Pennsylvania Department of Health
 ST. JOHN NEUMANN CENTER FOR REHABILITATION & HEALTHCARE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ST. JOHN NEUMANN CENTER FOR REHABILITATION & HEALTHCARE
Inspection Results For:

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ST. JOHN NEUMANN 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 November 18, 2025, at St. John Neumann 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# 452202

Component 01

Main Building
Based on a Medicare/Medicaid Recertification Survey completed on November 18, 2025, it was determined St. John Neumann Center for Rehabilitation &; Healthcare 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 two-story, Type II (000), unprotected noncombustible building, with three partial basements, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Means of Egress Requirements - Other: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 Requirements - Other
List in the REMARKS section any LSC Section 18.2 and 19.2 Means of Egress 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.
18.2, 19.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0200 Based on observation and interview, it was determined the facility failed to ensure there were no obstructions to egress, affecting one of two levels. Based on observation and interview, it was determined the facility failed to ensure there were no obstructions to egress, affecting one of three levels. Findings include: 1. Observation on November 18, 2025, at 10:15 a.m., revealed an oversized recliner in front of the egress door from Daycare Room. Exit Interview with the Administrator, Regional and Local Maintenance Directors on November 18, 2025, at 2:30 PM, confirmed the door was obstructed. Refer to NFPA 101.19.2.10.1
 Plan of Correction - To be completed: 11/21/2025

1.The Day care room Recliner was immediately removed from area.
2.NHA/Designee will complete a house-wide education on keeping egress doors free of obstruction.
3.NHA/ Designee will audit exit doors and egress paths throughout the facility to ensure they are free of obstruction.
4.NHA/ Designee will conduct a random audit of egress paths and exit doors in Daycare weekly x 4, monthly x2 to ensure they remain free of obstruction. Results of the audit will be reported at monthly QA.

NFPA 101 STANDARD Exit Signage: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.
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293 Based upon observation and interview, it was determined the facility failed to ensure that exit signs were maintained on one of three levels in the component. Findings include, Observation made on November 18, 2025, at 1:50 p.m., revealed an exit sign located above signage "NOT AN EXIT" on an external door that leads outside into the closed in, 700/600-unit courtyard.Exit Interview with the Administrator, Regional and Local Maintenance Directors on November 18, 2025, at 2:30 p.m., confirmed the exit sign needed to depict proper guidance to egress options.
 Plan of Correction - To be completed: 11/21/2025

1.Exit sign to the closed in 700/600 unit was replaced to show proper direction to egress.
2.NHA/Designee will in-service maintenance department on the proper signage being posted on facility egresses.
3.The Director of maintenance/ designee will continue to complete monthly inspections of the exit signage to ensure proper functioning and access to exit.
4.NHA or designee will do audits of the monthly inspection x 3 months. Results of the audit will be reported at monthly QA.

NFPA 101 STANDARD Hazardous Areas - 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.
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 a hazardous area enclosure on 1 of 3 levels within the component. Findings include: Observation on November 18, 2025, at 12:35 p.m. inside 700 basement large storage room had damaged hinges on the doorframe, preventing the door to close and latch.Observation on November 18, 2025, at 1:20 p.m. inside Chapel basement medical records file room, the door leaf failed to latch, preventing the double doors to latch when closed.Exit Interview with the Administrator, Regional and Local Maintenance Directors on November 18, 2025, at 2:30 p.m.,confirmed the above deficiencies.
 Plan of Correction - To be completed: 11/21/2025

1.The 700-basement large storage area door frame- hinge was replaced and door closes and positively latches. Medical records room door was checked and adjusted to allow positive latching.
2.NHA/Designee will in-service maintenance department on ensuring facility doors positively latch and self-close.
3.Director of maintenance/ designee will complete random audits of fire-resistant doors to ensure they positively latch weekly x 2, then monthly x 2.
4.Results of audit to be reported at QAPI.

NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324 Based on document review and interview, it was determined the facility failed to maintain and inspect the kitchen hood suppression system, affecting the one of ten smoke compartments within the components. Findings include: 1. Document review on November 18, 2025, at 9:15 a.m., revealed the facility failed to provide documentation for a semi-annual kitchen hood suppression system testing within 6 months of 3/3/2025. Exit Interview with the Administrator, Regional and Local Maintenance Directors on November 18, 2025, at 2:30 PM, confirmed the missed semi-annual testing.
 Plan of Correction - To be completed: 11/21/2025

1.Kitchen suppression testing was completed on 3/3/2025. Semi-annual has been scheduled with fire safety vendor.
2.NHA/Designee will educate the Maintenance director on the requirement for completing the semi-annual testing of the kitchen suppression system.
3.NHA/designee will audit the inspection binder to ensure it is up to date
4.NHA/designee will audit facility inspection binder monthly x 3 months to ensure the testing is completed Report of Audit will be reported in QAPI meeting

NFPA 101 STANDARD Portable Fire Extinguishers: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.
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 maintain portable fire extinguishers, affecting two of ten smoke compartments within the component. Findings include: 1. Observation on November 18, 2025, between 10:15 a.m., and 2:15 p.m., revealed: a) The fire extinguisher, mid hall through 700 basement, had not had professional serviced performed within the previous 12 months. b) The fire extinguisher, next to exterior door inside the Daycare Room, was obstructed by a wicker chest located on the floor. Exit Interview with the Administrator, Regional and Local Maintenance Directors on November 18, 2025, at 2:30 PM, confirmed the portable fire extinguisher deficiencies.
 Plan of Correction - To be completed: 11/21/2025

1.700 basement fire extinguishers is scheduled for inspection by fire safety vendor. The wicker chest has been relocated and the fire extinguisher next to the exterior door is now unobstructed.
2.NHA/Designee to in-service maintenance staff on requirement of maintenance and inspection of fire extinguishers monthly, ensuring they remain free from obstruction.
3.The Maintenance director/ Designee has completed an inspection of fire extinguishers in the building to ensure they are professionally serviced and unobstructed.
4.The maintenance director/designee will conduct a random audit (10 total) of the fire extinguishers monthly x 3 to ensure they are properly maintained and inspected. Report of Audit will be reported in QAPI meeting.

NFPA 101 STANDARD Corridor - Doors: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.
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, it was determined the facility failed to maintain corridor doors, to positively latch, in two of ten smoke zones within the component. Findings include: 1. Observation on November 18, 2025, between 10:15 P.M. and 2:15 P.M., revealed corridor doors failed to positively latch or had impediment to the closing of the doors at the following locations: a) Resident Room 305 due to missing latching hardware. b) Resident Room 304 due to damaged latch plate. c) Resident Room 303 due to a tape overed latch plate. d) Resident Room 600 utilized a door stop. Exit Interview with the Administrator, Regional and Local Maintenance Directors on November 18, 2025, at 2:30 PM, confirmed the doors failed to positively latch.
 Plan of Correction - To be completed: 11/21/2025

1.The doors for rooms 305, 304, and 303 were fixed and latching properly. Resident room door in 600 stopper was removed and is positively latching
2.NHA/ designee to educate Maintenance staff on ensuring facility doors are positively latching system.
3.The maintenance director/designee will conduct a random audit of doors in 300 unit monthly x 3 to ensure they are properly latching and free of door stops. 4. Report of Audit will be reported in QAPI meeting.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar: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.
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, document review and interview, it was determined the facility failed to maintain smoke compartments within required square footages, affecting three of ten smoke compartments. Observation and document review on November 18, 2025, at 10:00 a.m., revealed smoke compartments one, two, and five exceed the maximum allowance of 22,500 square feet in total area. Smoke compartment one included Katharine, Drexel, and St. Anthony Avenue (300 &; 400 Wings). Smoke compartment two included St. Elizabeth's Garden and All Saints Boulevard (500 &; 600 Wings). Smoke compartment five contained the Chapel and Administration offices (Non-Patient Care Area). Exit Interview with the Administrator and Maintenance Director on November 18, 2024, at 1:45 p.m., confirmed smoke compartments exceeded the maximum allowance.
 Plan of Correction - To be completed: 11/21/2025

1.It is the policy of the facility to ensure the smoke barriers are to provide at least two smoke compartments on every sleeping floor with a 30 or more -patient bed capacity.
2.Size of the compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any one point in the compartment to a door in the smoke carrier.
3.Smoke Compartment One (300 and 400 wings)
4.Smoke Compartment Two (500 and 600 wings)
5.Smoke Compartment Five (Chapel and Administration)
6.The facility request that the required FSES worksheet to be completed by the Department of Health in accordance with NAPA 101A.


NFPA 101 STANDARD Electrical Systems - Other: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.
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 - Component: 01 - Tag: 0911 Based on observation and interview, it was determined the facility failed to comply with NFPA 99 Chapter 6.3.2.1, for electrical wiring and equipment, affecting one of three levels within the component. Findings include: 1. Observation on November 18, 2025 at 2:00 p.m., revealed 2nd floor apartment #1, had a side wall light fixture missing mounting hardware and exposed wiring. confirmed the unprotected electrical components. Exit Interview with the Administrator and the Regional and Local Maintenance Directors on November 18, 2025, at 2:30 PM, confirmed the unprotected electrical components.
 Plan of Correction - To be completed: 11/21/2025

1.2nd floor apartment #1 light fixture has been remounted and is properly fitting. The wiring has been contained.
2.NHA/Designee to educate maintenance staff on ensuring electrical wiring and equipment is properly maintained.
3.The Maintenance director/designee will complete an audit of 2nd floor electrical equipment to ensure they are properly maintained and mounted
4.Maintenance director/ designee will complete a random audit of 2nd floor apartment to assure the electrical wiring is maintained and mounted weekly x 4 and then monthly x2. Report of Audit will be reported in QAPI meeting.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
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 - Component: 01 - Tag: 0920 Based upon observation and interview, it was determined the facility failed to ensure the prohibited use of extension cords and outlet multipliers in the following locations intwo of ten smoke compartments within the component. Findings include: 1. Observation made on November 18, 2025, at between 10:15 a.m., and 2:15 p.m. revealed: a) Inside the 600-unit cart room, a mini refrigerator was plugged into a power strip into extension cord. b) Inside the 300- Unit Nursing Station, a mini refrigerator was plugged into an extension cord. Exit Interview with the Administrator and the Regional and Local Maintenance Directors on November 18, 2025, at 2:30 PM, confirmed the prohibited use of extension cords and devices.
 Plan of Correction - To be completed: 11/21/2025

1.The extension cords in the 600-unit cart room office and the 300-unit nursing station have been removed.
2.NHA/Designee to complete a facility-wide education on the prohibition of unauthorized use of electrical devices.
3.Maintenance Director/designee will complete an audit of nursing stations and administrative office to ensure no extension cords are in use.
4.Maintenance director/designee will complete a random audit of offices, nursing stations, and/or common areas to ensure there are no unauthorized uses of electrical devices. weekly x4 and monthly x2.
5.Report of completion will be reported in QAPI meeting annually.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923 Based on observation and interview, it was determined the facility failed to ensure precautionary signs were installed; and ensure oxygen cylinders stored within rooms, were distanced from combustible materials / ignition sources in one of three levels within this component. Findings include: 1. Observation made on November 18, 2025, between 10:15 a.m., and 2:15 p.m., revealed all cylinder storage locations throughout the component lacked regulation approved precautionary signage that read "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.". Exit Interview with the Administrator, Regional and Local Maintenance Directors on November 18, 2025, at 2:30 PM, confirmed that doors lacked the regulation approved precautionary signage. 2. Observation made on November 18, 2025, between 10:15 a.m., and 2:15 p.m., revealed within the 400 Oxygen Storage room, oxygen cylinders were stored less than five feet from electrical receptacles and Hoyer Lift battery charging stations. Exit Interview with the Administrator, Regional and Local Maintenance Directors on November 18, 2025, at 2:30 PM, confirmed that the cylinders were stored less than five feet from combustible / ignition sources.
 Plan of Correction - To be completed: 11/21/2025

1.New signage that reads "CAUTION: OXIDIXZING GAS(ES) STORED WITHIN NO SMOKING" have been placed on all cylinder storage location doors. The oxygen cylinders within the 400 oxygen storage room have been moved so they are not within five feet from electrical receptables.
2.NHA/Designee will educate the maintenance director on the requirement for the oxygen Storage room signage and ensuring oxygen cylinders remain at least five feet away electrical receptacles.
3.The maintenance director/designee will audit the doors to the oxygen Storage rooms in the facility to ensure they have the correct signage and that no cylinders are within five feet of the electrical receptacles.
4.The NHA/Designee will audit oxygen storage rooms weekly x4, then monthly x2 to ensure they have the proper signage and that no cylinders are within five feet of any electrical receptacles. Report of Audit will be reported in monthly QA meeting.


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