Pennsylvania Department of Health
MULBERRY HEALTHCARE AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 52 surveys for this facility. Please select a date to view the survey results.

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MULBERRY HEALTHCARE AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Based on an Onsite Revisit to an Emergency Preparedness Survey completed on September 30, 2025, at Mulberry 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 #021802
Component 01
Main Building

Based on an Onsite Revisit to a Medicare/Medicaid Recertification Survey completed on September 30, 2025, it was determined that Mulberry 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 one-story, Type V (000), unprotected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on observation, document review, and interview, the facility failed to maintain general requirements, affecting the entire facility.

Findings include:

1. Document review on September 30, 2025, at 10:20 a.m., revealed the facility failed to provide a set of accurate, portable floor plans. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site, to be used during the Life Safety Code Survey.

The Life Safety Code Floor Plan shall include the following:
a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls (1-2 hour walls);
c. Horizontal exits;
d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls.

Interview with the maintenance supervisor on September 30, 2025, at 10:20 a.m., confirmed the facility's Life Safety Code floor plan listed smoke barrier walls and a two-hour separation, but failed to list the rated designated rooms at the time of the survey.

2. Observation on September 30, 2025, at 12:00 p.m., revealed the facility failed to obtain required approval from the Department of Health State Plan Review and a granted occupancy from the Life Safety Division for the change of use of resident room 37 to a storage room in the resident wing currently closed.

Interview with the administrator and maintenance director on September 30, 2025, at 12:30 p.m., confirmed the facility did not submit the required paperwork for the room change of use.

3. Observation on September 30, 2025, at 12:35 p.m., revealed the facility failed to report a ceiling-mounted, gas-powered heater incident that caused the unit to smoke in a storage room containing combustible material. The facility was unable to provide documentation of annual service cleanings or inspections, per manufacturer guidelines. The facility failed to report when the incident occurred or what protocols were followed. There was noticeable smoke damage to the ceiling above the unit and a build up of smoke, dust, and foreign matter on the deflector blades at the time of the survey. The unit was not in use at the time it was disconnected.

Interview with the administrator and maintenance director on September 30, 2025, at 12:35 p.m., confirmed the facility did not submit an incident report.

****************
Based on document review and interview during an Onsite Revisit Survey conducted on November 25, 2025, at 10:00 a.m., the facility failed to update its life safety plans to include item 1, A-F.
Interview with the administrator and the maintenance supervisor on November 25, 2025, at 10:00 a.m., confirmed the facility did not correct the life safety plan deficiency.

Plan of Correction - To be completed: 12/29/2025

An architectural draftsman has been secured to update a most current floor plan to include the noted items and a key. Upon completion the plans will be kept on site and available for inspection as needed.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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.

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, the facility failed to meet hazardous room requirements in one of five smoke compartments.

Findings include:

Observation on September 30, 2025, at 10:44 a.m., revealed the storage room at the end of the business wing was full of combustibles measuring over 50 square feet and not protected by a hazardous enclosure or designated as a hazardous enclosure in the facility floor plans, as rated.

Interview with the maintenance supervisor on September 30, 2025, at 10:00 a.m., confirmed the deficiency at the time of the survey.

****************
Based on observation and interview during an Onsite Revisit Survey conducted on November 25, 2025, at 9:02 a.m., the storage room was still not designated a hazardous enclosure in the facility floor plan. The facility was unable to provide documentation that the room was changed to a storage room with approved plans from Department of Health Plan Review. The room during the onsite inspection was still full of combustible storage.
Interview with the administrator and the maintenance supervisor on November 25, 2025, at 9:02 a.m., confirmed the facility did not correct the deficiencies.

Plan of Correction - To be completed: 12/29/2025

Historic review was completed with the Department of Health to identify that the storage room was officially changed with plan review in July of 2017. The storage room will be reflected as such on the updated floor plans.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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, the facility failed to meet fire alarm system requirements for one of one system.

Findings include:

Observation on September 30, 2025, at 9:59 a.m., revealed the facility was unable to provide documentation the following fire alarm system requirements at the time of the survey:
A. (9:59 a.m.) Semi-annual visual inspection;
B. (9:59 a.m.) Sensitivity testing.

Interview with the maintenance supervisor on September 30, 2025, at 10:00 a.m., confirmed the deficiencies at the time of the survey.

****************
Based on observation and interview during an Onsite Revisit Survey conducted on November 25, 2025, at 9:20 a.m., the facility failed to provide documentation for the annual visual inspection and sensitivity testing of the fire alarm system.
Interview with the administrator and the maintenance supervisor on November 25, 2025, at 9:20 a.m., confirmed the facility did not have the documentation.

Plan of Correction - To be completed: 12/29/2025

On 12/4/2025 Directec took over service of the fire alarm systems for the facility and completed a visual inspection with sensitivity testing of the updated system.
This new fire alarm monitoring vendor has been secured and will complete Sensitivity testing and Semi-annual Visual inspections. They will be following for timely completion of these required inspections. The Maintenance Director will upload completed inspection reports into the TELS system for additional timely prompting of compliance.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

This is a less serious (but not lowest level) 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 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.

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on document review and interview, the facility failed to meet smoke barrier requirements for one of one facility.

Findings include:

Document review on September 30, 2025, at 10:55 a.m., revealed the "fire door inspection" completed on January 31, 2024, listed the "duct damper" total number as "3." Further investigation revealed the inspection did not provide the individual damper locations that were inspected, if they were exercised, or if there were any deficiencies found. A full operational fire damper inspection was completed on November 15, 2019, listing seven dampers in total, conflicting with the most-recent report.

Interview with the maintenance supervisor on September 30, 2025, at 10:55 a.m., confirmed the fire door inspection on January 31, 2024, failed to list necessary criteria.

****************
Based on document review and interview during an Onsite Revisit Survey conducted on November 25, 2025, at 9:45 a.m., the facility was unable to provide any additional documentation at the time of the survey.
Interview with the administrator and the maintenance supervisor on November 25, 2025, at 9:45 a.m., confirmed the facility did not have additional documentation.

Plan of Correction - To be completed: 12/29/2025

United Safety Services has been secured to complete a thorough report on the dampers and ducts in the facility. This report will be placed on file in the TELS system and monitored for completion based on requirements.

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