) On the second floor Nursing Station, next to room 217, an electrical receptacle missing a cover behind copier; d) On the second floor Soiled Laundry, next to room 217, a broken light switch cover; e) In the basement elevator equipment room, revealed an MC cable that was not terminated in a junction box. Reference: NFPA 70-314.17, NFPA 70-314.28 (C), and NFPA 300.11 Exit interview with the Administrator, Regional Maintenance Director and Maintenance Director on September 23, 2025, at 12:15 p.m., confirmed the above electrical system deficiencies.

Plan of Correction - To be completed: 01/07/2026

Electrical deficiencies cited inside IT room, (corridor) at A115, 2nd Fl. at 217, 2nd Fl. Soiled Utility room and basement elevator have been repaired to ensure electrical systems are maintained.

NHA will educate the Maintenance department to ensure that the electrical system is inspected and maintained per regulations.

NHA/designee will complete random weekly audits x 3 weeks and monthly x 1 month to
ensure that the electrical system is inspected and maintained per regulations

Maintenance Director will report audit findings to the QAPI Committee x 3 months for review.

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