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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 48 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.


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 June 5, 2024, 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 June 5, 2024, 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 Fire Alarm System - Testing and Maintenance:

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 - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

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

Findings include:

Observation on June 5, 2024, at 9:30 a.m., revealed the May 2024, fire alarm inspection report listed the following deficiencies, which remained uncorrected at time of survey:

a. Unable to find the three smoke detectors in the storeroom.
b. Unable to locate duct detector on the first floor.
c. Heat detector on the first floor in hallway by therapy did not activate.
d. Heat detector on the first floor in hallway by Chapel did not activate.

Exit Interview with the Administrator and Maintenance Director on June 5, 2024, at 1:15 p.m., confirmed the fire alarm deficiencies.

Plan of Correction - To be completed: 07/18/2024

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 the Fire Alarm System.

1. Three smoke detectors and one duct detector has been located and will be tested by Keystone. Two heat detectors on the first floor will be changed and proper documentation will be supplied by Keystone Fire Protection.

2.All testing and maintenance paperwork will be rechecked upon completion.

3.Education is completed with Maintenance Director to review paperwork from the fire alarm system and ensure that any deficiencies found are addressed.

4.The Maintenance Director or designee review paperwork once a month for three months to ensure fire alarm system is free from deficiencies. 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:

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 upon observation and interview, it was determined the facility failed to maintain sprinkler system components, affecting one of five levels.

Observation on June 5, 2024, at 10:35 a.m., revealed the gauges on two clean agent cylinders indicated recharge condition.

Exit Interview with the Administrator and Maintenance Director on June 5, 2024, at 1:15 p.m., confirmed the discharged clean agent cylinders.

Plan of Correction - To be completed: 07/18/2024

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 clean agent cylinders in Electrical room were inspected and are in compliance.

2. All other areas have been checked and Extinguishers and Sprinkler are ready for use. All resident areas are free from hazard and all systems are operating as designed.

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

4.The Maintenance Director or designee will check monthly for 3 months, random sprinkler heads throughout the facility to ensure they are free from dust, paint, corrosion, or missing components. This information will then be entered on a log and will be presented at the QAPI meeting.

NFPA 101 STANDARD Portable Fire Extinguishers:

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 - Component: 01 - Tag: 0355

Based upon observation and interview, it was determined the facility failed to ensure that portable fire extinguishers were accessible, affecting one of five levels.

Observation on June 5, 2024, at 11:30 a.m., revealed, on the second floor, in private dining area, the wall mounted fire extinguisher was obstructed by a cart and chair.

Exit Interview with the Administrator and Maintenance Director on June 5, 2024, at 1:15 p.m., confirmed the obstructed fire extinguisher.

Plan of Correction - To be completed: 07/18/2024

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 Fire Extinguishers are properly accessible.

1.The Fire Extinguisher located in the private dining room on the second floor has had the chair and cart removed and access is no longer obstructed.

2.All other Fire Extinguishers within the building has been checked to ensure they are not obstructed and were in compliance.

3. Education has been completed with Maintenance staff regarding monitoring that Fire Extinguishers are not obstructed by objects.

4.The Maintenance Director or designee will check Fire Extinguishers monthly for 3 months throughout the facility to ensure fire extinguishers are not obstructed, this information will then be entered on a log and will be presented at the QAPI meetings.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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 the fire rating of the smoke barrier walls, affecting two of five levels.

Findings include:

Observations on June 5, 2024, revealed unsealed penetrations of smoke barrier walls in the following locations:

a. 11:10 a.m., on the third floor, double elevator lobby, around MC and data wires.
b. 11:50 a.m., on the second floor, above smoke doors by room 217, around MC wire.

Exit Interview with the Administrator and Maintenance Director on June 5, 2024, at 1:15 p.m., confirmed the penetrations.

Plan of Correction - To be completed: 07/18/2024

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 smoke barrier by 3rd floor double elevator lobby and 2nd floor smoke door by 217 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 and were found in compliance.
3. Education completed with Maintenance staff regarding sealing of penetrations.
4.Monthly for 3 months, the Maintenance Director or designee will check for penetrations 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:

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 protection of electrical wiring, affecting one of five levels.

Findings include:

Observation on June 5, 2024, at 11:40 a.m., revealed, on the second floor, in the elevator lobby, a duplex receptacle had a damaged grounding prong.

Exit Interview with the Administrator and Maintenance Director on June 5, 2024, at 1:15 p.m., confirmed the damaged receptacle.

Refer to NFPA 70, National Electric Code, and NFPA 99, 6.3.2.1.

Plan of Correction - To be completed: 07/18/2024

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 damaged duplex receptacle with the damaged grounding prong has been replaced.
2. Building wide inspection of duplex receptables grounding prongs has been completed and are in compliance.
3. Education completed with Maintenance staff regarding monitoring duplex receptables for damaged grounding prongs.
4. Monthly for three months, the Maintenance Director or designee will check random areas of the facilities to ensure duplex receptables are not damaged. This information will then be entered on a log and will be presented to the QAPI meeting.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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.

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 - 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 5, 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 Maintenance Director on June 5, 2024, at 1:15 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 07/18/2024

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 the emergency generator.

1. Generator 4-hour load test has been completed on 6/20/2024.

2. Facility inspection of generator has been completed and documented.

3. Education completed with Maintenance director regarding completing 4-hour load test every three years.

4.Monthly for 3 months, the Maintenance Director or designee will ensure that monthly and weekly and other required exercises of the generator are completed. This information will then be entered on a log and will be presented to the QAPI meeting.

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 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the improper and unauthorized use of electrical devices, affecting one of five levels.

Findings include:

Observation on June 5, 2024, at 12:30 p.m., revealed an orange extension cord plugged into a power strip, on the first floor, Human Resources Office.

Exit Interview with the Administrator and Maintenance Director on June 5, 2024, at 1:15 p.m., confirmed the unauthorized electrical device.

Plan of Correction - To be completed: 07/18/2024

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 prohibit the improper and unauthorized use of electrical devices.

1. Orange extension cord plugged into a power strip on the 1st floor has been removed.

2. All other areas of the facility have been inspected to ensure no other extension cords are plugged into a power strip and were found in compliance.

3. Education completed with Maintenance staff regarding the need to maintain surge protectors plugged into properly approved devices only.

4. Monthly for 3 months, the Maintenance Director or designee will check surge protectors throughout the facility ensure only approved devices are plugged into surge protectors. This information will then be entered on a log and will be presented at 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 June 5, 2024, it was determined that Immaculate Mary Center For Rehabilitation & Healthcare - Chapel, 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 one-story, Type II (000), unprotected non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: BUILDING 02 (CHAPEL) - Component: 02 - Tag: 0225

Based on observation and interview, it was determined that the facility failed to maintain stairways, affecting one of two components within the facility.

Findings include:

Observation on June 5, 2024, at 10:15 a.m. revealed various items stored under the landing in stairway on the first floor.

Exit Interview with the Administrator and Maintenance Director on June 5, 2024, at 1:15 p.m., confirmed the storage within the stair tower.

Plan of Correction - To be completed: 07/18/2024

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 goal of this facility to ensure that stairways and smoke-proof enclosures used as exits are in accordance with 7.2, 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4 and 7.2.

1. Stairway in chapel has been cleared of items being stored under the landings on the first floor.

2. All stairwell doors throughout the facility have been checked and are free from storage.

3. Education done with Maintenance staff regarding checking stairwells not being used as a storage location.

4. Once a month for three months, the Maintenance Director or designee will randomly select stairwells to ensure they are not being used as storage. This information will then be entered on a log and will be presented at the QAPI meeting.

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