Pennsylvania Department of Health
YORK NORTH SKILLED NURSING AND 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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YORK NORTH SKILLED NURSING AND 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 March 12, 2026, at York North Skilled Nursing and 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 - Component: 01 - Tag: 0000
Facility ID# 025602Component 01Main Building Based on a Medicare/Medicaid Recertification Survey completed on March 12, 2026, it was determined that York North Skilled Nursing and Rehabilitation Center, 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 one-story, Type III (200), unprotected ordinary structure, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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.

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0345 Based on document review and interview, it was determined the facility failed to provide fire alarm system semi-annual reports, which serves the entire component. Findings include: 1. Review of documentation on March 12, 2026, between 8:15 AM and 10:30 AM, revealed the facility lacked documentation, verifying the semi-annual visual inspection was performed. Interview at the time of the exit conference with the Administrator and Director of Maintenance on March 12, 2026, at 2:00 PM, confirmed the lack of documentation, verifying the fire alarm semi-annual visual inspection.

Plan of Correction - To be completed: 03/31/2026

1. Unable to retroactively provide semi-annual fire alarm system reports as reports were not completed.

2. Audit of required semi-annual fire alarm system reports completed to determine if any reports were missing.

3. Education to be completed with Maintenance Director and Maintenance Assistant related to semi-annual fire alarm system reports.

4. Maintenance Director/Designee will conduct monthly audits x 3 quarters to ensure facility system reports are maintained timely. Results will be forwarded to the QAPI committee to determine the need for future follow up/monitoring.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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 - Component: 01 - Tag: 0353 Based on document review and interview, it was determined the facility failed to provide quarterly and semi-annual sprinkler system reports, which serves the entire component. Findings include: 1. Review of documentation on March 12, 2026, between 8:45 AM and 8:53 AM, revealed the facility lacked documentation, for the following: a. 8:45 AM, wet system, semi-annual, Valve Supervisory Switches and Pressure Switch Waterflow Alarm; b. 8:53 AM, 2nd, 3rd and 4th quarterly wet inspections; Interview at the time of the exit conference with the Administrator and Director of Maintenance on March 12, 2026, at 2:00 PM, confirmed the lack of documentation for wet sprinkler systems.

Plan of Correction - To be completed: 03/31/2026

1. Unable to retroactively provide quarterly and semi-annual sprinkler system reports as reports were not completed.

2. Audit of required quarterly and semi-annual sprinkler system reports completed for last quarter to determine if any reports were missing.

3. Education to be completed with Maintenance Director and Maintenance Assistant related to quarterly and semi-annual sprinkler system reports.

4. Maintenance Director/Designee will conduct quarterly audits x 3 quarters to ensure facility sprinkler system reports are maintained timely. Results will be forwarded to the QAPI committee to determine the need for future follow up/monitoring.

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0521 Based on document review and interview, it was determined the facility lacked documentation verifying the 4-year fire damper maintenance and exercise was performed, throughout the entire component. Findings include: 1. Review of documentation on March 12, 2026, between 8:15 AM and 10:30 AM, failed to provide documentation of the 4-year fire damper exercise and maintenance. Interview at the time of the exit conference with the Administrator and Director of Maintenance on March 12, 2026, at 2:00 PM, confirmed the lack documentation for fire dampers.

Plan of Correction - To be completed: 03/31/2026

1. Unable to retroactively provide the 4-year fire damper maintenance and exercise completion report.The 4-year fire damper inspection and maintenance is scheduled to be performed on April 7, 2026.

2. Audit of required 4-year fire damper maintenance and exercise completion report completed to determine if any additional reports were missing.

3. Education to be completed with Maintenance Director and Maintenance Assistant related to ensuring the 4-year fire damper maintenance and exercise completion report is completed timely.

4. Maintenance Director/Designee will conduct semi-annual audits x 3 quarters to ensure facility s4-year fire damper maintenance and exercise is performed timely.Results will be forwarded to the QAPI committee to determine the need for future follow up/monitoring.

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