Pennsylvania Department of Health
NURSING AND REHABILITATION AT THE MANSION
Building Inspection Results

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NURSING AND REHABILITATION AT THE MANSION
Inspection Results For:

There are  43 surveys for this facility. Please select a date to view the survey results.

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NURSING AND REHABILITATION AT THE MANSION - 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 November 25, 2024, at Nursing and Rehabilitation at the Mansion, 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# 130502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on November 25, 2024, it was determined that Nursing and Rehabilitation at the Mansion was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.70(a).

This is a three story, Type V (000), unprotected, wood frame building, with a partial attic and a partial basement, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting five of five smoke compartments.

Findings include:

1. Observation on November 25, 2024, between 9:15 a.m., and 11:30 a.m., revealed the building story height exceeds the maximum allowable by two stories.

Exit interview with the facility administrator and facility maintenance at 12:00 p.m., on November 25, 2024, confirmed the building story height exceeds the maximum allowable by two stories.






 Plan of Correction - To be completed: 01/07/2025

Nursing and Rehabilitation at the Mansion request to continue to use FSES regarding 0161
NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
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 provide not less than two exits, remote from one another, affecting five of five smoke compartments.

Findings include:

1. Observation on November 25, 2024, between 11:00 a.m., and 11:45 a.m., revealed the second and third floor lacked an acceptable second means of egress.

Exit interview with the facility administrator and facility maintenance at 12:00 p.m., on November 25, 2024, confirmed the lack of an acceptable second means of egress from the second and third floors.







 Plan of Correction - To be completed: 01/07/2025

Nursing and Rehabilitation at the Mansion request to continue to use FSES regarding 0025
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 on one of three floors.
Findings include:
1. Observation on November 25, 2024, at 10:40 a.m., basement level, revealed the Medical record storage door, lacked a self-closure due to combustible materials stored within. (Varies decorations, 8 full file cabinets, cleaning supplies and approximately 20 gallons of alcohol-based hand sanitizer.)

Exit interview with the facility administrator and facility maintenance at 12:00 p.m., on November 25, 2024, confirmed the storage of the combustible material.












 Plan of Correction - To be completed: 01/07/2025

The door on the medical records storage room will be corrected by installing a door self-closure.
We will audit all other doors in the facility also to ensure any room that needs a self-closure has one.
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 maintain corridor doors in one of five smoke compartments.

Findings include:

1. Observation on November 25, 2024, at 10:50 a.m., basement level, revealed the Employee break room door failed to latch into frame when tested.

Exit interview with the facility administrator and facility maintenance at 12:00 p.m., on November 25, 2024, confirmed the door failed to latch.







 Plan of Correction - To be completed: 01/07/2025

The basement level break room door will be corrected to ensure appropriate latching.
The facility will conduct an audit of facility doors to ensure appropriate latching.
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 the emergency generator in one instance, affecting the entire facility.

Findings include:

1. Observation on November 25, 2024, between 9:15 a.m., and 10:30 a.m., revealed the facility failed to provide documentation, verifying that the emergency fuel quality testing had been conducted, within the previous twelve months.

Exit interview with the facility administrator and facility maintenance at 12:00 p.m., on November 25, 2024, confirmed the lack of documentation.












 Plan of Correction - To be completed: 01/07/2025

The facility has already set up an appointment for the generator company to come out and conduct the appropriate fuel quality testing. We will appropriately follow up on finding.

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