Pennsylvania Department of Health
GUY AND MARY FELT MANOR, INC.
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 51 surveys for this facility. Please select a date to view the survey results.

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GUY AND MARY FELT MANOR, INC. - 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 July 30, 2024, at Guy and Mary Felt 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 # 072702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on July 30, 2024, it was determined that Guy and Mary Felt Manor 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 (111), protected, non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Exit Signage:

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.

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on observation and interview, the facility failed to meet exit signage requirements in one of four smoke compartments.

Findings include:

Observation on July 30, 2024, revealed the dining room had a door leading to the patio with a sign stating, "warning alarm emergency exit only." The door is not an emergency exit and would create confusion in the event of an emergency.

Interview with the maintenance director on July 30, 2024, confirmed the patio door was not an emergency exit.

Plan of Correction - To be completed: 07/31/2024

On 07/31/2024, the Maintenance Supervisor removed the section of the label that said "emergency exit". The sign now states warning alarm only. QA committee will oversee that no one tampers with the sign for two weeks to ensure compliance.

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 document review and interview, the facility failed to maintain one of four quarterly sprinkler system inspections.

Findings include:

Document review on July 30, 2024, revealed the facility lacked documentation for the fourth quarter sprinkler inspection.

Interview with the administrator and maintenance director on July 30, 2024, confirmed the lack of documentation at the time of the survey.

Plan of Correction - To be completed: 08/19/2024

NHA called Johnson Controls, the company that performs the quarterly sprinkler inspections. The service manager informed the NHA that in the fall of 2023, Johnson Controls was involved in a cybersecurity event. This contributed to the missed inspection. The company has increased administrative functions for upcoming inspection reviews and processes. They have also added in a dedicated manager to oversee these inspections to ensure they are completed timely.
NHA will receive a matrix of inspections and dates for the remainder of the year and moving forward. NHA or designee will be responsible to ensure the inspections are completed quarterly.
QA committee will over see the process X 1 month to ensure compliance.

NFPA 101 STANDARD Electrical Systems - Receptacles:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on observation and interview, the facility failed to meet receptacle requirements in one of over ten wet location areas.

Findings include:

Observation on July 30, 2024, revealed the soiled utility room, near room 15, had an outlet located within six feet of a water source that was not protected by a ground fault circuit interrupter.

Interview with the maintenance director on July 30, 2024, confirmed the deficiency.

Plan of Correction - To be completed: 08/30/2024

The Maintenance Supervisor will install a ground fault circuit interrupter on the outlet located in the soiled utility room. QA committee will oversee and ensure completion of the project.

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