Pennsylvania Department of Health
YORKVIEW NURSING AND REHABILITATION
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 48 surveys for this facility. Please select a date to view the survey results.

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YORKVIEW NURSING AND REHABILITATION - 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 May 6, 2025, at Yorkview Nursing and Rehabilitation, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: 63 BUILDING - Component: 01 - Tag: 0000

Facility ID #033402
Component 01
A, B, C, and Service Wings
(1963 Building)

Based on a Medicare/Medicaid Recertification Survey completed on May 6, 2025, it was determined that Yorkview Nursing and Rehabilitation was not in compliance with the following requirements of the Life Safety Code for an existing healthcare 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 V (111), protected wood frame structure, with a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Number of Exits - Story and Compartment:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4

Observations:
Name: 63 BUILDING - Component: 01 - Tag: 0241

Based on observation and interview, it was determined the facility failed to provide required not less than two exits for each story of the building, affecting two of three floors within the component.
Findings include:

1. Observation on May 6, 2025, between 11:00 AM and 1:00 PM, revealed the facility lacked two exits, remote from each other, on each story, at the following locations:

a. 11:00 AM, basement;
b. 1:00 PM, 2nd floor offices.

Interview with the Maintenance Director on May 6, 2025, at 1:00 PM, confirmed the facility lacked two remote exits for each story.

NFPA 101 STANDARD Exit Signage:

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.

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: 63 BUILDING - Component: 01 - Tag: 0293

Based on document review and interview, it was determined the facility failed to provide documentation verifying exit signage had been subjected to visual inspections, on a monthly basis, during the previous twelve months, affecting the entire component.

Findings include:

1. Review of documentation on May 6, 2025, at 10:06 AM, revealed the facility failed to provide documentation verifying exit signage had been subjected to visual inspections, within the previous twelve months.

Interview with the Maintenance Director on May 6, 2025, at 10:06 AM, confirmed the lack of documentation verifying exit signage had been subjected to visual inspections.

Plan of Correction - To be completed: 05/27/2025

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. The monthly documented visual inspection of exit signs was completed.
2. Completion date May 22, 2025.
3. The Maintenance Department has been educated on maintaining documented monthly visual inspection audits of the exit signs.
4. Maintenance Director/Designee will audit completions of the monthly visual inspections of the exit signs monthly. Findings will be reported at the monthly Quality Assurance and Performance Improvement Committee to address any trends or patterns for further review and/or recommendations.
5. Date of Compliance May 27, 2025.

NFPA 101 STANDARD Portable Fire Extinguishers:

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.

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: 63 BUILDING - Component: 01 - Tag: 0355

Based on document review and interview, it was determined the facility failed to provide documentation verifying portable fire extinguishers had been subjected to visual inspections, on a monthly basis, during the previous twelve months, affecting one of four smoke compartments within the component.

Findings include:

1. Review of documentation on May 6, 2025, at 12:41 PM, revealed the facility lacked documentation verifying the portable fire extinguisher, located in the Boiler Room, had been inspected between May, 2024 and September 1, 2024.

Interview with the Maintenance Director on May 6, 2025, at 12:41 PM, confirmed the lack of documentation verifying portable fire extinguishers had been subjected to monthly visual inspections, during the previous twelve months.

Plan of Correction - To be completed: 05/27/2025

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. Fire extinguisher in the boiler room is current with inspection and is now on the fire extinguisher list.
2. Maintenance Department audited the facility to ensure that all fire extinguishers are on the list.
3. Maintenance Department will be educated to include a list of all fire extinguisher locations in the Life Safety Book to prevent any fire extinguishers from being missed.
4. Maintenance Director/Designee will audit documented completions of the monthly visual inspections of the facility portable fire extinguishers monthly x3. Findings will be reported at the Quality Assurance and Performance Improvement Committee to address any trends or patterns for further review and/or recommendations.
5. Date of Compliance May 27, 2025.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:

Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.

Observations:
Name: 63 BUILDING - Component: 01 - Tag: 0371

Based on observation and interview, it was determined the facility failed to provide smoke compartments of not less than 22,500 square feet, affecting one of three floors within the component.

Findings include:

1. Observation on May 6, 2025, between 11:00 AM and 11:30 AM revealed two smoke compartments, on the 1st floor, were greater than 22,500 square feet, in area.

Interview with the Maintenance Director on May 6, 2025, at 11:30 AM confirmed the smoke compartments exceeded the maximum size.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: 63 BUILDING - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of surge suppressors, affecting one of four smoke compartments within the component.

Findings include:

1. Observation on May 6, 2025, at 12:33 PM, revealed a surge suppressor, supplying electrical power to another surge suppressor, within the 1st floor Zone 3 MDS Office.

Interview with the Maintenance Director on May 6, 2025, at 12:33 PM, confirmed the daisy-chained surge suppressors.

Plan of Correction - To be completed: 05/27/2025

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. The surge suppressor supplying electrical power to another surge suppressor was disconnected and removed from MDS Office.
2. Completion Date May 22, 2025.
3. Maintenance Director/Designee will conduct a facility wide audit quarterly for daisy-chained surge suppressors within the facility and will correct any findings.
4. Maintenance Director/Designee will inspect the facility quarterly for daisy-chained surge suppressors and will correct any findings. Maintenance Director/designee will report results of inspections monthly at the Quality Assurance and Performance Improvement Committee to address any trends or patterns for further review and/or recommendations.
5. Date of Compliance May 27, 2025.

Initial comments:Name: 73 BUILDING - Component: 02 - Tag: 0000

Facility ID #033402
Component 02
D, E, F East & F West Building
(1973 Building)

Based on a Medicare/Medicaid Recertification Survey completed May 6, 2025, it was determined that Yorkview Nursing and Rehabilitation 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 III (200), unprotected ordinary structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: 73 BUILDING - Component: 02 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire component.

Findings include:

1. Observation on May 6, 2025, at 12:00 PM, revealed the component is a two-story, Type III (200), unprotected ordinary structure, which exceeds the maximum allowable story height for this construction type in a health care facility.

Interview with the Maintenance Director on May 6, 2025, at 12:00 PM, confirmed the construction type and height are not permitted in health care.

NFPA 101 STANDARD Exit Signage:

Observations:
Name: 73 BUILDING - Component: 02 - Tag: 0293

Based on document review and interview, it was determined the facility failed to provide documentation verifying exit signage had been subjected to visual inspections, on a monthly basis, during the previous twelve months, affecting the entire component.

Findings include:

1. Review of documentation on May 6, 2025, at 10:06 AM, revealed the facility failed to provide documentation verifying exit signage had been subjected to visual inspections, within the previous twelve months.

Interview with the Maintenance Director on May 6, 2025, at 10:06 AM, confirmed the lack of documentation verifying exit signage had been subjected to visual inspections.

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: 73 BUILDING - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler protection system in a continuously reliable operating condition, affecting one of six smoke compartments within the component.

Findings include:

1. Observation on May 6, 2025, at 10:56 AM, revealed the escutcheons of six concealed sprinkler heads, protecting the Rear Car Port, were caulked shut and permanently affixed to the structure.

Interview with the Maintenance Director on May 6, 2025, at 10:56 AM, confirmed the sprinkler escutcheons were not free to break away during the activation of the sprinkler system.

Plan of Correction - To be completed: 05/27/2025

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. Identified escutcheons of sprinkler heads are now free from obstruction.
2. Completion Date May 22, 2025.
3. Maintenance Director/Designee will conduct an annual observation audit of sprinkler escutcheons for obstruction. Any identified obstructed sprinkler escutcheons will be corrected.
4. The Maintenance Director/Designee will audit sprinkler escutcheons to ensure they are free from obstruction weekly for 4 weeks. Trends will be reported to the QAPI committee for further action planning.
5. Date of Compliance May 27, 2025.

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: 73 BUILDING - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain the positive latching of corridor doors, affecting one of six smoke compartments within the component.

Findings include:

1. Observation on May 6, 2025, at 11:04 AM, revealed the door to the Zone 3 Clean Linen Room, across from the Nurses' Station, did not positively latch within the door frame.

Interview with the Maintenance Director on May 6, 2025, at 11:04 AM, confirmed the door did not positively latch within the frame.

Plan of Correction - To be completed: 05/27/2025

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. The door to the Clean Linen Room in Zone 3 now positively latches within the door frame.
2. Completion date 5/6/25.
3. Facility staff will be educated by Maintenance Director/Designee on reporting malfunctioning doors.
4. The Maintenance Director/Designee will audit facility corridor doors for positive latching, and then random doors monthly. Findings will be reported at the monthly Quality Assurance and Performance Improvement Committee to address any trends or patterns for further review and/or recommendations.
5. Date of Compliance May 27, 2025.

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: 73 BUILDING - Component: 02 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of smoke barrier walls, affecting two of six smoke compartments within the component.

Findings include:

1. Observation on May 6, 2025, at 11:10 AM, revealed an unprotected penetration of the Zone 2 & 3 smoke barrier wall, above the suspended ceiling, above the double doors next to Resident Room 610.

Interview with the Maintenance Director on May 6, 2025, at 11:10 AM, confirmed the unprotected penetration of the smoke barrier wall.

Plan of Correction - To be completed: 05/27/2025

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. The identified unprotected penetration near room 610 has been repaired using an approved through penetration fire stop system.
2. Completion date May 22, 2025.
3. The maintenance department will maintain the rating of the smoke barrier walls during routine weekly maintenance rounds.
4. The Maintenance Director/designee will audit the facility to ensure there are no unprotected penetrations within the component for 4 weeks and report trends to QAPI for further action planning.
5. Date of compliance May 27, 2025.

NFPA 101 STANDARD Utilities - Gas and Electric:

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Observations:
Name: 73 BUILDING - Component: 02 - Tag: 0511

Based on observation and interview, it was determined the facility failed to maintain the physical integrity of electrical receptacles, affecting one of six smoke compartments within the component.

Findings include:

1. Observation on May 6, 2025, at 11:01 AM, revealed the Zone 3 electrical receptacle, within the corridor, across from the Staff Development Office, was physically broken.

Interview with the Maintenance Director on May 6, 2025, at 11:01 AM, confirmed the compromised physical integrity of the electrical receptacle.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Observations:
Name: 73 BUILDING - Component: 02 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of receptacle multipliers and surge suppressors, affecting two of six smoke compartments within the component.

Findings include:

1. Observation on May 6, 2025, at 11:15 AM, revealed a three-to-one receptacle multiplier, in use, in the Zone 2 Janitor's Closet, across from Tub Room 1.

Interview with the Maintenance Director on May 6, 2025, at 11:15 AM, confirmed the use of a receptacle multiplier.

2. Observation on May 6, 2025, at 11:26 AM, revealed a surge suppressor, supplying electrical power to another surge suppressor, within the Zone 5 Supervisor's Office.

Interview with the Maintenance Director on May 6, 2025, at 11:26 AM, confirmed the daisy-chained surge suppressors.

Plan of Correction - To be completed: 05/27/2025

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. The three-to-one receptacle multiplier in the Janitor's Closet was removed. The surge suppressor supplying electrical power to another surge suppressor was disconnected and removed from RN Supervisor's Office.
2. Completion Date May 22, 2025.
3. Maintenance Director/Designee will conduct a facility wide audit for three-to-one receptacle multipliers and daisy-chained surge suppressors within the facility and will correct any findings.
4. Maintenance Director/Designee will inspect the facility monthly for three-to-one receptacle multipliers and daisy-chained surge suppressors and will correct any findings. Maintenance Director/designee will report results of inspections monthly at the Quality Assurance and Performance Improvement Committee to address any trends or patterns for further review and/or recommendations.
5. Date of Compliance May 27, 2025.

Initial comments:Name: SUBACUTE BLDG - Component: 03 - Tag: 0000

Facility ID #033402
Component 03
Subacute Care Building
(1989 Building)

Based on a Medicare/Medicaid Recertification Survey completed on May 6, 2025, it was determined that Yorkview Nursing and Rehabilitation 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 III (211), protected ordinary structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Exit Signage:

Observations:
Name: SUBACUTE BLDG - Component: 03 - Tag: 0293

Based on document review and interview, it was determined the facility failed to provide documentation verifying exit signage had been subjected to visual inspections, on a monthly basis, during the previous twelve months, affecting the entire component.

Findings include:

1. Review of documentation on May 6, 2025, at 10:06 AM, revealed the facility failed to provide documentation verifying exit signage had been subjected to visual inspections, within the previous twelve months.

Interview with the Maintenance Director on May 6, 2025, at 10:06 AM, confirmed the lack of documentation verifying exit signage had been subjected to visual inspections.

NFPA 101 STANDARD Corridor - Doors:

Observations:
Name: SUBACUTE BLDG - Component: 03 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain the positive latching of corridor doors, affecting one of two floors within the component.

Findings include:

1. Observation on May 6, 2025, at 10:40 AM, revealed the door to the 2nd floor Clean Linen Room did not positively latch within the door frame, due to a piece of paper taped over the strike plate of the frame.

Interview with the Maintenance Director on May 6, 2025, at 10:40 AM, confirmed the door did not positively latch within the frame.

Plan of Correction - To be completed: 05/27/2025

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. The door to the Clean Linen Room on the 2nd floor now positively latches within the door frame.
2. Completion date 5/6/25.
3. The Maintenance Director will complete an observation audit for corridor doors positively latching within the door frame.
4. The Maintenance Director/Designee will audit corridor doors monthly for positive latching. Findings will be reported at the monthly Quality Assurance and Performance Improvement Committee to address any trends or patterns for further review and/or recommendations.
5. Date of Compliance May 27, 2025.

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