Pennsylvania Department of Health
MOUNTAIN LAUREL HEALTHCARE AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 54 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


MOUNTAIN LAUREL HEALTHCARE 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 July 29, 2026, it was determined that Mountain Laurel Healthcare and Rehabilitation Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(d), 416.54(d), 418.113(d), 441.184(d), 482.15(d), 483.475(d), 483.73(d), 484.102(d), 485.542(d), 485.625(d), 485.68(d), 485.727(d), 485.920(d), 486.360(d), 491.12(d), 494.62(d) STANDARD EP Training and Testing:

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.

§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.

*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).

*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.

Observations:
Name: - Component: -- - Tag: 0036

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one emergency preparedness plan.

Findings include:

Document review on July 29, 2026, at 12:35 p.m., revealed the facility failed to provide and maintain annual staff emergency preparedness procedures training at the time of the survey.

Interview with the maintenance supervisor on July 29, 2026, at 12:35 p.m., confirmed the deficiency at the time of the survey.

Plan of Correction - To be completed: 09/02/2026

1. Facility is unable to retroactively correct these deficiencies because required timelines have passed.

2. Staff of the facility have the potential to be affected by this deficient practice.

3. Nursing Home Administrator educated the Maintenance Director on the requirements of annual emergency preparedness education for staff.

4. The Nursing Home Administrator or designee will complete a monthly audit of staff to ensure they have received the required education on emergency preparedness procedures. To ensure compliance, the Nursing Home Administrator or designee will complete this audit monthly for three months.

5. Findings will be reviewed at monthly Quality Assurance and Performance Improvement meeting.

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

Facility ID #032702
Component 01
Main Building (A & B Wings)

Based on a Medicare/Medicaid Recertification Survey completed on July 29, 2026, it was determined that Mountain Laurel Healthcare 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 building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

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 01 - Component: 01 - Tag: 0100

Based on observation and interview, the facility failed to maintain general requirements of the Life Safety Code that are not addressed by specific K-tags, but are deficient, in one of over three wings.

Findings include:

Observation on July 29, 2026, at 11:33 a.m., revealed the facility failed to obtain Department of Health State Plan Review approval and a granted occupancy from Life Safety Division for the change of use of resident rooms to storage rooms on the first floor, in the closed wing.

Interview with the administrator and maintenance supervisor on July 29, 2026, at 11:33 a.m., confirmed the facility did not submit the required paperwork.

Plan of Correction - To be completed: 09/02/2026

1. Facility is unable to retroactively correct these deficiencies because required timelines have passed. Moving forward the closed will will no longer be used as a storage area.

2. This is an isolated deficient practice.

3. Maintenance Director staff were educated by Director of Maintenance on the requirements of storage and that the closed unit must not be used to store items.

4. the Maintenance Director of designee will complete a monthly check of the closed unit to ensure it is not being used as storage as part of preventative maintenance. The ensure compliance, the Maintenance Director or designee will complete this audit monthly for three months.

5. Findings will be reviewed at the month Quality Assurance and Performance Improvement meeting.

NFPA 101 STANDARD Cooking Facilities:

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on document review and interview, the facility failed to maintain cooking facility requirements for one of one kitchen.

Findings include:

Document review on July 29, 2026, at 10:20 a.m., revealed the facility failed to provide documentation for one of two required kitchen hood cleanings.

Interview with the maintenance supervisor on July 29, 2026, at 10:20 a.m., confirmed the documentation was unavailable at the time of the survey.

Plan of Correction - To be completed: 09/02/2026

1. Facility is unable to retroactively correct these deficiencies because required timelines have passed.

2. This is an isolated incident and does not affect the rest of the building. The code requires the kitchen hood system to be cleaned twice annually. The last hood cleaning was on 3/6/2026 and a recent hood cleaning was completed on 8/4/2026. The next scheduled hood cleaning will be in the next quarter.

3. Maintenance staff were educated by Director of Maintenance on the requirements of the kitchen hood cleaning.

4. Maintenance Director or designee will complete a monthly check of the hood cleaning as part of preventative maintenance. Maintenance Director will schedule quarterly cleanings. To ensure compliance, the Maintenance director or designee will complete this audit monthly for three months.

5. Findings will be reviewed at monthly Quality Assurance and Performance Improvement meeting.

NFPA 101 STANDARD Fire Alarm System - Installation:

Fire Alarm System - Installation
A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity.
18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0341

Based on document review, observation, and interview, the facility failed to meet NFPA 72 fire alarm system requirements, affecting the entire facility.

Findings include:

Observation on July 29, 2026, at 10:01 a.m., revealed the facility fire alarm system pull stations were mounted above 52 inches from the floor throughout the facility. The fire alarm pull stations must be mounted so that the operable part is located between 42-48 inches above the finished floor.

Interview with the maintenance supervisor on July 29, 2026, at 10:01 a.m., confirmed the pull stations were mounted over 52 inches throughout the facility.

Plan of Correction - To be completed: 09/02/2026

1. Facility is unable to retroactively correct these deficiencies because required timelines have passed. Moving forward the fire alarm system pull stations will be moved from current position to between 42-48 inches above the finished floor.

2. Other areas throughout the building were inspected for other concerns and addressed as necessary.

3. Maintenance Staff were educated by Director of Maintenance on the proper placement of the pull systems.

4. The Maintenance Director or designee will complete a monthly check of fire alarm pulls stations for proper placement as part of preventative maintenance. To ensure compliance, the Maintenance Director or designee will complete this audit monthly for three months.

5. Findings will be reviewed at monthly Quality Assurance and Performance Improvement meeting.

NFPA 101 STANDARD HVAC:

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.

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 01 - Component: 01 - Tag: 0521

Based on document review and interview, the facility failed to maintain heating, ventilating, and air conditioning (HVAC) equipment, affecting the entire facility.

Findings include:

Document review on July 29, 2026, at 9:37 a.m., revealed the facility failed to provide documentation for the current fire/ceiling/smoke damper inspection. 80 of 163 total dampers have been exercised within the previous four years.

Interview with the maintenance supervisor on July 29, 2026, at 9:37 a.m., confirmed the documentation was unavailable at the time of the survey.

Plan of Correction - To be completed: 09/02/2026

1. Facility is unable to retroactively correct these deficiencies because required timelines have passed. Moving forward the Maintenance Director has scheduled the fire/ceiling/smoke damper inspection for the entire building to be completed all at once in August 2026, instead of tapering the different area inspections.

2. Areas that contain dampers have the potential to be affected by previous practice.

3. Maintenance staff were educated by Director of Maintenance on the importance of completing an inspection of the dampers every 4 years.

4. The Maintenance Director or designee will complete a monthly audit to ensure Fire/ceiling/smoke damper has been inspected as part of preventative maintenance. To ensure compliance, the Maintenance Director or designee will complete this audit monthly for three months.

5. Findings will be reviewed at monthly Quality Assurance and Performance Improvement meeting.

NFPA 101 STANDARD HVAC - Suspended Unit Heaters:

Suspended Unit Heaters
Suspended unit heaters are permitted provided the following are met:
* Not located in means of egress or in patient rooms.
* Located high enough to be out of reach of people in the area.
* Has a safety feature to stop fuel and shut down equipment if there is excessive temperature or ignition failure.
18.5.2.3(1), 19.5.2.3(1)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0523

Based on observation, document review, and interview, the facility failed to maintain suspended unit heater requirements, affecting one of one facility.

Findings include:

Observation and document review on July 29, 2026, at 11:20 a.m., revealed the facility had suspended unit heaters throughout the egress corridors. The facility was unable to provide documentation of the UL listing or product specifications to determine the heaters' temperature safety features.

Interview with the maintenance supervisor on July 29, 2026, at 11:20 a.m., confirmed the documentation was unavailable at the time of the survey.

Plan of Correction - To be completed: 09/02/2026

1. Facility is unable to retroactively correct these deficiencies because required timelines have passed.

2. This is an isolated deficient practice.

3. Maintenance staff were educated by the Maintenance Director on the requirements of the suspended unit heaters throughout the egress corridors and why it is important to provide documentation of the UL listing or product specifications to determine the heaters temperature safety features.

4. Maintenance Director has contacted EPIC HVAC about the heater's safety features. The heaters do not have the correct safety features required by code. WE will be getting a quote to replace these to comply with code.

5. The Maintenance Director or designee will complete a monthly check of the suspended unit heaters once they are replaced. To ensure compliance, the Maintenance Director or designee will complete the audit monthly for three months.

6. Findings will be reviewed at monthly Quality Assurance and Performance Improvement meeting.

NFPA 101 STANDARD Fire Drills:

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 document review and interview, the facility failed to meet fire drill requirements for three of three shifts.

Findings include:

Document review on July 29, 2026, at 9:30 a.m., revealed the following shifts lacked unexpected fire drills that varied with time and conditions:

A. (9:30 a.m.) First shift, third and forth quarters;
B. (9:30 a.m.) Second shift, third and forth quarters;
C. (9:30 a.m.) Third shift, first and third quarters.

Interview with the maintenance supervisor on July 29, 2026, at 9:30 a.m., confirmed the deficiencies.

Plan of Correction - To be completed: 09/02/2026

1. Facility is unable to retroactively correct these deficiencies because required timelines have passed. Moving forward the Maintenance Director has scheduled quarterly unexpected fire drills on each shift.

2. All areas throughout the facility have the potential to be affected by this previous practice.

3. Maintenance staff were educated by Director of Maintenance that unexpected fire drills must be completed on each shift for each quarter.

4. The Maintenance Director or designee will complete a monthly audit to ensure each shift has an unexpected fire drill completed as part of preventative maintenance. To ensure compliance, the Maintenance Director or designee will complete this audit monthly for three months.

5. Findings will be reviewed at monthly Quality Assurance and Performance Improvement meeting.

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

Facility ID #032702
Component 02
A Wing Annex

Based on a Medicare/Medicaid Recertification Survey completed on July 29, 2026, it was determined that Mountain Laurel Healthcare 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 II (000), unprotected, non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Fire Alarm System - Installation:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0341

Based on document review, observation, and interview, the facility failed to meet NFPA 72 fire alarm system requirements, affecting the entire facility.

Findings include:

Observation on July 29, 2026, at 10:01 a.m., revealed the facility fire alarm system pull stations were mounted above 52 inches from the floor throughout the facility. The fire alarm pull stations must be mounted so that the operable part is located between 42-48 inches above the finished floor.

Interview with the maintenance supervisor on July 29, 2026, at 10:01 a.m., confirmed the pull stations were mounted over 52 inches throughout the facility.

Plan of Correction - To be completed: 09/02/2026

1. Facility is unable to retroactively correct these deficiencies because required timelines have passed. Moving forward the fire alarm system pull stations will be moved from current position to between 42-48 inches above the finished floor.

2. Other areas throughout the building were inspected for other concerns and addressed as necessary.

3. Maintenance Staff were educated by Director of Maintenance on the proper placement of the pull systems.

4. The Maintenance Director or designee will complete a monthly check of fire alarm pulls stations for proper placement as part of preventative maintenance. To ensure compliance, the Maintenance Director or designee will complete this audit monthly for three months.

5. Findings will be reviewed at monthly Quality Assurance and Performance Improvement meeting.

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: BUILDING 02 - Component: 02 - Tag: 0521

Based on document review and interview, the facility failed to maintain heating, ventilating, and air conditioning (HVAC) equipment, affecting the entire facility.

Findings include:

Document review on July 29, 2026, at 9:37 a.m., revealed the facility failed to provide documentation for the current fire/ceiling/smoke damper inspection. 80 of 163 total dampers have been exercised within the previous four years.

Interview with the maintenance supervisor on July 29, 2026, at 9:37 a.m., confirmed the documentation was unavailable at the time of the survey.

Plan of Correction - To be completed: 09/02/2026

1. Facility is unable to retroactively correct these deficiencies because required timelines have passed. Moving forward the Maintenance Director has scheduled the fire/ceiling/smoke damper inspection for the entire building to be completed all at once in August 2026, instead of tapering the different area inspections.

2. Areas that contain dampers have the potential to be affected by previous practice.

3. Maintenance staff were educated by Director of Maintenance on the importance of completing an inspection of the dampers every 4 years.

4. The Maintenance Director or designee will complete a monthly audit to ensure Fire/ceiling/smoke damper has been inspected as part of preventative maintenance. To ensure compliance, the Maintenance Director or designee will complete this audit monthly for three months.

5. Findings will be reviewed at monthly Quality Assurance and Performance Improvement meeting.

NFPA 101 STANDARD HVAC - Suspended Unit Heaters:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0523

Based on observation, document review, and interview, the facility failed to maintain suspended unit heater requirements, affecting one of one facility.

Findings include:

Observation and document review on July 29, 2026, at 11:20 a.m., revealed the facility had suspended unit heaters throughout the egress corridors. The facility was unable to provide documentation of the UL listing or product specifications to determine the heaters' temperature safety features.

Interview with the maintenance supervisor on July 29, 2026, at 11:20 a.m., confirmed the documentation was unavailable at the time of the survey.

Plan of Correction - To be completed: 09/02/2026

1. Facility is unable to retroactively correct these deficiencies because required timelines have passed.

2. This is an isolated deficient practice.

3. Maintenance staff were educated by the Maintenance Director on the requirements of the suspended unit heaters throughout the egress corridors and why it is important to provide documentation of the UL listing or product specifications to determine the heaters temperature safety features.

4. Maintenance Director has contacted EPIC HVAC about the heater's safety features. The heaters do not have the correct safety features required by code. WE will be getting a quote to replace these to comply with code.

5. The Maintenance Director or designee will complete a monthly check of the suspended unit heaters once they are replaced. To ensure compliance, the Maintenance Director or designee will complete the audit monthly for three months.

6. Findings will be reviewed at monthly Quality Assurance and Performance Improvement meeting.

NFPA 101 STANDARD Fire Drills:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0712

Based on document review and interview, the facility failed to meet fire drill requirements for three of three shifts.

Findings include:

Document review on July 29, 2026, at 9:30 a.m., revealed the following shifts lacked unexpected fire drills that varied with time and conditions:

A. (9:30 a.m.) First shift, third and forth quarters;
B. (9:30 a.m.) Second shift, third and forth quarters;
C. (9:30 a.m.) Third shift, first and third quarters.

Interview with the maintenance supervisor on July 29, 2026, at 9:30 a.m., confirmed the deficiencies.

Plan of Correction - To be completed: 09/02/2026

1. Facility is unable to retroactively correct these deficiencies because required timelines have passed. Moving forward the Maintenance Director has scheduled quarterly unexpected fire drills on each shift.

2. All areas throughout the facility have the potential to be affected by this previous practice.

3. Maintenance staff were educated by Director of Maintenance that unexpected fire drills must be completed on each shift for each quarter.

4. The Maintenance Director or designee will complete a monthly audit to ensure each shift has an unexpected fire drill completed as part of preventative maintenance. To ensure compliance, the Maintenance Director or designee will complete this audit monthly for three months.

5. Findings will be reviewed at monthly Quality Assurance and Performance Improvement meeting.

Initial comments:Name: BUILDING 03 - Component: 03 - Tag: 0000

Facility ID #032702
Component 03
Unit C

Based on a Medicare/Medicaid Recertification Survey completed on July 29, 2026, it was determined that Mountain Laurel Healthcare 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 three-story, Type II (222), fire resistive building, that is fully sprinklered.

Plan of Correction:

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 03 - Component: 03 - Tag: 0321

Based on observation and interview, the facility failed to maintain hazardous enclosure requirements on one of three building levels.

Findings include:

Observation on July 29, 2026, at 10:06 a.m., revealed the following hazardous enclosure deficiencies:

A. (10:06 a.m.) Basement, across from the education room, had storage room doors with louvers, allowing air flow to the corridor;
B. (10:06 a.m.) Basement, across from education room, had a storage room full of combustibles as well as a door lacking a door knob to positively close.

Interview with the maintenance supervisor on July 29, 2026, at 10:06 a.m., confirmed the deficiencies at the time of the survey.

Plan of Correction - To be completed: 09/02/2026

1. Facility is unable to retroactively correct these deficiencies because required timelines have passed. Moving forward Maintenance Director has reached out to a vendor to have storage room doors replaced versus moving the contents to a different area in order to meet the requirements.

2. Maintenance Director inspected other areas of the facility and no other areas are affected.

3. Maintenance staff were educated by Director of Maintenance on the requirements of storage room doors.

4. The Maintenance director or designee will complete a monthly check of storage room doors for hazardous enclosure requirements as part of preventative maintenance. To ensure compliance, the Maintenance Director or designee will complete this audit monthly for three months.

5. Findings will be reviewed at monthly Quality Assurance and Performance Improvement meeting.

NFPA 101 STANDARD Fire Alarm System - Installation:

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0341

Based on document review, observation, and interview, the facility failed to meet NFPA 72 fire alarm system requirements, affecting the entire facility.

Findings include:

Observation on July 29, 2026, at 10:01 a.m., revealed the facility fire alarm system pull stations were mounted above 52 inches from the floor throughout the facility. The fire alarm pull stations must be mounted so that the operable part is located between 42-48 inches above the finished floor.

Interview with the maintenance supervisor on July 29, 2026, at 10:01 a.m., confirmed the pull stations were mounted over 52 inches throughout the facility.

Plan of Correction - To be completed: 09/02/2026

1. Facility is unable to retroactively correct these deficiencies because required timelines have passed. Moving forward the fire alarm system pull stations will be moved from current position to between 42-48 inches above the finished floor.

2. Other areas throughout the building were inspected for other concerns and addressed as necessary.

3. Maintenance Staff were educated by Director of Maintenance on the proper placement of the pull systems.

4. The Maintenance Director or designee will complete a monthly check of fire alarm pulls stations for proper placement as part of preventative maintenance. To ensure compliance, the Maintenance Director or designee will complete this audit monthly for three months.

5. Findings will be reviewed at monthly Quality Assurance and Performance Improvement meeting.

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: BUILDING 03 - Component: 03 - Tag: 0521

Based on document review and interview, the facility failed to maintain heating, ventilating, and air conditioning (HVAC) equipment, affecting the entire facility.

Findings include:

Document review on July 29, 2026, at 9:37 a.m., revealed the facility failed to provide documentation for the current fire/ceiling/smoke damper inspection. 80 of 163 total dampers have been exercised within the previous four years.

Interview with the maintenance supervisor on July 29, 2026, at 9:37 a.m., confirmed the documentation was unavailable at the time of the survey.

Plan of Correction - To be completed: 09/02/2026

1. Facility is unable to retroactively correct these deficiencies because required timelines have passed. Moving forward the Maintenance Director has scheduled the fire/ceiling/smoke damper inspection for the entire building to be completed all at once in August 2026, instead of tapering the different area inspections.

2. Areas that contain dampers have the potential to be affected by previous practice.

3. Maintenance staff were educated by Director of Maintenance on the importance of completing an inspection of the dampers every 4 years.

4. The Maintenance Director or designee will complete a monthly audit to ensure Fire/ceiling/smoke damper has been inspected as part of preventative maintenance. To ensure compliance, the Maintenance Director or designee will complete this audit monthly for three months.

5. Findings will be reviewed at monthly Quality Assurance and Performance Improvement meeting.

NFPA 101 STANDARD HVAC - Suspended Unit Heaters:

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0523

Based on observation, document review, and interview, the facility failed to maintain suspended unit heater requirements, affecting one of one facility.

Findings include:

Observation and document review on July 29, 2026, at 11:20 a.m., revealed the facility had suspended unit heaters throughout the egress corridors. The facility was unable to provide documentation of the UL listing or product specifications to determine the heaters' temperature safety features.

Interview with the maintenance supervisor on July 29, 2026, at 11:20 a.m., confirmed the documentation was unavailable at the time of the survey.

Plan of Correction - To be completed: 09/02/2026

1. Facility is unable to retroactively correct these deficiencies because required timelines have passed.

2. This is an isolated deficient practice.

3. Maintenance staff were educated by the Maintenance Director on the requirements of the suspended unit heaters throughout the egress corridors and why it is important to provide documentation of the UL listing or product specifications to determine the heaters temperature safety features.

4. Maintenance Director has contacted EPIC HVAC about the heater's safety features. The heaters do not have the correct safety features required by code. WE will be getting a quote to replace these to comply with code.

5. The Maintenance Director or designee will complete a monthly check of the suspended unit heaters once they are replaced. To ensure compliance, the Maintenance Director or designee will complete the audit monthly for three months.

6. Findings will be reviewed at monthly Quality Assurance and Performance Improvement meeting.

NFPA 101 STANDARD Fire Drills:

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0712

Based on document review and interview, the facility failed to meet fire drill requirements for three of three shifts.

Findings include:

Document review on July 29, 2026, at 9:30 a.m., revealed the following shifts lacked unexpected fire drills that varied with time and conditions:

A. (9:30 a.m.) First shift, third and forth quarters;
B. (9:30 a.m.) Second shift, third and forth quarters;
C. (9:30 a.m.) Third shift, first and third quarters.

Interview with the maintenance supervisor on July 29, 2026, at 9:30 a.m., confirmed the deficiencies.

Plan of Correction - To be completed: 09/02/2026

1. Facility is unable to retroactively correct these deficiencies because required timelines have passed. Moving forward the Maintenance Director has scheduled quarterly unexpected fire drills on each shift.

2. All areas throughout the facility have the potential to be affected by this previous practice.

3. Maintenance staff were educated by Director of Maintenance that unexpected fire drills must be completed on each shift for each quarter.

4. The Maintenance Director or designee will complete a monthly audit to ensure each shift has an unexpected fire drill completed as part of preventative maintenance. To ensure compliance, the Maintenance Director or designee will complete this audit monthly for three months.

5. Findings will be reviewed at monthly Quality Assurance and Performance Improvement meeting.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0923

Based on observation, document review, and interview, the facility failed to meet gas equipment requirements for one of one gas equipment room.

Findings include:

Observation and document review on July 29, 2026, at 11:44 a.m., revealed the oxygen storage room had UL-listed transom panels framed in the fire door assembly. The facility lacked documentation for the transom panel fire rating.

Interview with the maintenance supervisor on July 29, 2026, at 11:44 a.m., confirmed the documentation was unavailable at the time of the survey.

Plan of Correction - To be completed: 09/02/2026

1. Facility is unable to retroactively correct these deficiencies because required timelines have passed. Moving forward Maintenance Director has reached out to a vendor to have storage room doors replaced in order to meet the requirements. Vendor is reaching out to the company that manufactured the door to see if there is proof that transform panels within the door assembly are fire rated.

2. Maintenance Director inspected other areas of the facility, and no other areas are affected.

3. Maintenance staff were educated by the Director of Maintenance on the requirements of storage room doors.

4. The Maintenance Director or designee will complete a monthly check of storage room doors for hazardous enclosure requirements as part of preventative maintenance. To ensure compliance, the Maintenance Director or designee will complete this audit monthly for three months.

5. Findings will be reviewed at monthly Quality Assurance and Performance Improvement meeting.

Initial comments:Name: BUILDING 04 - Component: 04 - Tag: 0000

Facility ID #032702
Component 04
B Wing Annex

Based on a Medicare/Medicaid Recertification Survey completed on July 29, 2026, it was determined that Mountain Laurel Healthcare 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 II (000), unprotected, non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Fire Alarm System - Installation:

Observations:
Name: BUILDING 04 - Component: 04 - Tag: 0341

Based on document review, observation, and interview, the facility failed to meet NFPA 72 fire alarm system requirements, affecting the entire facility.

Findings include:

Observation on July 29, 2026, at 10:01 a.m., revealed the facility fire alarm system pull stations were mounted above 52 inches from the floor throughout the facility. The fire alarm pull stations must be mounted so that the operable part is located between 42-48 inches above the finished floor.

Interview with the maintenance supervisor on July 29, 2026, at 10:01 a.m., confirmed the pull stations were mounted over 52 inches throughout the facility.

Plan of Correction - To be completed: 09/02/2026

1. Facility is unable to retroactively correct these deficiencies because required timelines have passed. Moving forward the fire alarm system pull stations will be moved from current position to between 42-48 inches above the finished floor.

2. Other areas throughout the building were inspected for other concerns and addressed as necessary.

3. Maintenance Staff were educated by Director of Maintenance on the proper placement of the pull systems.

4. The Maintenance Director or designee will complete a monthly check of fire alarm pulls stations for proper placement as part of preventative maintenance. To ensure compliance, the Maintenance Director or designee will complete this audit monthly for three months.

5. Findings will be reviewed at monthly Quality Assurance and Performance Improvement meeting.

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: BUILDING 04 - Component: 04 - Tag: 0521

Based on document review and interview, the facility failed to maintain heating, ventilating, and air conditioning (HVAC) equipment, affecting the entire facility.

Findings include:

Document review on July 29, 2026, at 9:37 a.m., revealed the facility failed to provide documentation for the current fire/ceiling/smoke damper inspection. 80 of 163 total dampers have been exercised within the previous four years.

Interview with the maintenance supervisor on July 29, 2026, at 9:37 a.m., confirmed the documentation was unavailable at the time of the survey.

Plan of Correction - To be completed: 09/02/2026

1. Facility is unable to retroactively correct these deficiencies because required timelines have passed. Moving forward the Maintenance Director has scheduled the fire/ceiling/smoke damper inspection for the entire building to be completed all at once in August 2026, instead of tapering the different area inspections.

2. Areas that contain dampers have the potential to be affected by previous practice.

3. Maintenance staff were educated by Director of Maintenance on the importance of completing an inspection of the dampers every 4 years.

4. The Maintenance Director or designee will complete a monthly audit to ensure Fire/ceiling/smoke damper has been inspected as part of preventative maintenance. To ensure compliance, the Maintenance Director or designee will complete this audit monthly for three months.

5. Findings will be reviewed at monthly Quality Assurance and Performance Improvement meeting.

NFPA 101 STANDARD HVAC - Suspended Unit Heaters:

Observations:
Name: BUILDING 04 - Component: 04 - Tag: 0523

Based on observation, document review, and interview, the facility failed to maintain suspended unit heater requirements, affecting one of one facility.

Findings include:

Observation and document review on July 29, 2026, at 11:20 a.m., revealed the facility had suspended unit heaters throughout the egress corridors. The facility was unable to provide documentation of the UL listing or product specifications to determine the heaters' temperature safety features.

Interview with the maintenance supervisor on July 29, 2026, at 11:20 a.m., confirmed the documentation was unavailable at the time of the survey.

Plan of Correction - To be completed: 09/02/2026

1. Facility is unable to retroactively correct these deficiencies because required timelines have passed.

2. This is an isolated deficient practice.

3. Maintenance staff were educated by the Maintenance Director on the requirements of the suspended unit heaters throughout the egress corridors and why it is important to provide documentation of the UL listing or product specifications to determine the heaters temperature safety features.

4. Maintenance Director has contacted EPIC HVAC about the heater's safety features. The heaters do not have the correct safety features required by code. WE will be getting a quote to replace these to comply with code.

5. The Maintenance Director or designee will complete a monthly check of the suspended unit heaters once they are replaced. To ensure compliance, the Maintenance Director or designee will complete the audit monthly for three months.

6. Findings will be reviewed at monthly Quality Assurance and Performance Improvement meeting.

NFPA 101 STANDARD Fire Drills:

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.

Observations:
Name: BUILDING 04 - Component: 04 - Tag: 0712

Based on document review and interview, the facility failed to meet fire drill requirements for three of three shifts.

Findings include:

Document review on July 29, 2026, at 9:30 a.m., revealed the following shifts lacked unexpected fire drills that varied with time and conditions:

A. (9:30 a.m.) First shift, third and forth quarters;
B. (9:30 a.m.) Second shift, third and forth quarters;
C. (9:30 a.m.) Third shift, first and third quarters.

Interview with the maintenance supervisor on July 29, 2026, at 9:30 a.m., confirmed the deficiencies.

Plan of Correction - To be completed: 09/02/2026

1. Facility is unable to retroactively correct these deficiencies because required timelines have passed. Moving forward the Maintenance Director has scheduled quarterly unexpected fire drills on each shift.

2. All areas throughout the facility have the potential to be affected by this previous practice.

3. Maintenance staff were educated by Director of Maintenance that unexpected fire drills must be completed on each shift for each quarter.

4. The Maintenance Director or designee will complete a monthly audit to ensure each shift has an unexpected fire drill completed as part of preventative maintenance. To ensure compliance, the Maintenance Director or designee will complete this audit monthly for three months.

5. Findings will be reviewed at monthly Quality Assurance and Performance Improvement meeting.

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