Pennsylvania Department of Health
LEHIGH VALLEY HOSPITAL TRANSITIONAL SKILLED UNIT
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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LEHIGH VALLEY HOSPITAL TRANSITIONAL SKILLED UNIT - 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 29, 2025, at Lehigh Valley Hospital Transitional Skilled Unit, 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# 012702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 29, 2025, it was determined that Lehigh Valley Hospital Transitional Skilled Unit 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 seven story, Type II (222), fire resistive building, with a basement and rooftop mechanical spaces, that is fully sprinklered.

Note: the transitional care unit is located on the sixth floor of the main hospital building

Plan of Correction:

NFPA 101 STANDARD Doors with Self-Closing Devices:

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.

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 doors with self-closing device, affecting one of four smoke compartments.

Findings include:

1. Observation on April 29, 2025, at 9:52 am, revealed the Storage room door failed to latch into frame when tested, near the Resident room 5S32.

Interview at the time of the exit conference with the Administrator and Facilities Director on April 29, 2025, at 10:30 am, confirmed the door failed to positive latch.

Plan of Correction - To be completed: 05/20/2025

1. Latch was adjusted on storage room door on 4/30/2025.

2. Director of Engineering/designee will inspect all other doors with self-closing devices to ensure proper latch.

3. Routine inspections of doors with self closing devices will be completed by engineering department.

4. Reports will be submitted to QAPI 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 one maintain hazardous area enclosure, affecting one of four smoke compartments.

Findings include:

1. Observation on April 29, 2025, at 10:10 am, revealed the Soiled Utility room door failed to latch into frame when tested, near the DON office.

Interview at the time of the exit conference with the Administrator and Facilities Director on April 29, 2025, at 10:30 am, confirmed the door failed to positive latch.

Plan of Correction - To be completed: 05/20/2025

1. Latch was adjusted on soiled utility door on 5/1/2025.

2. Director of Engineering/designee will inspect all other soiled utility doors to ensure proper latch.

3. Routine inspections of all soiled utility doors will be completed by engineering department.

4. Reports will be submitted to QAPI 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 six floors.

Findings include:

1. Observation on April 29, 2025, at 9:50 a.m., revealed an escutcheon plate was missing from the sprinkler head in Resident Room 5S41.

Exit interview with the Facility Administrator and Facilities Manager on April 29, 2025, at 10:30 a.m., confirmed the confirmed the sprinkler system deficiency.

Plan of Correction - To be completed: 05/20/2025

1. Escutcheon plate replaced on 4/29/2025.

2. Director of Engineering/Designee will continue to monitor sprinkler heads on a random basis for compliance. Director of Engineering will report back to QAPI Committee.

3. LVHN Fire Marshall completes inspection in conjunction with Kistler O'Brien annually.

4. QAPI Committee will monitor and recommend additional audits as necessary.

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