Pennsylvania Department of Health
INGLIS HOUSE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 55 surveys for this facility. Please select a date to view the survey results.

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INGLIS HOUSE - 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 3, 2024, at Inglis House, 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 & THERAPY BUILDING - Component: 01 - Tag: 0000

Facility ID # 090202
Component 01
Main and Therapy Buildings

Based on a Medicare/Medicaid Recertification Survey conducted on June 3, 2024, it was determined that Inglis House 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 five-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Aisle, Corridor, or Ramp Width:

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.

Aisle, Corridor or Ramp Width
2012 EXISTING
The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5.
19.2.3.4, 19.2.3.5

Observations:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0232

Based on observation, document review, and interview, the facility failed to maintain the minimum width of access corridors, affecting two of six levels.

Findings include:

Observation on June 3, 2024, between 8:30 a.m. and 1:15 p.m., revealed the exit access corridors measured less than four feet in width on the third floor north wing, on the second floor north wing, and on the second floor south wing.

Exit interview with the Administrator and Director of Engineering Services on June 3, 2024, at 1:15 p.m., confirmed the above deficiencies.

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

Inglis House is requesting the Pa Division of Life Safety to update the F.S.E.S. for this facility.
The Engineering Director or designee will monitor this plan.

NFPA 101 STANDARD Number of Exits - Corridors:

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 & THERAPY BUILDING - Component: 01 - Tag: 0252

Based on observation, document review, and interview, the facility failed to ensure two remote exits for each floor, affecting two of nine smoke compartments.

Findings include:

Observation and document review on June 3, 2024, between 8:30 a.m. and 2:15 p.m., revealed the south wing, on the fourth floor, lacked two remote exits.

Exit interview with the Administrator and Director of Engineering Services on June 3, 2024, at 1:15 p.m., confirmed the above deficiency.

NFPA 101 STANDARD Vertical Openings - Enclosure:

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.

Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.

Observations:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0311

Based on observation, document review, and interview, the facility failed to ensure vertical openings between floors were enclosed with the required fire resistance rating, affecting five of six levels.

Findings include:

Observation on June 3, 2024, between 8:30 a.m. and 2:30 p.m., revealed insulated pipes penetrating the floor slab at the resident bathroom sink units.

Exit interview with the Administrator and Director of Engineering Services on June 3, 2024, at 1:15 p.m., confirmed the above penetrations through the floor.

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 & THERAPY BUILDING - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of hazardous areas, in sprinklered locations, affecting one of six levels.

Findings include:

Observations on June 3, 2024, revealed the following hazardous area deficiencies:

a. 12:35 p.m., on the ground floor, transfer gear room, unsealed hole penetration by the door.
b. 12:55 p.m., on the ground floor, North transformer room by dietary, open conduit penetration.

Exit interview with the Administrator and Director of Engineering Services on June 3, 2024, at 1:15 p.m., confirmed the unsealed penetrations.

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

A.
At the Main Ground Floor, Transfer Gear room had an unsealed penetration. The penetration was sealed using system 3M W-L0031. To prevent this from occurring again an additional directive to check this mechanical area annually will be added to the Life Safety work order that is generated automatically from the Mp2 Maintenance Work Order System (Annual Life Safety Main Building Mechanical Rooms and Shops)
The Engineering Director or designee will monitor this plan.

B. At the Main Ground Floor, transformer room near Dietary had an unsealed penetration around a conduit pipe. The penetration was sealed using system 3M C-AJ-1001-L-2299. To prevent this from occurring again an additional directive to check this (storage) area annually will be added to the Life Safety work order that is generated automatically from the Mp2 Maintenance Work Order System (Annual Life Safety Main Building Mechanical Rooms and Shops)
The Engineering Director or designee will monitor this plan.

NFPA 101 STANDARD Cooking Facilities:

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0324

Based on document review and interview, it was determined the facility failed to ensure the kitchen suppression system was inspected and serviced at required intervals, affecting one of six levels.

Findings include:

Document review on June 3, 2024, at 9:30 a.m., revealed the facility could not produce documentation showing the kitchen suppression system inspection had been performed twice in the prior year.

Exit interview with the Administrator and Director of Engineering Services on June 3, 2024, at 1:15 p.m., confirmed the missing documentation.

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

Documentation provided showed 2 inspections for 2023 and the most current inspection in June 2024 failed due to an expired GW Mistery Hood Twin Nozzle. Inglis has contracted with Nelbud and has replaced the expired nozzle and can provide a hood compliant certification. To prevent this condition from occurring again, a task instruction to check expiration dates on this nozzle will be added to the "MONTHLY KITCHEN HOOD FIRE SUPPRESION IN-SERV" preventative maintenance task to check the expiration date on the twin nozzle suppression head.

The Engineering Director or designee will monitor this plan.

NFPA 101 STANDARD Sprinkler System - Installation:

Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Observations:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0351

Based on observation and interview, it was determined the facility failed to maintain complete automatic sprinkler protection, affecting one of six levels.

Findings Include:

Observation on June 3, 2024, at 12:20 p.m., revealed the sub-basement " tunnel room " lacked sprinkler protection.

Exit interview with the Administrator and Director of Engineering Services on June 3, 2024, at 1:15 p.m., confirmed the incomplete sprinkler coverage.

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

At the tunnel room lacking sprinkler coverage, proper sprinkler coverage will be installed per NFPA. Inglis will contract with Keystone Fire Protecton to install according to NFPA Code. As a preventative measure for this condition, a task will be added to the weekly tunnel inspection to verify the new sprinkler heads are clear of any obstructions per Life Safety Code.This task will be generated from the Mp2 Maintenance Work Order System and kept for DOH 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 & THERAPY BUILDING - Component: 01 - Tag: 0353

Based on document review, observation, and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting two of six levels.

Findings include:

Observations on June 3, 2024, revealed the following sprinkler system deficiencies:

a. 12:20 pm, on the ground floor, mechanical wing storage room, sprinkler obstructed by pipe rack.
b. 12:55 pm, on the ground floor, kitchen above Vulcan oven, grease buildup on sprinkler.
c. 11:39 am, on the first floor, North above the ceiling, outside of the elevator, MC cables strapped to sprinkler pipes.

Exit interview with the Administrator and Director of Engineering Services on June 3, 2024, at 1:15 p.m., confirmed the sprinkler deficiencies.

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

A. At the Mechanical Room on the Ground Floor Mechanical Wing, the pipes will be removed from the steel ceiling gurders.To prevent this condition again a task instruction will be added to the Prevent Maintenance " Task Bi-Mech08 Mechanical Room Check and Cleaning".

B.
At the Ground Floor Kitchen, the build up of grease will be cleaned and removed. To prevent this from happening again a task instruction " check suppression head cleanliness" will be added to the MONTHLY KITCHEN HOOD FIRE SUPPRESION IN-SERV" preventative maintenance task.

C
At the 1st fl north elevator above the ceiling tile, the MC cables will be removed from the sprinkler pipe. To prevent this condition a task instruction will be added to the Month Penetration Preventative Maintenance Task to "check all elevator shafts for penetrations"

The Engineering Director or designee will monitor this plan.

NFPA 101 STANDARD Utilities - Gas and Electric:

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Observations:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting one of six levels in the facility.

Findings include:

1. Observation on June 3, 2024, 11:00 a.m. and 11:30 a.m. revealed the following:

a. 11:26 a.m., on the first floor outside the 1N Utility Room, an unsecured junction box above the ceiling
b. 11:20 a.m., on the first floor (South) outside room 137, an unsecured junction box above the ceiling

2. Observation on June 3, 2024, at 11:00 a.m., revealed, on the second floor in the 2C Housekeeping closet, the electrical panel was missing a circuit breaker protective blank.

Exit interview with the Administrator and Director of Engineering Services on June 3, 2024, at 1:15 p.m., confirmed the above deficiencies.

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

1.A.At the first floor outside of the 1North Utility Room, the unsecured junction box will be properly anchored to the wall or ceiling. To prevent this condition from happening again a task will be added to the Monthly Penetration PM task that will state " "Check above ceiling tiles for unsecured junction boxes"
B.
At the first floor south near room 137, the junction box will be properly secured to the wall or ceiling. To prevent this condition from happening again a task will be added to the Monthly Penetration PM task that will state " "Check above ceiling tiles for unsecured junction boxes"

2 At the 2 Center Housekeeping Closet a protective blank cover will be installed on the circuit space missing one. To prevent this condition from happening again a task instruction will be added to the Monthly Electrical Panel PM that will state "CHECK FOR MISSING CIRCUIT BREAKER BLANK COVERS"

The Engineering Director or designee will monitor this plan

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, affecting the entire facility.

Findings include:

Document review on June 3, 2024, at 9:30 a.m., revealed the facility could not produce documentation showing that a 3-year 4-hour exercise of the generator had been performed.

Exit interview with the Administrator and Director of Engineering Services on June 3, 2024, at 1:15 p.m., confirmed the missing documentation.

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

Inglis will redo the 4 hour test that was done for only 3 hours to a complete 4 hour test. To prevent this mistake and to prevent confusion with this task Inglis will change from a manual generated untitled work order for this task requirement to an automatically generated Preventative Maintenance task generated from the Mp2 maintenance data base. It will be titled "3 YEAR 4 HOUR TEST" to prevent confusion. Detailed task instructions will be included.

The Engineering Director or designee will monitor this plan.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

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 & THERAPY BUILDING - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to ensure that the unauthorized use of power strips was prohibited on two of six levels within this component.

Findings include:

Observations made on June 3, 2024, between 8:30 a.m. and 1:15 p.m., revealed the unauthorized use use of power strips in the following locations:

a. 9:40 a.m., on the fourth floor, North, Therapeutic Education Office, a coffee machine plugged into a power strip.
b. 9:49 a.m., on the fourth floor, South, Community Outing Coordinator Office, a microwave, refrigerator, and coffee machine plugged into a power strip.
c. 11:46 a.m., on the first floor, North, Clinical Reimbursement Office, a coffee machine plugged into a power strip.

Exit interview with the Administrator and Director of Engineering Services on June 3, 2024, at 1:15 p.m., confirmed the unauthorized use of power strips.

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

A. At the 4th floor north Therapeutic Education Office the power strip will be removed. To prevent this condition from happening the Power Strip check for the entire building will have the frequency increased from January and July to 3 times per year. This preventative maintenance task is automatically generated from the MP2 maintenance data base.
B. At the 4th floor south community outing coordinator office, the power strip will be removed. To prevent this condition from happening the Power Strip check for the entire building will have the frequency increased from January and July to 3 times per year. This preventative maintenance task is automatically generated from the MP2 maintenance data base
C. At the first floor north Clinical Reimbursement Office the power strip will be removed. To prevent this condition from happening the Power Strip check for the entire building will have the frequency increased from January and July to 3 times per year.
The Engineering Director or designee will monitor this plan.

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