Pennsylvania Department of Health
TITUSVILLE NURSING AND REHAB
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 45 surveys for this facility. Please select a date to view the survey results.

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TITUSVILLE NURSING AND REHAB - 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 30, 2026, at Titusville Healthcare and Rehabilitation 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 #331102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 30, 2026, it was determined that Titusville Healthcare and Rehabilitation Center 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 (000), unprotected, wood building, 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, the facility failed to maintain the building construction type and height in all areas of the building.

Findings include:

Observation on June 30, 2026, at 9:45 a.m., revealed the building height exceeded the height requirements for a two-story, Type V (000), unprotected, wood building.

Interview with the maintenance supervisor on June 30, 2026, at 9:45 a.m., confirmed the building height exceeded requirements.

Plan of Correction - To be completed: 07/17/2026

Requested continuance of FSES and Time Limited waiver. This will not have any adverse effect on our residents' health and safety.

NFPA 101 STANDARD Doors with Self-Closing Devices:

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.

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, the facility failed to maintain doors with self-closing devices for one of over ten doors.

Findings include:

Observation on June 30, 2026, at 12:35 p.m., revealed the basement soiled utility room self-closing door failed to close and latch in the frame.

Interview with the maintenance supervisor on June 30, 2026, at 12:35 p.m., confirmed the door failed to close and latch in the frame at the time of the survey.

Plan of Correction - To be completed: 07/17/2026

Basement soiled utility room self-closing door has been readjusted to allow doors to auto close.
All auto close doors will be audited three times a week for one week, then weekly until compliance is met ensure doors auto close.
Results of audits will be reviewed at the quality assurance meeting until compliance is met.

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 on observation and interview, the facility failed to maintain the automatic sprinkler system in one of four building zones.

Findings include:

Observation on June 30, 2026, between 12:33 p.m. and 12:45 p.m., revealed the following areas had foreign objects attached to the sprinkler pipe:

A. (12:33 p.m.) Basement med room had string hanging on pipe;
B. (12:45 p.m.) Basement central supply room had plastic mesh zip-tied to pipe.

Interview with the maintenance supervisor on June 30, 2026, at 12:45 p.m., confirmed the sprinkler deficiencies.

Plan of Correction - To be completed: 07/17/2026

Basement med room sprinkler pipe has had string removed.
Sprinkler pipes will be audited three times a week for one week, then weekly until compliance is met.
Results of audits will be reviewed at the quality assurance meeting until compliance is met.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID #331102
Component 02
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 30, 2026, at Titusville Healthcare and Rehabilitation Center, it was determined there were no deficiencies identified under the 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 one-story, Type V (111), protected, wood building, that is fully sprinklered.

Plan of Correction:

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