Pennsylvania Department of Health
MT. MACRINA MANOR
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MT. MACRINA MANOR - 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 July 21, 2026, at Mt. Macrina Manor, 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 #394102
Component 01
Main building

Based on a Medicare/Medicaid Recertification Survey completed on July 21, 2026, it was determined that Mt. Macrina Manor was not in compliance with the following requirements of the Life Safety Code for an existing healthcare 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 II (000), unprotected, non-combustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

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.

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview, the facility failed to maintain the means of egress in one instance, affecting one of twelve smoke compartments.

Findings include:

Observation on July 21, 2026, at 10:00 a.m., revealed a wheelchair was blocking the door to stairwell #4, which would impede the emergency exit egress route.

Interview with the facility director of nursing and maintenance director, on July 21, 2026, at 1:30 p.m., confirmed the means of egress deficiency.

Plan of Correction - To be completed: 08/11/2026

The wheelchair obstructing the door to Stairwell #4 was removed immediately upon identification during the Life Safety survey, restoring the required means of egress.
A facility-wide inspection of all exit doors, stairwells, exit corridors, and means of egress was completed by the Maintenance Director to ensure that no additional obstructions were present. Any items identified during routine rounds will be removed immediately.
To prevent recurrence, the facility will:
- Re-educate all nursing, environmental services, rehabilitation, activities, and ancillary staff regarding the requirement to keep all exits, stairwell doors, corridors, and means of egress free from obstruction at all times.
- Reinforce that wheelchairs, carts, lifts, equipment, and other items may not be stored in front of exit doors or within required egress pathways.
The Maintenance Director or designee will audit compliance weekly for four weeks and monthly thereafter for three months. Audit findings will be reported to the Quality Assurance and Performance Improvement (QAPI) Committee. Additional education and corrective action will be implemented if deficiencies are identified.

NFPA 101 STANDARD Corridor - Doors:

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, the facility failed to maintain corridor doors in one instance, affecting one of twelve smoke compartments.

Findings include:

Observation on July 21, 2026, at 11:30 a.m., revealed the door to room 201 was blocked by a tray table and would not close.

Interview with the facility director of nursing and maintenance director on July 21, 2026, at 1:30 p.m., confirmed the corridor door would not close and latch.

Plan of Correction - To be completed: 08/11/2026

The tray table obstructing the corridor door to Room 201 was removed immediately upon identification, allowing the door to close and positively latch as required.
Maintenance conducted a facility-wide inspection of resident room corridor doors to verify that all doors were capable of closing and latching properly and that no furniture or equipment obstructed door operation. Any deficiencies identified during the inspection were corrected immediately.
To prevent recurrence, the facility has:
- Educated nursing staff, environmental services, therapy, activities, and other departments regarding the prohibition against placing equipment or furniture that interferes with corridor door operation.
- Reinforced that corridor doors must remain capable of closing and latching at all times.
The Maintenance Director or designee will perform weekly audits of corridor door operation for four weeks and monthly thereafter for three months. Results will be reviewed by the QAPI Committee. Additional corrective action and staff education will be provided as necessary.

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