Pennsylvania Department of Health
DEER MEADOWS REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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DEER MEADOWS REHABILITATION CENTER - 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 August 25, 2026, at Deer Meadows Rehabilitation Center, 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 (BAIR PAVILION) - Component: 01 - Tag: 0000
Facility ID# 020202

Component 01

Bair Pavilion

Based on a Medicare/Medicaid Recertification Survey completed on August 25, 2026, it was determined that Deer Meadows Rehabilitation Center - Bair Pavilion, 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 five-story, Type II (222), fire-resistive building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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 (BAIR PAVILION) - Component: 01 - Tag: 0353 Based on observation, review, and interview, it was determined the facility failed to maintain Fire Department Connections (FDC), affecting one of six FDC connections. Findings include: 1. Observation made on August 25, 2026, at 10:50 a.m., revealed the facility's Fire Department Connection (FDC) that is located at the rear of the building was missing a protective cap. Exit interview with the Administrator and the Regional Maintenance Director on August 25, 2026 at 1:30 p.m., confirmed the FDC missing a protective cap.

Plan of Correction - To be completed: 10/12/2026

The provider submits the following plan of correction in good faith to comply with Federal regulation. This plan is not admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the statement deficiencies
Missing cap missing from the fire dept ordered and replaced
Maintenance director or designee will educate maintenance staff about k0353
Director of maintenance or designee will complete audit of all Fire dept connection for missing cap weekly 4, then monthly x3
Result of findings will be presented at monthly QAPI until substantial compliance is achieved

Initial comments:Name: BUILDING 02 (WALTON CENTER) - Component: 02 - Tag: 0000
Facility ID# 020202

Component 02

Walton Center Building

Based on a Medicare/Medicaid Recertification Survey on August 25, 2026, it was determined that Deer Meadows Rehabilitation Center - Walton Center Building, 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 (111), protected non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

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 (WALTON CENTER) - Component: 02 - Tag: 0211 Based on observation and interview, it was determined the facility failed to maintain means of egress free of obstructions, affecting one of two floors. Findings include: 1. Observation on August 25, 2026, at 11:55 a.m., revealed the exit door required excessive force to open when tested, on the Ground Floor, the Multipurpose/WCC Room. Exit interview with the Administrator and the Regional Maintenance Director on August 25, 2026, at 1:30 p.m., confirmed the deficient exit door.

Plan of Correction - To be completed: 10/12/2026

The exit door on the Ground floor multipurpose room /WCC repaired and tested and does not require force to open
Maintenance director or designee will complete education of K0211
Maintenance director or designee will complete audit of all exit doors to ensure they are functioning properly weekly x4, monthly x3
Results of audits will be presented at monthly QAPI until substantial compliance is achieved

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: BUILDING 02 (WALTON CENTER) - Component: 02 - Tag: 0321 Based on observation and interview, it was determined the facility failed to ensure doors in hazardous area enclosures were maintained; self-closing and positively latching, affecting one of two floors. Findings include: 1. Observations on August 25, 2026, at 11:40 a.m., revealed the doors failed to close and latch when tested, on the Ground Floor, Diesel Tank Room. Exit interview with the Administrator and the Regional Maintenance Director on August 25, 2026, at 1:30 p.m., confirmed the door failed to close and latch when tested.

Plan of Correction - To be completed: 10/12/2026

Ground floor diesel tank room door repaired and latching properly
Maintenance director/designee will check other hazardous material room doors for proper latching. Any repair will be completed at the time of audit
Maintenance director/designee will complete education with maintenance staff about K0321
Maintenance director/designee will complete weekly audit of Hazardous room doors to ensure that doors are latching properly weekly x4, monthly x3
Results of audit will be presented at monthly QAPU until substantial compliance is achieved

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: BUILDING 02 (WALTON CENTER) - Component: 02 - Tag: 0372 Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting one of two floors. Findings include: 1. Observation on August 25, 2026, at 11:50 a.m., revealed five wall penetrations above double smoke doors, on the Ground Floor, near Multi-Purpose Room and Smoking Area Door. Exit interview with the Administrator and the Regional Maintenance Director on August 25, 2026, at 1:30 p.m., confirmed the smoke wall penetrations.

Plan of Correction - To be completed: 10/12/2026

The 5 penetrations above double smoke doors on the Ground floor near multi-purpose room sealed with 3MUL approved WL2002 through wall
Maintenance director/designee will complete audit of above double doors for penetration. Any penetration found will be repaired at the time
Maintenance director/designee will complete education with maintenance staff about K0372
Maintenance director or designee will complete audit of above double smoke doors for penetrations weekly x4, monthly x3
Results of the audits will be presented at monthly QAPI until substantial compliance is achieved

NFPA 101 STANDARD Smoking Regulations:

Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: BUILDING 02 (WALTON CENTER) - Component: 02 - Tag: 0741 Based on observation and interview, it was determined the facility failed to ensure the facility maintained a smoke-free environment, outside of the designated smoking area, affecting one of two floors. Findings include: 1. Observation on August 25, 2026, at 12:00 p.m., revealed numerous cigarette butts scattered in the area, the exterior of the Ground Floor, near the Multipurpose Room/WCC exit door. Exit interview with the Administrator and the Regional Maintenance Director on August 25, 2026, at 1:30 p.m., confirmed the numerous cigarette butts.

Plan of Correction - To be completed: 10/12/2026

Cigarette butts scattered in the area of the exterior door ground floor near the multipurpose room/WCC cleaned of cigarette butts
Dept. directors will complete education of the staff about smoking in dedicated smoking are and use of cigarette ash tray for cigarette disposal
Director of maintenance or designee will complete audit of facility exterior exit doors for cigarette butts weekly x4, monthly x3
Results of audit will be presented at monthly QAPI until substantial compliance is achieved.

NFPA 101 STANDARD Electrical Systems - Other:

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: BUILDING 02 (WALTON CENTER) - Component: 02 - Tag: 0911 Based on observation and interview, it was determined the facility failed to protect electrical system wiring in accordance with NFPA 99 2012 Edition, 6.3.2.1 Electrical Installation, affecting one of two floors. Findings include: 1. Observation on August 25, 2026, at 11:45 a.m., revealed a ceiling light with an MC cable not securely attached with exposed wires, on the Ground Floor, Boiler Room, above B-1B Boiler. Exit interview with the Administrator and the Regional Maintenance Director on August 25, 2026, at 1:30 p.m., confirmed the exposed wires.

Plan of Correction - To be completed: 10/12/2026

Ceiling light with MC cable with exposed wires on the ground floor, boiler room above B-1B boiler exposed wire secured and no longer exposed
Maintenance director/designee will complete education of maintenance staff about K0911
Maintenance director/designee will complete weekly audit of ceiling light with MC cable to ensure that wires are secured and not exposed weekly x4, then monthly x3
Results of audit will be present at monthly QAPI until substantial compliance is achieved

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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.

Electrical Systems - Essential Electric System Alarm Annunciator
A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator.
6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)

Observations:
Name: BUILDING 02 (WALTON CENTER) - Component: 02 - Tag: 0916 Based on observation and interview, it was determined the facility failed to maintain alarm annunciation for the Essential Electrical System, affecting the entire facility. Findings Include: 1. Observation on August 25, 2026, at 12:35 p.m., revealed the remote annunciator panel was not connected to the temporary emergency generator, on the Ground Floor, Lobby Desk. Exit interview with the Administrator and the Regional Maintenance Director on August 25, 2026, at 1:30 p.m., confirmed the annunciator was not connected to the generator.

Plan of Correction - To be completed: 10/12/2026

Facility will be requesting for a time limited waiver due to plan to replace temporary emergency powered generator with a permanent generator very soon
Maintenance director will educate maintenance staff about visual observation check of temporary generator condition for operational every shift and weekly testing of temporary emergency generator
Director of maintenance/designee will complete audit of the implemented emergency generator visual observation check for functioning and weekly testing
Results of audit will be reported at monthly QAPI until substantial compliance is achieved
Contact will be made with DOH Plan Review Department for installation of the new emergency generator and the electrical infrastructure upgrades.

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