Pennsylvania Department of Health
FOX SUBACUTE AT MECHANICSBURG
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
FOX SUBACUTE AT MECHANICSBURG
Inspection Results For:

There are  36 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.
FOX SUBACUTE AT MECHANICSBURG - 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 February 16, 2024, at Fox Subacute at Mechanicsburg, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: FOX SUBACUTE AT MECHANICSBURG - Component: 01 - Tag: 0000


Facility ID #22220201
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 16, 2024, it was determined that Fox Subacute at Mechanicsburg 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 483.90(a).

This is a two-story, Type V (111), protected wood frame structure, with a basement, which 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: FOX SUBACUTE AT MECHANICSBURG - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of exit stairtower enclosures, affecting one of three floors within the component.

Findings include:

1. Observation on February 16, 2024, at 11:51 AM, revealed the 2nd floor door to the Exit Stairtower, by the Dining/Lounge Room, did not positively latch within the door frame.

Interview with the Director of Maintenance on February 16, 2024, at 11:51 AM, confirmed the door did not latch within the frame.



 Plan of Correction - To be completed: 03/22/2024

1. The Emergency Push Latch Bar was removed, inspected, cleaned and lubricated.
2. The Latch Bar was reinstalled and checked to ensure positive latching.
3. Maintenance Supervisor will monitor Emergency Exit doors for positive latching randomly for 3 months and then quarterly.
4. Maintenance Supervisor will report findings to Quality Assurance Committee
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: FOX SUBACUTE AT MECHANICSBURG - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain the positive latching of corridor doors, affecting one of three floors within the component.

Findings include:

1. Observation on February 16, 2024, at 10:48 AM, revealed the basement door to the Bio-Hazard Room, by the Kitchen, failed to positively latch within the door frame.

Interview with the Director of Maintenance on February 16, 2024, at 10:48 AM, confirmed the door did not latch within the frame.



 Plan of Correction - To be completed: 03/22/2024

1. Basement door was removed and inspected.
2. Door hinges were replaced and door was rehung.
3. Adjustments were made to ensure positive latching.
4. Maintenance Supervisor will audit random doors for 3 months and then quarterly for compliance.
5. Maintenance Supervisor will report findings to Quality Assurance Committee
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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 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: FOX SUBACUTE AT MECHANICSBURG - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of surge suppressors, affecting one of three floors within the component.

Findings include:

1. Observation on February 16, 2024, at 11:32 AM, revealed a surge suppressor, supplying electrical power to a microwave, within the 1st floor P.T. Room.

Interview with the Director of Maintenance on February 16, 2024, at 11:32 AM, confirmed the high draw appliance was plugged into a surge suppressor.



 Plan of Correction - To be completed: 03/22/2024

1. Surge suppressor and microwave were removed from the PT room.
2. Maintenance Supervisor inspected facility for any other unauthorized use of Surge suppressors.
3. Maintenance Supervisor will audit random rooms for 3 months and then quarterly for compliance.
5. Maintenance Supervisor will report findings to Quality Assurance Committee
Initial comments:Name: 12 BED ADDITION - Component: 02 - Tag: 0000


Facility ID #22220201
Component 02
12 Bed Addition

Based on a Medicare/Medicaid Recertification Survey completed on February 16, 2024, it was determined that Fox Subacute at Mechanicsburg was not in compliance with the following requirements of the Life Safety Code for a new 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 noncombustible structure, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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: 12 BED ADDITION - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain components of the automatic sprinkler protection system, in a continuously reliable operating condition, affecting one of approximately 100 sprinkler heads inspected within the component.

Findings include:

1. Observation on February 16, 2024, at 11:10 AM, revealed the basement Garage sprinkler head, located by the overhead door, did not have an escutcheon installed.

Interview with the Director of Maintenance on February 16, 2024, at 11:10 AM, confirmed the missing escutcheon.



 Plan of Correction - To be completed: 03/22/2024

1. Sprinkler head had the escutcheon replaced.
2. Maintenance Supervisor will audit sprinkler heads for 3 months and then quarterly for compliance.
3. Maintenance Supervisor will report findings to Quality Assurance Committee

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port