Pennsylvania Department of Health
FULTON COUNTY MEDICAL CENTER
Building Inspection Results

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FULTON COUNTY MEDICAL CENTER
Inspection Results For:

There are  29 surveys for this facility. Please select a date to view the survey results.

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FULTON COUNTY MEDICAL 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 April 22, 2025, at Fulton County Medical Center it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.






 Plan of Correction:


Initial comments:Name: FULTON COUNTY MEDICAL CENTER (SNF) - Component: 10 - Tag: 0000

Facility ID# 061902
Component 10
Long Term Care Building

Based on a Medicare/Medicaid Recertification Survey completed on April 22, 2025, it was determined that Fulton County Medical 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 one-story, Type II (000), unprotected, non-combustible building, without 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: FULTON COUNTY MEDICAL CENTER (SNF) - Component: 10 - 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 April 22, 2025, at 12:25 p.m., revealed there were two unsealed penetrations in the ceiling tiles of the LTC Gym (left side of the gym), which could affect the operation of the automatic sprinkler system.

Interview with the Facility Administrator and Plant Operations Manager on April 22, 2025, at 2:00 p.m., confirmed the automatic sprinkler system deficiency.







 Plan of Correction - To be completed: 05/23/2025

1. The facility replaced 2 ceiling tiles and corrected unsealed penetrations in the LTC gym on April 23, 2025.

2. Facility maintenance staff will complete visual inspection of ceiling tiles each quarter during their regular penetration inspections. The LTC Quarterly Penetration Inspection form was updated on 5/6/2025 to reflect documentation of the visual inspection.

3. Completion of visual inspection of ceiling tiles and documentation of such will be audited during the monthly Building and Safety meeting which is attended by Plant Operations Manager, Director of Environmental Services, FCMC Safety Officer, Nursing Home Administrator and Chief Operations Officer for twelve 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: FULTON COUNTY MEDICAL CENTER (SNF) - Component: 10 - Tag: 0363



Based on observation and interview, it was determined the facility failed to maintain corridor doors in two instances, affecting two of four smoke compartments.

Findings include:

1. Observation on April 22, 2025, revealed the following corridor door deficiencies:

a) 10:58 a.m., the door to Room 23B, Overly Wing, would not close and latch in its frame;
b) 11:35 a.m., the door to Room 10B, Shimer Wing, would not close and latch in its frame.

Interview with the Facility Administrator and Plant Operations Manager on April 22, 2025 at 2:00 p.m., confirmed the corridor door deficiencies.





 Plan of Correction - To be completed: 05/23/2025

1. Facility maintenance staff fixed latch on doors to resident rooms 23B and 10B and ensured doors closed and latched on 4/30/2025.

2. Monthly door inspection form was created and provided to Plant Operations manager on 05/06/2025.

3. Facility maintenance staff will begin documenting monthly fire door inspections of all fire doors on both corridors by 5/23/2025.

4. Completion of inspections and corresponding documentation will be audited at the Building and Safety Meeting attended by The Plant Operations Manager, Director of Environmental Services, FCMC Safety Officer, Nursing Home Administrator and Chief Operations Officer for six months.

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