Pennsylvania Department of Health
INGLIS HOUSE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 57 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.


INGLIS HOUSE - 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 March 25, 2025, at Inglis House, 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 & THERAPY BUILDING - Component: 01 - Tag: 0000

Facility ID # 090202
Component 01
Main and Therapy Buildings

Based on a Medicare/Medicaid Recertification Survey conducted on March 25, 2025, it was determined that Inglis House was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is five-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Aisle, Corridor, or Ramp Width:

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.

Aisle, Corridor or Ramp Width
2012 EXISTING
The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5.
19.2.3.4, 19.2.3.5

Observations:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0232

Based on observation, document review, and interview, the facility failed to maintain the minimum width of access corridors, affecting two of six levels.

Findings include:

Observation on March 25, 2025, between 9:30 a.m. and 12:00 p.m., revealed the exit access corridors measured less than four feet in width on the third floor north wing, on the second-floor north wing, and on the second floor south wing.

Exit interview with the Administrator and Director of Engineering Services on March 25, 2025, at 12:55 p.m., confirmed the above deficiencies.

Plan of Correction - To be completed: 05/06/2025

Inglis House is requesting the Pa
Division of Life Safety to update the
F.S.E.S. for this facility.

The Engineering Director or
designee will monitor this plan.

NFPA 101 STANDARD Number of Exits - Corridors:

Number of Exits - Corridors
Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies.
18.2.5.4, 19.2.5.4

Observations:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0252

Based on observation, document review, and interview, the facility failed to ensure two remote exits for each floor, affecting two of nine smoke compartments.

Findings include:

Observation and document review on March 25, 2025, at 10:30 a.m.. revealed the south wing, on the fourth floor, lacked two remote exits.

Exit interview with the Administrator and Director of Engineering Services on March 25, 2025, at 12:55 p.m., confirmed the above deficiency.

NFPA 101 STANDARD Vertical Openings - 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.

Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.

Observations:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0311

Based on observation, document review, and interview, the facility failed to ensure vertical openings between floors were enclosed with the required fire resistance rating, affecting five of six levels.

Findings include:

1. Observation on March 25, 2025, between 10:00 a.m. and 12:00 p.m., revealed insulated pipes penetrating the floor slab at the resident bathroom sink units.

Exit interview with the Administrator and Director of Engineering Services on March 25, 2025, at 12:55 p.m., confirmed the above penetrations through the floor.

2. Observation on March 25, 2025, at 11:20 a.m., revealed, on the ground floor, in North Stair elevator mechanical room, the rated access door to the mechanical shaft failed to self-close and latch when tested.

Exit interview with the Administrator and Director of Engineering Services on March 25, 2025, at 12:55 p.m., confirmed the shaft door deficiency.

Plan of Correction - To be completed: 05/06/2025

1.Inglis House is requesting the Pa
Division of Life Safety to update the
F.S.E.S. for this facility.
The Engineering Director or
designee will monitor this plan.

2. On the Ground Floor, near the North Stair Tower in the Elevator Mechanical Room, the rated access door to the mechanical shaft will be adjusted to latch properly. To prevent this condition from happening again a task will be added to the Annual Life Safety Building and Mechanical Room Check to " Check all Mechanical Room Access Door To Shafts for Proper Operation and Latching"

The Director of Engineering Services/ designee Will Monitor This Plan

NFPA 101 STANDARD Fire Alarm System - Initiation:

Fire Alarm System - Initiation
Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200' travel distance is not exceeded.
18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5

Observations:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0342

Based on observation and interview, it was determined the facility failed to maintain fire alarm initiating devices, affecting one of six levels.

Findings include:

Observations on March 25, 2025, at 11:00 a.m., revealed a heat detector dislodged from the ceiling assembly, 2 Center Urological Supplies Closet.

Exit interview with the Administrator and Director of Engineering Services on March 25, 2025, at 12:55 p.m., confirmed the dislodged heat detector.

Plan of Correction - To be completed: 05/06/2025

1) At the 2 Center Urological Supplies Closet, the out of service detector from a prior system will be removed.
2) To prevent this condition the Engineering Service Director will tour and check the entire facility including closets to identify any other areas this out of service component may still be. If any are any found they will be removed.
3) A work order for this task will be generated from the Engineering Services Maintenance Database and Work Order System Mp2, completed and kept on file for review when follow up survey occurs.

The Director of Engineering services/ designee Will Monitor This Plan

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 & THERAPY BUILDING - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain sprinklers, affecting two of four levels in the component.
Findings include:
Observation on March 25, 2025, between 10:34 a.m. and 11:22 a.m. revealed in the following locations the facility failed to ensure sprinkler heads were not obstructed:
a. 10:34 a.m., on the third floor, Therapy hallway by elevator I and J, sprinkler head obstructed by two exit signs mounted to ceiling tiles.
b. 11:22 a.m., on the first floor south wing, staff lounge, spackle mud applied to > 50% of sprinkler head.
Exit interview with the Administrator and Director of Engineering Services on March 25, 2025, at 12:55 p.m., confirmed the obstructed sprinkler heads.

Plan of Correction - To be completed: 05/06/2025

c. 1) At the third floor Therapy Hallway by elevator I and J, there is a sprinkler head obstructed by two exit signs. Inglis Engineering Department will relocate the exit signs to not be within 24 inches from the sprinkler head. This is a large area and the exit signs will be in the same line of view. On the first floor South Wing staff lounge, the sprinkler head that has spackle on it will be replaced.
d.
e. 2) To prevent this condition from happening again a task will be added to the Monthly Exit Sign Preventative Maintenance Workorder and a Tri Annual Power Strip Safety Check Preventative Maintenance Workorder which are both automatically generated from the Inglis Maintenance Data Base and Workorder System, it includes all staff lounge locations, to check and make sure all sprinkler heads are not obstructed on have any debris on them.
3)The Director of Engineering Services/ designee Will Monitor This Plan

NFPA 101 STANDARD Utilities - Gas and Electric:

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Observations:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting one of six levels.

Findings include:

Observation on March 25, 2025, at 11:15 a.m., revealed, on the ground floor, in the kitchen, a non-GFCI outlet located within 6 feet of a sink. Per NFPA 70 210.8(B)5, a GFCI outlet is required where receptacles are installed within 6 ft of the outside edge of the sink.

Exit interview with the Administrator and Director of Engineering Services on March 25, 2025, at 12:55 p.m., confirmed the unprotected outlet.

Plan of Correction - To be completed: 05/06/2025

1) In the Kitchen on the Ground Floor a GFCI will be installed by the sink.
2) To prevent this condition from happening again a task will be added to the Weekly Dietary Inspection Preventative Maintenance Workorder which is automatically generated from the Inglis Maintenance Data Base and Workorder System, to check and make sure all receptacles within 6 feet of a sink or water supply are GFCI protected. The rest of Inglis House has a weekly check by the Engineering Director's / designee "Weekly Rounds" and documentation is kept at the Engineering Office.

The Director of Engineering Services/ designee Will Monitor This Plan

NFPA 101 STANDARD Smoking Regulations:

Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0741

Based on documentation, observation, and interview, it was determined the facility failed to maintain designated smoking areas and smoking policies, affecting one of six levels.

Findings include:

Observation on March 25, 2025, at 10:50 a.m., revealed the following smoking deficiencies:

a. Metal containers with self-closing cover devices into which ashtrays can be emptied were not available at the designated outdoor smoking area, on the ground floor.
b. Ash receptacles contained combustible trash items, indoor smokers lounge on the ground floor.

Exit interview with the Administrator and Director of Engineering Services on March 25, 2025, at 12:55 p.m., confirmed the smoking deficiencies.

Plan of Correction - To be completed: 05/06/2025

1. At the designated outdoor smoking area on the Ground Floor, Inglis House will purchase and put in place 2 self-closing ash trays to be in addition to the existing table top self-closing ash trays.

2. At the indoor smokers lounge on the Ground Floor the floor mount ash receptacles that can contain trash will be removed and replaced with additional table top self-closing ash trays.
3. The Director of Engineering Services/designee Will Monitor This Plan

NFPA 101 STANDARD Electrical Systems - Other:

Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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.
Chapter 6 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain access to electrical panels, affecting two of six levels.

Findings include:

Observation on March 25, 2025, revealed the following electrical deficiencies:

a. 10:40 a.m., electrical panel blocked by a cart, 2N Medical Room.
b. 10:45 a.m., electrical panel blocked by custodial equipment, 2N Housekeeping Closet.
c. 11:45 a.m., electrical panel blocked by boxes, 4N Air Handler Unit Room.

Exit interview with the Administrator and Director of Engineering Services on March 25, 2025, at 12:55 p.m., confirmed the blocked electrical panels.

Plan of Correction - To be completed: 05/06/2025

1) At the 2 North Medical Room in front of the electrical panel the equipment will be moved. As a prevention the Engineering Director / designee will check this location as part of weekly hallway rounds.

2) At the 2 North Electrical Closet near the housekeeping closet. The equipment will be moved from in front of the fire the electrical panel. As a prevention the Engineering Director/ designee will check this location as part of the weekly hallway
rounds.

3) At the 4N air handler unit room the equipment will be moved from in from of the electrical panel. As a prevention the Engineering Director/ designee will check this location as part of the weekly hallway rounds.

4) To prevent this condition from happening again a New Life Safety Preventative Maintenance Workorder will be set up and be automatically generated annually from the Inglis Maintenance Data Base and Workorder System Mp2. There will be a task instruction to check for blocked electrical panels and removed items if any panel is blocked.

4) The Director of Engineering Services/ Designee Will Monitor This Plan

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

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: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the improper and unauthorized use of electrical devices, affecting one of six levels.

Findings include:

Observation on March 25, 2025, at 12:10 p.m., revealed a power strip plugged into an extension cord, security office on the ground floor.

Exit interview with the Administrator and Director of Engineering Services on March 25, 2025, at 12:55 p.m., confirmed the unauthorized electrical device.

Plan of Correction - To be completed: 05/06/2025

1) At the Ground Floor Security Office, the
power strip will be removed.
2) To prevent this condition from
happening again the Power Strip check for
the entire building will have the
frequency increased from January
and July to 3 times per year. This
preventative maintenance task is
automatically generated from the
MP2 maintenance data base.
3) The Director of Engineering Services/ designee Will Monitor This Plan

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