Pennsylvania Department of Health
MILTON REHABILITATION AND NURSING CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MILTON REHABILITATION AND NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 379902
Component 01
Main Building

Based on a Relicensure Survey completed on October 27, 2025, it was determined that Milton Rehabilitation and Nursing 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 483.70(a).

This is a one story, Type V (000), unprotected, wood frame building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Doors with Self-Closing Devices:

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, it was determined the facility failed to maintain two doors with self-closing devices, affecting one of two floors.

Findings include:

1. Observation on October 27, 2025, between 10:21 am, and 10:27 am, revealed the following:

a. At 10:21 am, Therapy, Storage Room door had the self-closure disconnected.
b. At 10:27 am, Dietary, Kitchen door (left) failed to close and positive latch into frame when tested.

Exit interview with the Facilities Manager on October 27, 2025, at 11:15 am, confirmed the self-closing door deficiencies.

Plan of Correction - To be completed: 11/15/2025

Maintenance repaired the required self-closure device on the therapy storage room door and left kitchen/dietary door. The Maintenance Director or designee will monitor to ensure compliance during weekly environmental rounds.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
2012 EXISTING
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. 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

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 one hazardous area door openings, on one of two floors.

Findings include:

1. Observation on October 27, 2025, at 10:30 am, Main Activities, Storage Room door lacked a self-closure. (Combustible decorations and activity supplies stored within.)

Exit interview with the Facilities Manager on October 27, 2025, at 11:15 am, confirmed the storage room lacked a self-closure device.

Plan of Correction - To be completed: 11/15/2025

Maintenance installed the required self-closure device to activities storage room door. The Maintenance Director or designee will monitor to ensure compliance during weekly environmental rounds.

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 documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in three locations, affecting one of two floors.

Findings include:

1. Observation on October 27, 2025, between 10:32 am, and 10:53 am, revealed the following:

a. At 10:32 am, Dietary, Walk-In freezer lacked sprinkler coverage in two areas due to missing sprinkler heads.
b. At 10:35 am, Laundry, sealed ceiling within laundry had an unsealed penetration, folding side.
c. At 10:53 am, Main Entrance, Canopy was missing an escutcheon.

Exit interview with the Facilities Manager on October 27, 2025, at 11:15 am, confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 11/15/2025

Maintenance installed the two required sprinkler heads in the walk in freezer, sealed the ceiling in the laundry room, and replaced the missing escutcheon in canopy. The Maintenance Director or designee will monitor to ensure compliance during weekly environmental rounds.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:

Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0371

Based on observation and interview, it was determined the facility failed to provide acceptable travel distance, affecting one of four smoke compartments within the facility.

Findings include:

1. Observation on October 27, 2025, at 10:45 am, revealed travel distance within the first floor, grade-level, north smoke compartment was more than two hundred feet in length.

Exit interview with the Facilities Manager on October 27, 2025, at 11:15 am, confirmed the smoke compartment travel distance deficiency.

Plan of Correction - To be completed: 11/15/2025

The facility requests the DOH Division of Life Safety to conduct a FSES regarding this matter.

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