Pennsylvania Department of Health
 IMMACULATE MARY CENTER FOR REHABILITATION & HEALTHCARE
Building Inspection Results

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IMMACULATE MARY CENTER FOR REHABILITATION & HEALTHCARE
Inspection Results For:

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IMMACULATE MARY CENTER FOR REHABILITATION & HEALTHCARE - 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 28, 2025, at Immaculate Mary Center for Rehabilitation & Healthcare, 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#090902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 28, 2025, it was determined that Immaculate Mary Center for Rehabilitation & Healthcare - Main Building 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 four-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Interior Nonbearing Wall Construction: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.
Interior Nonbearing Wall Construction
Interior nonbearing walls in Type I or II construction are constructed of noncombustible or limited-combustible materials.
Interior nonbearing walls required to have a minimum 2 hour fire resistance rating are permitted to be fire-retardant-treated wood enclosed within noncombustible or limited-combustible materials, provided they are not used as shaft enclosures.
19.1.6.4, 19.1.6.5
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0163
Based on observation and interview, it was determined the facility failed to maintain the building wall construction within fire resistive construction, affecting one of five levels.

Findings include:

Observation on April 28, 2025, at 10:15 a.m., on the fourth floor, revealed a wall penetration surrounding a pipe that was sealed with an orange unknown expanding spray foam.

Exit Interview with the V.P. of Facilities and the Maintenance Director on April 28, 2025, at 12:00 p.m., confirmed the use of spray foam.






 Plan of Correction - To be completed: 06/01/2025

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

It is the practice of the facility to have proper sealing of penetration with approved fire rating.

1. The facility has removed the orange unknown expanding spray foam around the fourth-floor wall penetration and properly sealed it with UL rated fire caulk using proper UL approved "through penetration fire stop system".

2. Maintenance checked other similar penetrations throughout the building and confirmed no other areas contained sealant products that are not approved for healthcare facilities.

3. Education is completed with Maintenance staff to understand how to seal penetrations with proper materials.

4. Every quarter for a year, the Maintenance Director or designee reviews random areas for proper penetration seals. This information will then be entered on a log and will be presented to the QAPI meeting

NFPA 101 STANDARD Exit Signage: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.
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, it was determined the facility failed to maintain exit directional signage, affecting one of five levels.

Findings include:

Observation on April 28, 2025, at 11:40 a.m., revealed on the first floor, Dialysis exit directional signage was missing.

Exit Interview with the V.P. of Facilities and the Maintenance Director on April 28, 2025, at 12:00 p.m., confirmed the missing signage.





 Plan of Correction - To be completed: 06/01/2025

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

It is the practice of the facility to maintain lighted directional exit signs.

1. The exit sign by dialysis has been changed with proper arrows showing proper egress direction.

2. All exit signs were checked for functionality and direction and were in compliance.

3. Education done with Maintenance staff regarding monitoring of exit sign illumination and direction.

4. Every quarter for a year, the Maintenance Director or designee will complete testing of exit signs on a random floor of the facility. This information will then be entered on a log and will be presented to the QAPI meeting.

NFPA 101 STANDARD Alcohol Based Hand Rub Dispenser (ABHR):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.
Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0325

Based on observation and interview, it was determined the facility failed to protect Alcohol Based Hand Rub Dispensers (ABHR), affecting one of five levels.

Findings include:

Observation on April 28, 2025, at 10:30 a.m., revealed an ABHR was installed directly above a duplex electrical outlet, North by room 405, on the fourth floor.

Exit Interview with the V.P. of Facilities and the Maintenance Director on April 28, 2025, at 12:00 p.m., confirmed the ABHR location.





 Plan of Correction - To be completed: 06/01/2025

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

It is the practice of the facility to ensure the ABHR is correctly installed.

1. The ABHR's found by room 405 has been moved to not be located directly over a power outlet on 5/5/2025.

2. All other areas of the facility have been checked and no ABHR's were found to be over outlets.

3. Education completed with Maintenance staff regarding proper installation of ABHR's being near power outlets.

4. Every quarter for a year, the Maintenance Director or designee will check random ABHR's to ensure proper installation. This information will then be entered on a log and will be presented at QAPI meeting.

NFPA 101 STANDARD Fire Alarm System - Initiation: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.
Fire Alarm System - Initiation
Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200' travel distance is not exceeded.
18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0342

Based on observation and interview, it was determined the facility failed to maintain fire alarm initiating devices, affecting one of five levels.

Findings include:

Observation on April 28, 2025, at 10:10 a.m., revealed a smoke detector was not securely mounted to the ceiling, Maintenance Office in the basement.

Exit Interview with the V.P. of Facilities and the Maintenance Director on April 28, 2025, at 12:00 p.m., confirmed the smoke detector deficiency.






 Plan of Correction - To be completed: 06/01/2025

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

It is the practice of the facility to have proper installation of smoke detectors.

1. The smoke detector not securely installed to the ceiling box in basement has been installed correctly

2. All other smoke detectors have been checked and are properly installed.

3. Education is completed with Maintenance staff to confirm proper installation to fire alarm initiating devices.

4. Every quarter for a year the Maintenance Director or designee will check random smoke detectors to ensure they are properly mounted. This information will then be entered on a log and will be presented to the QAPI meeting.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain fire suppression system components, affecting one of five levels.

Findings Include:

Observation on April 28, 2025, at 10:00 a.m., revealed in the basement electrical room, the clean agent system was missing 2- nozzles toward the rear of the room.

Exit Interview with the V.P. of Facilities and the Maintenance Director on April 28, 2025, at 12:00 p.m., confirmed the missing system component.





 Plan of Correction - To be completed: 06/01/2025

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

It is the practice of the facility to ensure the extinguishing system is ready for use.

1. The two nozzle heads were checked by Fire and Safety company and were addressed and installed as per manufacturer design system.

2. All other areas have been checked, and the system is ready for use. All residents are free from hazards and all systems operate as designed.

3. Education completed with Maintenance staff regarding proper inspection of sprinkler system and its components.

4. Every quarter for a year, the Maintenance Director or designee will check random sprinkler heads throughout the facility to ensure they are free from missing components. This information will then be entered on a log and will be presented at QAPI meeting.

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 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure corridor doors were maintained to resist the passage of smoke, affecting one of five levels.

Findings include:

Observation on April 28, 2025, at 11:15 a.m., revealed open holes above and below the door hardware, south Bathing Suite on the second floor.

Exit Interview with the V.P. of Facilities and the Maintenance Director on April 28, 2025, at 12:00 p.m., confirmed corridor door penetrations.




 Plan of Correction - To be completed: 06/01/2025

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

It is the practice of the facility to ensure smoke, Fire and corridor doors will operate as per design.

1. 1. The door by bathing suite have been repaired and properly sealed with UL rated fire caulk using proper UL approved "through penetration fire stop system" and now they are penetration free as design as of 5/5/2025.

2. Doors throughout the facility were checked to allow for closure and penetration, all residents are free from hazards and all systems are operating as designed as of 5/5/2025.

3. Education completed with Maintenance staff regarding monitoring doors for penetrations.

4. Every quarter for a year, the Maintenance Director or designee will check random doors throughout the facility to ensure there are no penetrations on the doors. This information will then be entered on a log and will be presented at the QAPI meeting.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
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 five levels.

Findings include:

Observation on April 28, 2025, at 11:05 a.m., two unsealed penetrations above the ceiling tile, double smoke doors at Dining Room entrance, on the second floor north.

Exit Interview with the V.P. of Facilities and the Maintenance Director on April 28, 2025, at 12:00 p.m., confirmed the unsealed penetrations.




 Plan of Correction - To be completed: 06/01/2025

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

It is the practice of the facility to ensure smoke barrier door free of unsealed penetrations.

1. Penetration above the smoke barrier above the ceiling by dining room on the second floor was sealed with a UL approved "through penetration fire stop system".

2. All penetrations were sealed with a UL approved "through penetration fire stop system" for all the common fire wall penetrations. All residents are free from hazards and all systems operate as designed.

3. Education was completed with Maintenance staff regarding sealing of penetrations.

4. Every quarter for a year, the Maintenance Director or designee will check for penetration on a random floor of the facility. This information will then be entered on a log and will be presented to the QAPI meeting.

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 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined facility failed to maintain access to electrical components, affecting one of five levels.

Findings include:

Observation on April 28, 2025, at 11:50 a.m., revealed on the first floor, in kitchen dry storage, an electrical panel was blocked by pallets.

Exit Interview with the V.P. of Facilities and the Maintenance Director on April 28, 2025, at 12:00 p.m., confirmed the obstructed electrical panel.

~Refer to the 2011 edition of NFPA 70, 110.26 (A) (1)






 Plan of Correction - To be completed: 06/01/2025

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

It is the practice of the facility to protect electrical wiring in accordance with NFPA99 2012 edition, 6.3.2.1. Electrical Installation.

1. The electrical panel in the kitchen dry storage room that was blocked by pallets has been corrected and free from obstruction as of 5/5/2025.

2. Building wide inspection of electrical systems has been completed on 5/5/2025 and all area panels are free of storage or obstructions.

3. Education completed with Maintenance staff regarding monitoring areas for obstructions near or around electrical panels.

4. Every quarter for a year, the Maintenance Director or designee will check random areas of the facility to ensure no panels are blocked. This information will then be entered on a log and will be presented to the QAPI meeting

Initial comments:Name: BUILDING 02 (CHAPEL) - Component: 02 - Tag: 0000


Facility ID# 090902
Component 02
Chapel

Based on a Medicare/Medicaid Recertification Survey completed on April 28, 2025, at Immaculate Mary Center for Rehabilitation & Healthcare - Chapel, it was determined there were no deficiencies identified under the 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 one-story, Type II (000), unprotected non-combustible building, that is fully sprinklered.





 Plan of Correction:



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