Pennsylvania Department of Health
PARK LANE POST ACUTE LLC
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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PARK LANE POST ACUTE LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Based on a revisit to an Emergency Preparedness Survey completed on March 25, 2025, it was determined that Park Lane Post Acute Llc was in substantial compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

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

Facility ID #01150201
Component 01
Main Building

Based on a revisit to a Medicare/Medicaid Recertification Survey completed on March 25, 2025, it was determined that Park Lane Post Acute Llc 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 (111), protected noncombustible structure, with a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General 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.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0100

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on observation and interview, it was determined the following item did not meet the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component.

Findings include:

1. Observation on March 25, 2025, at 9:45 AM, revealed current and active renovation and construction work being performed in areas including the basement Physical Therapy Rooms, to include new walls, corridors, ceiling and flooring. No prior approval for this work to be performed had been issued by the PA Department of Health.

Interview with the Maintenance Director on March 25, 2025, at 9:45 AM, confirmed there were no approved plans for the renovation/new construction work.

*** Observation on May 15, 2025, at 1:00 PM, revealed finding 1 was not corrected.

Interview with the Maintenance Director on May 15, 2025, at 1:00 PM, confirmed finding 1 was not corrected. ***

Plan of Correction - To be completed: 06/15/2025

1. Plans are in final stages with architect and will be submitted to plan review once finalized.

2. Future renovations/projects will be submitted to the Division of Life Safety for approval prior to beginning said project(s).

3. Education provided to Project Manager that plans must be drawn and submitted for approval prior to beginning renovations/projects.

4. NHA or designee will perform random weekly audits x4 weeks, then monthly thereafter to ensure any future projects are submitted to Plan Review prior to starting. Results of the audits will be discussed at QAPI and issues addressed PRN.

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