Pennsylvania Department of Health
ST. MARY'S VILLA NURSING HOME, INC.
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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ST. MARY'S VILLA NURSING HOME, INC. - 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 July 14, 2026, at St. Mary's Villa Nursing Home, 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# 711502
Component 01
Building 01

Based on a Medicare/Medicaid Recertification Survey completed on July 14, 2026, it was determined that St. Mary's Villa Nursing Home, Inc., 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 two story, Type II (222), fire resistive building, with basement, and basement-level crawl space, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

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.

Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain rated building construction requirements in four locations affecting two of three floors.

Findings include:

1. Observation on July 14, 2026, between 10:45 am, and 11:36 am, revealed the following:

a. At 10:45 am, Basement level, Men's locker room had a large, unsealed penetration of the ceiling due to water damage.
b. At 10:52 am, Basement level, Activity storage room had 2 unsealed penetrations of the ceiling.
c. At 10:56 am, Basement level, Laundry room (folding) had a large, unsealed penetration of the ceiling due to water damage.
d. At 11:36 am, 2nd floor, Ext 31 Soiled linen room had an unsealed penetration of the ceiling around a group of mc cables and electrical conduit.

Exit interview with the Facility Administrator and the Facilities Manager on July 14, 2026, at 12:15 pm, confirmed the building construction deficiency.

Plan of Correction - To be completed: 08/17/2026

1)The penetration has been repaired in the basement men's locker room, basement activity storage room, basement laundry room and Ext 31 soiled linen room.

2)Maintenance audited the facility to ensure that building construction requirements are maintained.

3)Maintenance will be in-serviced on Maintaining building construction requirements.

4)An audit will be conducted on monthly safety rounds to ensure that building construction requirements are maintained. Results will be presented to the QAPI committee for review and recommendations

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 five hazardous area enclosures, affecting three of three floors.

Findings include:

1. Observation on July 14, 2026, between 10:52 am, and 11:29 am, revealed the following:

a. At 10:52 am, Basement level, Activity storage room had an unsealed penetration of the wall around a mc cable.
b. At 10:55 am, Basement level, Soiled Linen chute discharge room door was being held open by unapproved means.
c. At 11:05 am, Basement level, Brief storage room door failed to latch into frame when tested.
d. At 11:12 am, 1st floor, Ext 28 Soiled linen room door failed to latch into frame when tested.
e. At 11:29 am, 2nd floor, Ext 30 Linen storage room door failed to latch into frame when tested.

Exit interview with the Facility Administrator and the Facilities Manager on July 14, 2026, at 12:15 pm, confirmed the hazardous area enclosure deficiencies.

Plan of Correction - To be completed: 08/17/2026

1)The activity storage room wall around the mc cable was sealed.
The soiled linen room door was closed immediately.
The latch on the basement level storeroom door, ext 28 soiled linen room door and ext 30 linen room door were adjusted.
2)Maintenance audited the facility to ensure that all hazardous area enclosures and within guidelines.

3)Maintenance will be in serviced on hazardous area enclosure guidelines.

4)An audit will be conducted on monthly safety rounds to ensure that all hazardous area enclosures are within guidelines. Results will be presented to the QAPI committee for review and recommendations

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 observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of three floors.

Findings include:

1. Observation on July 14, 2026, at 10:51 am, Basement level, Housekeeping office lacked several ceiling tiles due to water damage.

Exit interview with the Facility Administrator and the Facilities Manager on July 14, 2026, at 12:15 pm, confirmed the missing ceiling tiles.

Plan of Correction - To be completed: 08/17/2026

1)The ceiling tiles have been replaced

3)Maintenance will be in serviced on missing ceiling tiles.

4)An audit will be conducted on monthly safety rounds to ensure that all ceiling tiles are in place. Results will be presented to the QAPI committee for review and recommendations

NFPA 101 STANDARD Fire Drills:

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.

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform fire drills on a random basis, affecting the entire facility.

Findings include:

1. Review of documentation on July 14, 2026, between 9:45 am, and 10:30 am, revealed that the facility conducted 3 of 4 quarterly fire drills for 2nd shift within the same hour. (1905, 1920, 1950).

Exit interview with the Facility Administrator and the Facilities Manager on July 14, 2026, at 12:15 pm, confirmed the fire drills were done in the same hour.

Plan of Correction - To be completed: 08/17/2026

1)Fire drills will be conducted on varying hours on the second shift.

2)Maintenance will be in serviced on fire drill guidelines.

3)An audit will be conducted quarterly on fire drill times. Results will be presented to the QAPI committee for review and recommendations

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain the emergency generator which serves the entire facility.

Findings include:

1. Review of documentation on July 14, 2026, between 9:45 am, and 10:30 am, revealed the facility failed to provide documentation verifying the following generator visual and/or testing since 2/18/2026.

a. weekly inspection/ visual checks.
b. weekly inspections of the electrolyte level or battery voltage.
c. monthly testing and recording of electrolyte specific gravity or conductance testing.
d. monthly 30-minute load.
e. monthly operation of the transfer switches.

Exit interview with the Facility Administrator and the Facilities Manager on July 14, 2026, at 12:15 pm, confirmed the lack of the documentation.

Plan of Correction - To be completed: 08/17/2026

1)The facility will document on paper the generator visual checks that were only available in picture format at the time of the survey.
2) Maintenance will document the generator checks on paper after each check

2)Maintenance will be in serviced on generator documentation guidelines.

3)An audit will be conducted monthly to ensure that all generator testing documentation is completed. Results will be presented to the QAPI committee for review and recommendations

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID# 711502
Component 02
Building 02

Based on a Medicare/Medicaid Recertification Survey completed on July 14, 2026, it was determined that St. Mary's Villa Nursing Home, Inc., 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 two story, Type II (000), unprotected, noncombustible building, with basement, and basement-level crawl space, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

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.

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: BUILDING 02 - Component: 02 - Tag: 0211

Based on observation and interview, it was determined the facility failed to ensure that exit access was being maintained readily accessible at all times in one location, affecting one of three floors.

Findings include:

1. Observation on July 14, 2026, at 12:01 am, revealed that there was therapy equipment blocking the corridor exit door to the outside, near Physical therapy.

Exit interview with the Facility Administrator and the Facilities Manager on July 14, 2026, at 12:15 pm, confirmed the corridor exit door being blocked.

Plan of Correction - To be completed: 08/17/2026

1)The therapy equipment blocking the corridor was removed.

2)Maintenance will audit the corridor exits to ensure they are maintained.

3)Maintenance will be in serviced on maintaining the corridor exits.

4)An audit will be conducted on monthly safety rounds to ensure that all corridor exits are clear. Results will be presented to the QAPI committee for review and recommendations.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain one exit stair tower location, affecting three of three floors.

Findings include:

1. Observation on July 14, 2026, at 11:50 am, revealed several cardboard boxes were stored within the 1st floor #7-1 stair tower enclosure.

Exit interview with the Facility Administrator and the Facilities Manager on July 14, 2026, at 12:15 pm, confirmed the stair tower enclosure deficiency.

Plan of Correction - To be completed: 08/17/2026

1)The boxes were removed in the #7 stair tower.
2)Maintenance will audit the stair towers to ensure they are maintained.

3)Maintenance will be in serviced on maintaining the stair towers.

4)An audit will be conducted on monthly safety rounds to ensure that all stair towers are maintained. Results will be presented to the QAPI committee for review and recommendations.

NFPA 101 STANDARD Exit Signage:

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: BUILDING 02 - Component: 02 - Tag: 0293

Based on observation and interview, it was determined the facility failed to maintain exit signage in one location, affecting one of three floors.

Findings include:

1. Observation on July 14, 2026, at 11:59 am, revealed exit signage within Physical Therapy above the exit door to the outside was not illuminated.

Exit interview with the Facility Administrator and the Facilities Manager on July 14, 2026, at 12:15 pm, confirmed the exit sign was not illuminated.

Plan of Correction - To be completed: 08/17/2026

1)The exit sign was repaired to illuminate.

2)Maintenance will audit the exit signs to ensure they illuminate.

3)Maintenance will be in serviced on maintaining exit signs.

4)An audit will be conducted on monthly safety rounds to ensure that all exit signs are illuminated. Results will be presented to the QAPI committee for review and recommendations.

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