Pennsylvania Department of Health
 INGLIS HOUSE
Building Inspection Results

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INGLIS HOUSE
Inspection Results For:

There are  59 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
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 March 2nd - 3rd, 2026, 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 # 090202Component 01Main and Therapy BuildingsBased on a Medicare/Medicaid Recertification Survey conducted on March 2nd - 3rd, 2026, 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 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.
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, it was determined the facility failed to maintain the minimum width of access corridors, affecting two of six levels. Findings include: Document review and Observation on March 2, 2026, between 9:30 a.m. and 11:30 a.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 March 3, 2026, at 12:30 p.m., confirmed the above deficiencies.
 Plan of Correction - To be completed: 04/22/2026

K0232 At the time of the survey Inglis House supplied the Life Safety surveyor with an
updated version of the previously approved F.S.E.S.

All work and this plan of correction to be monitored by Director Of Engineering Services

NFPA 101 STANDARD Number of Exits - Corridors: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.
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, it was determined the facility failed to ensure two remote exits for each floor, affecting two of nine smoke compartments. Findings include: Observation and document review on March 2, 2026, at 10:30 a.m., revealed the south wing, on the fourth floor, lacked two remote exits. Exit interview with the Administrator and Director of Engineering Services on March 3, 2026, at 12:30 p.m., confirmed the above deficiency.
 Plan of Correction - To be completed: 04/22/2026

 At the time of the survey Inglis House supplied the Life Safety surveyor with an
updated version of the previously approved F.S.E.S.

All work and this plan of correction to be monitored by Director Of Engineering Services

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, it was determined the facility failed to ensure vertical openings between floors were enclosed with the required fire resistance rating, affecting five of six levels. Findings include: 1. Document review and Observation on March 2, 2026, between 10:00 a.m. and 11:30 a.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 March 3, 2026, at 12:30 p.m., confirmed the above penetrations through the floor.
 Plan of Correction - To be completed: 04/22/2026

At the time of the survey Inglis House supplied the Life Safety surveyor with an
updated version of the previously approved F.S.E.S.
All work and this plan of correction to be monitored by Director Of Engineering Services

NFPA 101 STANDARD Portable Fire Extinguishers: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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0355 Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers were accessible, affecting two of nine smoke zones within this facility. Findings Include: 1.Observation made at the following dates and times, revealed wall mounted fire extinguishers were blocked by equipment in the following locations: a) March 2, 2026 at 12:30 p.m., outside room 3055. b) March 2, 2026 at 12:43 p.m., outside room 321N. c) March 3, 2026 at 10:35 a.m., near resident room 108. Exit interview with the Administrator and Director of Engineering Services on March 3, 2026, at 12:30 p.m., confirmed access to the portable fire extinguisher were obstructed.
 Plan of Correction - To be completed: 04/22/2026

A. Outside of Room 305S the equipment was moved from in front of the fire
Extinguisher. To prevent this from happening again, a "Do Not Block" sign will be
posted. A task will be added to the Engineering Weekly Rounds to check for blocked
extinguishers.

B. Outside of Room 321N the equipment was moved from in front of the fire
Extinguisher. To prevent this from happening again, a "Do Not Block" sign will be
posted. A task will be added to the Engineering Weekly Rounds to check for blocked
extinguishers

C. Near room 108 the equipment was moved from in front of the fire
Extinguisher. To prevent this from happening again, a "Do Not Block" sign will be
posted. A task will be added to the Engineering Weekly Rounds to check for blocked
extinguishers
All work and this plan of correction to be monitored by Director Of Engineering Services

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: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0363 Based on observation and interview, it was determined the facility failed to maintain corridor doors, affecting two of nine smoke zones within the component. Findings include: 1. Observation on the following dates and times revealed the following: a) March 2, 2026, at 12:40 p.m.: resident room 330, failed to positively latch in the frame. b) March 2, 2026, at 11:15 a.m., resident room 110N failed to positively latch in frame. Exit interview with the Administrator and Director of Engineering Services on March 3, 2026, at 12:30 p.m., confirmed the above corridor door issues.
 Plan of Correction - To be completed: 04/22/2026

A. At resident room 330 the latch will be adjusted for proper latching. To prevent
this from happening again a preventative maintenance task will be generated
annually from the Maintenance Database Mp2 to check all resident doors.


B. At resident room 110N the latch will be adjusted for proper latching. To prevent
this from happening again a preventative maintenance task will be generated
annually from the Maintenance Database Mp2 to check all resident doors.
All work and this plan of correction to be monitored by Director Of Engineering Services

NFPA 101 STANDARD Electrical Systems - Other: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.
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 & THERAPY BUILDING - Component: 01 - Tag: 0911 Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, affecting one of nine smoke zones. Findings include: 1. Observation made on March 2, 2026, at 12:15 p.m., revealed an open junction box with exposed wiring above ceiling, inside third floor north's Med Room. Exit interview with the Administrator and Director of Engineering Services on March 3, 2026, at 12:30 p.m., confirmed the open junction box.
 Plan of Correction - To be completed: 04/22/2026

Above the ceiling in the 3rd floor north med room the junction box will have a cover
installed. To prevent this from occurring a task will be added to the Monthly
Penetration Preventative Maintenance work order to check above all med room
ceilings for open junction boxes.


All work and this plan of correction to be monitored by Director Of Engineering Services




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