Pennsylvania Department of Health
 IVORY NURSING & REHABILITATION
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
IVORY NURSING & REHABILITATION
Inspection Results For:

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.
IVORY NURSING & REHABILITATION - 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 August 24, 2026, at Ivory Wellness Center, 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# 125102Component 01Main BuildingBased on a Medicare/Medicaid Recertification Survey completed on August 24, 2026, it was determined that Ivory Wellness Center 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 three-story, Type II (000), unprotected non-combustible building, that is fully sprinklered. 
 Plan of Correction:


NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0225 Based on observation and interview, it was determined the facility failed to maintain stairways, affecting one of three levels. Findings include: 1. Observation on August 24, 2026, at 11:35 a.m., revealed two coolers on wheels and a safety cone being stored inside the stair tower, Basement North Tower. Interview at the exit conference with the Administrator and Maintenance Director on August 24, 2026, at 12:45 p.m., confirmed the items being stored in a stair tower.
 Plan of Correction - To be completed: 09/23/2026

K-225 E

The coolers and safety cone were removed from the North side basement stairwell


All residents may be affected by this deficient practice.




Dietary and Hskpg staff to be educated on the NFPA regulations regarding no storage in exit stairwells.
Maintenance director or designee will audit the facility stairwells daily x 1 week and weekly x 3 weeks to ensure that there are no items stored inside.



Findings of these audits will be presented at the facility's QAPI meeting. It will be determined at that time if continued audits are necessary.

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 - Component: 01 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintain doors to hazardous areas, affecting one of three levels. Findings include: 1. Observation on August 24, 2026, at 11:25 a.m., revealed the door did not latch closed when tested, Basement Clean Linen Room. Interview at the exit conference with the Administrator and Maintenance Director on August 24, 2026, at 12:45 p.m., confirmed the door did not latch closed.
 Plan of Correction - To be completed: 09/23/2026

The linen storage door was repaired to allow the door to close freely.




All residents may be affected by this deficient practice.




Maintenance director or designee will randomly audit the facility weekly x 4 weeks to ensure that storage room doors close freely.




Findings of these audits will be presented at the facility's QAPI meeting. It will be determined at that time if continued audits are necessary.

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 document review and interview, it was determined the facility failed to ensure the fire alarm system was maintained, affecting one of two fire alarm reports. Findings include: 1. Document review on August 24, 2026, at 9:00 a.m., revealed the annual fire alarm inspection report dated December 18, 2025, listed the following fire alarm deficiencies: a. Unable to test (2) smoke detectors at the time of inspection due to no access (Maintenance could not locate key). b. Unable to test elevator recall and elevator devices (Maintenance could not locate keys). c. Unable to test (1) Duct Detector. Evidence of corrective action was not available at time of survey. Interview at the exit conference with the Administrator and Maintenance Director on August 24, 2026, at 12:45 p.m., confirmed the missing documentation.
 Plan of Correction - To be completed: 09/23/2026

 On 7/1/2026 the facility vendor was onsite to test the previously inaccessible smoke detectors, and elevator devices. The vendor is scheduled to be onsite on 9/21 to access and test the duct detector.




All residents may be affected by this deficient practice.






The maintenance director or designee will audit the facility required inspections monthly x 3 months to ensure inspections and repairs are done timely and the paperwork is available for viewing.




Findings of these audits will be presented at the facility's QAPI meeting. It will be determined at that time if continued audits are necessary.

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 document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting one of four sprinkler reports. Findings include: 1. Document review on August 24, 2026, at 9:00 a.m., revealed the Annual Sprinkler inspection report dated March 12, 2026, listed the following sprinkler deficiencies: a. No safe access to the OS&;Y valve in the pit due to it being flooded at the time of inspection. b. Slow drip leak coming from upstream city OS&;Y valve stem. Also showing signs of IO. c. Dry drops outside front entrance and rear exit by Maintenance are due for replacement. Dated 2009 &; 20015. 2. Document review on August 24, 2026, at 9:00 a.m., revealed the facility could not provide a Third Quarter Sprinkler Report during the last 12 months. Evidence of corrective action was not available at time of survey. Interview at the exit conference with the Administrator and Maintenance Director on August 24, 2026, at 12:45 p.m., confirmed the missing documentation.
 Plan of Correction - To be completed: 09/23/2026

The vendor was onsite on 5/26/26 to repair the leaking OS&Y valve. On 6/1/26 the vendor was onsite to inspect the previously inaccessible pit. On 8/25/26 the facility signed the proposal to repair the dry drop sprinkler heads.
The third quarter sprinkler inspection was performed in close proximity to the fourth quarter inspection. The vendor was notified to ensure that all sprinkler inspections are to be done timely.



All residents may be affected by this deficient practice.




The maintenance director or designee will audit the facility required inspections monthly x 3 months to ensure inspections and repairs are done timely and the paperwork is available for viewing




Findings of these audits will be presented at the facility's QAPI meeting. It will be determined at that time if continued audits are necessary.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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 - 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 document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting one of nine generator reports. Findings include: 1. Document review on August 24, 2026, at 9:00 a.m., revealed the facility could not produce documentation of the 3-year, 4-hour Load Test. Interview at the exit conference with the Administrator and Maintenance Director on August 24, 2026, at 12:45 p.m., confirmed the missing documentation.
 Plan of Correction - To be completed: 09/23/2026

On 9/1/26 the generator company performed a 4-hour 3 year load test.




All residents may be affected by this deficient practice.



The maintenance director or designee will audit the facility required inspections monthly x 3 months to ensure inspections and repairs are done timely and the paperwork is available for viewing




Findings of these audits will be presented at the facility's QAPI meeting. It will be determined at that time if continued audits are necessary.


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