Pennsylvania Department of Health
LANCASTER 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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LANCASTER 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 April 21, 2025, at Lancaster 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 AND THERAPY ADDITION - Component: 01 - Tag: 0000

Facility ID #035302
Component 01
Main Building and Therapy Addition

Based on a Medicare/Medicaid Recertification Survey completed on April 21, 2025, it was determined that Lancaster 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 nine-story, Type II (222), fire resistive structure, with a penthouse and a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Exit Signage:

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.

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: MAIN BUILDING AND THERAPY ADDITION - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed to maintain the illumination of exit signage, affecting one of 11 floors within the component.

Findings include:

1. Observation on April 21, 2025, at 11:03 AM, revealed the ground floor exit sign within the Resident Support Services Room was not illuminated. This sign had an integral bulb, which was not lit.

Interview with the Director of Maintenance on April 21, 2025, at 11:03 AM, confirmed the exit signage was not illuminated.

Plan of Correction - To be completed: 06/18/2025

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.

K0293 NFPA exit signage
1. The bulb was replaced in the exit sign within the resident support services room.
2. House wide audit will be conducted on all exit signs to ensure they are all in working order.
3. The maintenance director or designee will audit the already required monthly exit sign check (ie, review documented exit light check, random exit lights against the documented exit sign sheet etc.) this will be ongoing monthly.
4. The findings of the audits will be reported to the facility quality assurance performance improvement committee to determine the need for additional actions or monitoring.
5. Date of Compliance: 6/18/25

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: MAIN BUILDING AND THERAPY ADDITION - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain the unobstructed closing of corridor doors, affecting one of 11 floors within the component.

Findings include:

1. Observation on April 21, 2025, at 10:00 AM, revealed the 6th floor door to Resident Room E601 was obstructed from closing by a clothes hanger hung from the doorknob hardware.

Interview with the Director of Maintenance on April 21, 2025, at 10:00 AM, confirmed the corridor door was obstructed from closing.

Plan of Correction - To be completed: 06/18/2025

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.

K0363 NFPA � Corridor-Doors
1. The clothes hanger was removed from resident room corridor door in E602, door handle at time of observation.
2. All house audit of corridor all doors to ensure that corridor doors are closing.
3. The NHA or Designee will provide re-education to the facility staff, including laundry and kitchen staff that nothing can block any corridor door.
4. The maintenance director or designee will complete random audits of corridor doors on all floors to ensure that nothing is blocking any corridor doors from closing, audit to be completed monthly.
5. The findings of the audits will be reported to the facility quality assurance performance improvement committee to determine the need for additional actions or monitoring.
6. Date of Compliance: 6/18/25

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: MAIN BUILDING AND THERAPY ADDITION - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of smoke barrier doors, affecting one of 11 floors within the component.

Findings include:

1. Observation on April 21, 2025, at 9:39 AM, revealed the 7th floor smoke barrier door, by Resident Room W702, did not fully close within the door frame. This door is equipped with positive latching hardware, which did not latch the door within the frame.

Interview with the Director of Maintenance on April 21, 2025, at 9:39 AM, confirmed the door did not fully close within the frame.

Plan of Correction - To be completed: 06/18/2025

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.

K0374 Smoke barrier doors
1. The latch was adjusted and working properly on the 7th floor smoke barrier door by resident room W 702.
2. All smoke barrier doors were checked to ensure a positive latch.
3. The maintenance director or designee will provide re-education to the facility maintenance staff that the smoke barrier doors must close and latch completely within the frame.
The maintenance director or Designee will educate all staff on how to report a door that doesn't latch when closed.
4. The maintenance director or designee will complete audits of all smoke barrier doors to ensure they close without restraint as well as latch effectively audit will be ongoing and completed quarterly.
5. Date of compliance: 6/18/25

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: MAIN BUILDING AND THERAPY ADDITION - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of receptacle multipliers, affecting one of 11 floors within the component.

Findings include:

1. Observation on April 21, 2025, at 11:31 AM, revealed a three-to-one receptacle multiplying extension cord, in use, within the basement Dryer Room.

Interview with the Director of Maintenance on April 21, 2025, at 11:31 AM, confirmed the use of a receptacle multiplier.

Plan of Correction - To be completed: 06/18/2025

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.

K0920 Electrical equipment
1. The three-to-one receptacle multiplying extension cord was removed from the basement dryer room.
2. House wide audit will be completed to ensure no three-to-one receptacle multiplying extension cords are being used.
3. The maintenance director or designee will provide re-education with the maintenance department that a receptacle multiplier cannot be used.
4. The maintenance director or designee will complete the audit to check for multipliers in laundry anytime a vendor has conducted any work or replacement of any of the machines. This will be an ongoing audit.
5. Date of compliance: 6/18/25

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