Pennsylvania Department of Health
IMMACULATE MARY CENTER FOR REHABILITATION & HEALTHCARE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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IMMACULATE MARY CENTER FOR REHABILITATION & HEALTHCARE - 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 April 1, 2026, at Immaculate Mary Center For Rehabilitation &; Healthcare, 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#090902Component 01Main BuildingBased on a Medicare/Medicaid Recertification Survey completed on April 1, 2026, it was determined that Immaculate Mary Center For Rehabilitation &; Healthcare - Main Building 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 a four story, Type II (222), fire resistive 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 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.

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, it was determined the facility failed to maintain the means of egress free of impediments to full and instant use, affecting one of five levels. Findings include: 1. Observation on April 1, 2026, at 11:00 a.m., revealed, on the third floor, the stair tower was obstructed by 2 unattended patient lifts parked in front of the stair tower door. Exit Interview with the Assistant Administrator and Maintenance Director on April 1, 2026, at 1:00 p.m., confirmed the obstructed egress.

Plan of Correction - To be completed: 05/08/2026

It is the practice of the facility to maintain means of egress and all residents had the potential to be affected by this deficiency.

1. The two patients' lifts have been moved and no longer obstruct the stair tower on the third floor.

2. All stair towers were checked for obstruction in the path of egress on 4/02/2026 and found to be free from obstructions.

3. The Director of Maintenance has completed training and education with Maintenance staff and nursing regarding monitoring egress paths and moveable equipment to remain free from the exit discharge paths.

4. Every quarter for a year the Maintenance Director or designee will complete monthly inspection of stair towers, means of egress, on all floors of the facility. This information will then be entered on a log and will be presented by the director of maintenance to the monthly QAPI meeting for one year.

NFPA 101 STANDARD Egress Doors:

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0222 Based on observation and interview, the facility failed to maintain egress doors with special locking arrangements, affecting one of at least fifteen egress doors within the component. Findings include: 1.Observation on April 1, 2026, at 12:05 p.m., revealed, on the fourth floor, the north stair tower door (across from room 427), equipped with special locking arrangement to release within 15 seconds of pressure applied against door, failed to release to provide access. Exit Interview with the Assistant Administrator and Maintenance Director on April 1, 2026, at 1:00 p.m., confirmed the egress door failed to release.

Plan of Correction - To be completed: 05/08/2026

It is the practice of the facility to have delayed egress functionality on exit doors, and all residents had the potential to be affected by this deficiency.

1. Facility has repaired the north stair tower door and delayed egress is now functioning as per the design.

2. All delayed egress doors have been tested on 4/02/2026 and are functioning as per the design. All resident areas are free from hazard, and all systems are operating as designed.

3. The Director of Maintenance has completed education and training with Maintenance staff on testing delayed egress doors for proper function.

4. Every quarter for a year the Maintenance Director or designee will complete testing of delayed egress doors. This information will then be entered on a log and will be presented by the director to the monthly QAPI meeting for one year.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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, it was determined the facility failed to maintain the fire resistance rating of hazardous areas, in sprinklered locations, affecting one of five levels. Findings include: 1. Observation on April 1, 2026, at 10:45 a.m., revealed numerous combustible boxes and various items were stored within the Dialysis Hall Storage room, on the first floor. The door to this room lacked a self-closing device. fourth door right side of corridor. Exit Interview with the Assistant Administrator and Maintenance Director on April 1, 2026, at 1:00 p.m., confirmed the hazardous area door condition.

Plan of Correction - To be completed: 05/08/2026

It is the practice of the facility to ensure hazardous storage areas self-close, and all residents had the potential to be affected by this deficiency.

1. A self-closure has been installed on the storage room door for dialysis.

2. All hazardous storage rooms have been inspected for self-closing devices on 4/2/2026. All residents were safe, and no hazards were present.

3. The Director of Maintenance has completed education with Maintenance staff to confirm proper installation of door equipment based on rooms designation and use.

4. Every quarter for a year the Maintenance Director or designee reviews storage rooms for self-closing operations. This information will then be entered on a log and will be presented by the director to the monthly QAPI meeting for one year.

NFPA 101 STANDARD Fire Alarm System - Notification:

Fire Alarm - Notification
2012 EXISTING
Positive alarm sequence in accordance with 9.6.3.4 are permitted in buildings protected throughout by a sprinkler system. Occupant notification is provided automatically in accordance with 9.6.3 by audible and visual signals.
In critical care areas, visual alarms are sufficient. The fire alarm system transmits the alarm automatically to notify emergency forces in the event of a fire.
19.3.4.3, 19.3.4.3.1, 19.3.4.3.2, 9.6.4, 9.7.1.1(1)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0343 Based on observation and interview, it was determined the facility failed to ensure fire alarm notification devices were maintained, affecting one of at least six pull stations on one of five levels. Findings include: 1.Observation on April 1, 2026, at 11:10 a.m., revealed a wall mounted manual pull station was obstructed by carts of kitchen supplies in the basement hallway outside of the electrical room. Exit Interview with the Assistant Administrator and Maintenance Director on April 1, 2026, at 1:00 p.m., confirmed the obstructed pull station.

Plan of Correction - To be completed: 04/08/2026

It is the practice of the facility to ensure Fire pull stations are properly accessible and all residents have the potential to be affected by this deficiency.

1. The Fire pull station in the basement hallway has had obstructions cleared from the area and pull station is fully accessible.

2. All Fire pull stations in the facility have been reinspected on 4/2/2026 and are ready for use and free from obstructions.

3. The Director of Maintenance has completed education with Maintenance staff regarding monitoring Fire pull station storage obstructions.

4. Every quarter for a year the Maintenance Director or designee will check Fire pull stations for obstructions throughout the facility to ensure they are ready for use. This information will then be entered on a log and will be presented by the director to the monthly QAPI meeting for one year.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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, it was determined the facility failed to maintain automatic sprinkler system components within compliance, affecting the entire facility. Findings include: 1. Observation on April 1, 2026, at 11:30 a.m., in basement sprinkler main room, revealed the sprinkler gauges were dated 2020 and were not replaced or re-calibrated within a five-year compliance date. Exit Interview with the Assistant Administrator and Maintenance Director on April 1, 2026, at 1:00 p.m., confirmed the gauges were out of the five-year replacement window.

Plan of Correction - To be completed: 05/08/2026

It is the practice of the facility to ensure gauges are replaced and maintained in accordance with requirements and all residents had the potential to be affected by this deficiency.

1. The sprinkler gauges have all been changed and calibrated as per the requirements.

2. All gauges around the building have been inspected as per the manufacturers' design. All residents were safe, and no hazards were present.

3. Education is completed with Maintenance staff to confirm proper compliance with the sprinkler system requirements.

4. Every quarter for a year the Maintenance Director or designee reviews sprinkler system components for cleanliness and compliance. This information will then be entered on a log and will be presented to the QAPI meeting.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355 Based on observation and interview, it was determined the facility failed to ensure that portable fire extinguishers were accessible, on one of five levels within the component. Findings Include: 1.Observation on April 1, 2026, at 11:13 a.m., revealed a wall mounted portable fire extinguisher was obstructed by carts of kitchen supplies in the basement hallway outside of the electrical room. Exit Interview with the Assistant Administrator and Maintenance Director on April 1, 2026, at 1:00 p.m., confirmed access to the portable fire extinguisher was obstructed.

Plan of Correction - To be completed: 05/08/2026

It is the practice of the facility to ensure Fire Extinguishers are properly accessible and all residents have the potential to be affected by this deficiency.

1. The Fire Extinguisher in basement hallway has had the obstruction removed to remain accessible for use.

2. All Fire Extinguishers in the facility have been reinspected and are ready for use and the staff inspect the extinguisher areas to prevent this from happening in the future.

3. The Director of Maintenance has completed education with Maintenance staff regarding monitoring Fire
Extinguishers by Maintenance Staff.

4. Every quarter for a year the Maintenance Director or designee will check Fire Extinguishers throughout the facility to ensure they are ready for use. This information will then be entered on a log and will be presented by the director to the monthly QAPI meeting for one year.

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 for three of over seventy-five corridor doors within the component. Findings include: 1. Observation on April 1, 2026, revealed the following: a) 11:28 a.m., resident room 408, failed to positively latch in the frame. b) 11:39 a.m., resident room 435, failed to positively latch in the frame. c) 12:37 p.m., resident room 314, failed to positively latch in the frame. Exit Interview with the Assistant Administrator and Maintenance Director on April 1, 2026, at 1:00 p.m., confirmed the above corridor door issues.

Plan of Correction - To be completed: 05/08/2026

It is the practice of the facility to ensure smoke, Fire and corridor doors will operate as per design and all residents had the potential to be affected by this deficiency.

1. The doors in room 408,435,314 have had the doors repaired and now they close, latch and are gap free as design.

2. Doors throughout the facility were checked to allow for closure, all residents are free from hazards and all systems are operating.

3. Education completed with Maintenance staff regarding monitoring doors and rating labels to ensure they close properly.

4. Every quarter for a year the Maintenance Director or designee will check random doors throughout the facility to ensure the doors are fully closed. This information will then be entered on a log and will be presented to the monthly QAPI meeting.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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 observation and interview, it was determined the facility failed to maintain smoke barrier walls, affecting one of five levels. Findings include: 1. Observation on April 1, 2026, at 10:15 a.m., revealed an unsealed penetration around data wires, on the fourth floor, the Dining- North side, above smoke doors. Exit Interview with the Assistant Administrator and Maintenance Director on April 1, 2026, at 1:00 p.m., confirmed the penetration.

Plan of Correction - To be completed: 05/08/2026

It is the practice of the facility to ensure smoke, Fire and are free from penetrations, and all residents had the potential to be affected by this deficiency.

1. The penetration above the 4-floor dining side smoke doors has been sealed using UL rated approved fire caulk (W-L-3001).

2. Smoke Barrier walls throughout the facility have been inspected for penetration and are free from any penetration, all residents are free from hazards and all systems are operating.

3. Education completed with Maintenance staff regarding monitoring penetrations through smoke walls and following behind vendors as work is completed to close any penetrations using approved fire caulk.

4. Every quarter for a year the Maintenance Director or designee will check random smoke walls throughout the facility to ensure they are free from penetration. This information will then be entered on a log and will be presented to the monthly QAPI meeting.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu:

Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0541 Based on observation and interview, it was determined the facility failed to maintain the fire protection rating for trash and linen chutes, affecting one of five levels. Findings include: 1. Observations on April 1, 2026, revealed linen chute deficiencies in the following locations: a. 10:10 a.m., basement lined chute discharge room door had a detached closer. b. 10:30 a.m., on the fourth floor, the linen chute door failed to positively latch. Exit Interview with the Assistant Administrator and Maintenance Director on April 1, 2026, at 1:00 p.m., confirmed the door deficiencies.

Plan of Correction - To be completed: 05/08/2026

It is the practice of the facility to have proper closing and latching of all rubbish chutes all residents had the potential to be affected by this deficiency.

1. Facility has installed a fire rated handle with a latch on the fourth-floor linen chute to ensure that not only does the chute magnetic lock remain locked, but the door closes and latches as per the design. The closer on the basement linen chute had the closer replaced with a fire rated closure.

2. All linen and trash chutes have been checked and adjustments made to allow for proper closing and latching. All resident areas are free from hazard, and all systems are operating as designed.

3. The Director of Maintenance has completed education and training with Maintenance staff to confirm proper operations of linen and trash chutes.

4. Every quarter for a year the Maintenance Director or designee review linen and trash chutes for proper function. This information will then be entered on a log and will be presented by the director to the monthly QAPI meeting for one year.

Initial comments:Name: BUILDING 02 (CHAPEL) - Component: 02 - Tag: 0000
Facility ID# 090902Component 02ChapelBased on a Medicare/Medicaid Recertification Survey completed on April 1, 2026, it was determined that Immaculate Mary Center For Rehabilitation &; Healthcare - Chapel, 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 a one-story, Type II (000), unprotected non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Egress Doors:

Observations:
Name: BUILDING 02 (CHAPEL) - Component: 02 - Tag: 0222 Based on observation and interview, it was determined that the facility failed to maintain egress doors with delayed egress locking systems affecting one of two components. Findings include: Observation on April 1, 2026, at 9:40 a.m., revealed the delayed-egress door by the Altar failed to release after 15 seconds as indicated on signage. Exit Interview with the Assistant Administrator and Maintenance Director on April 1, 2026, at 1:00 p.m., confirmed the door failed to release.

Plan of Correction - To be completed: 05/08/2026

It is the practice of the facility to have delayed egress functionality on exit doors, and all residents had the potential to be affected by this deficiency.

1. Facility has repaired the altar exit door and delayed egress is now functioning as per the design.

2. All delayed egress doors have been tested on 4/02/2026 and are functioning as per the design. All resident areas are free from hazard, and all systems are operating as designed.

3. The Director of Maintenance has completed education and training with Maintenance staff on testing delayed egress doors for proper function.

4. Every quarter for a year the Maintenance Director or designee will complete testing of delayed egress doors. This information will then be entered on a log and will be presented by the director to the monthly QAPI meeting for one year.

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: BUILDING 02 (CHAPEL) - Component: 02 - Tag: 0291 Based on document review and interview, it was determined the facility failed to ensure battery back-up lighting was maintained in operable condition, affecting one of two components. Findings include: 1. Observation on April 1, 2026, at 9:45 a.m., revealed the battery back-up light by the Altar side exit failed to illuminate when tested. Exit Interview with the Assistant Administrator and Maintenance Director on April 1, 2026, at 1:00 p.m., confirmed the battery back-up light deficiency.

Plan of Correction - To be completed: 05/08/2026

It is the practice of the facility to have proper backup lighting on all exit discharge paths, and all residents had the potential to be affected by this deficiency.

1. Facility has replaced the battery backup light by the the alter exit door is now functioning as per the design.

2. All battery backup lighting has been tested on 4/02/2026 and is functioning as per the design. All resident areas are free from hazard, and all systems are operating as designed.

3.The Director of Maintenance has completed education and training with Maintenance staff on testing battery backup lighting for proper function.

4. Every quarter for a year the Maintenance Director or designee will complete testing of battery backup lights. This information will then be entered on a log and will be presented by the director to the monthly QAPI meeting for one year.

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