Pennsylvania Department of Health
 LANCASTER NURSING AND REHABILITATION CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LANCASTER NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  44 surveys for this facility. Please select a date to view the survey results.

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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 May 6, 2024, 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 May 6, 2024 and May 7, 2024, 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 Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING AND THERAPY ADDITION - Component: 01 - Tag: 0225

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

Findings include:

1. Observation on May 7, 2024, between 9:20 AM and 11:10 AM, revealed the vertical access doors, to the pipe chase in the North Stairtower, lacked fire rating tags, at the following locations:

a. 9:20 AM, 6th floor;
b. 11:10 AM, 2nd floor.

Interview at the time of the exit conference with the Director of Operation Consultant, Administrator, Property Management Consultant, Director of Maintenance and Maintenance Tech on May 7, 2024, at 1:30 PM, confirmed the vertical access doors lacked fire rating tags.



 Plan of Correction - To be completed: 06/25/2024

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.

K 0225 NFPA 101 Stairways and Smokeproof Enclosures
1) An approved vertical access doors will be purchased with the fire rating tags on them for the vertical access doors, at the pipe chase in the Northwest stair tower on 6th floor and 2nd floor.
2) House wide audit will be completed on access doors to ensure the fire rating tags are present.
3) Maintenance Director or designee will complete random audits of the access doors monthly x 4 then quarterly.
4) Findings of the audit will be reported to the facility quality assurance performance improvement committee to determine the need for additional actions and or monitoring.
5) Center is requesting a Time Limited Waiver on this tag due to slow manufacture timelines on door rated devices. Date of compliance__8/31/24_______________

NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
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: MAIN BUILDING AND THERAPY ADDITION - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area door assembly fire rating, to be consistent and to self-close, affecting one of nine floors within the component.

Findings include:

1. Observation on May 6, 2024, at 11:15 PM, revealed the Kitchen Dry Storage left leaf of the rated door assembly lacked a fire rating label.

Interview at the time of the exit conference with the Director of Operation Consultant, Administrator, Property Management Consultant, Director of Maintenance and Maintenance Tech on May 7, 2024, at 1:30 PM, Kitchen Dry Storage door assembly fire rating was not consistently labeled.


2. Observation on May 6, 2024, at 1:50 PM, revealed the ground floor Electrical Closet was being used for storage, but did not have a self-closing device installed.

Interview at the time of the exit conference with the Director of Operation Consultant, Administrator, Property Management Consultant, Director of Maintenance and Maintenance Tech on May 7, 2024, at 1:30 PM, the Electrical Closet door lacked a self-closing device.



 Plan of Correction - To be completed: 06/25/2024

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.
K 0321 NFPA 101 Hazardous Areas – Enclosures
1) The door to the Kitchen Dry Storage, left leaf of the rated door assembly, will be verified and tagged with proper rating. If door needs to be replaced with rated door, that said door will be purchased and installed with correct label.
2) House wide audit will be completed on all door assembly's to ensure the fire rating tags are present.
3) Maintenance Director or designee will complete random audits door assembly's doors monthly x 4 then quarterly.
4) Findings of the audit will be reported to the facility quality assurance performance improvement committee to determine the need for additional actions and or monitoring.
5) Center is requesting a Time Limited Waiver on this tag due to slow manufacture timelines on door rated devices. Date of compliance___8/31/24.

1) Ground floor electrical closet has been cleaned and all storage boxes removed from the room.
2) House wide audit off all electrical rooms to ensure they are not being used for storage.
3) The Maintenance Director or designee will complete random audits of electrical rooms weekly x 4, then monthly x 4 then quarterly.
4) Findings of the audit will be reported to the facility quality assurance performance improvement committee to determine the need for additional actions and or monitoring.
5) Date of compliance___6/25/24

NFPA 101 STANDARD Cooking Facilities: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.
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 AND THERAPY ADDITION - Component: 01 - Tag: 0324

Based on document review and interview, it was determined the facility failed to provide semi-annual hood cleanings for one full year, affecting one of nine floors within the component.

Findings include:

1. Review of documentation on May 6, 2024, between 9:30 AM and 11:15 AM, revealed the facility could not provide documentation, verifying the Kitchen exhaust ductwork had been cleaned, on a semi-annual basis. Documentation verified last cycle was completed on May 5, 2023.

Interview at the time of the exit conference with the Director of Operation Consultant, Administrator, Property Management Consultant, Director of Maintenance and Maintenance Tech on May 7, 2024, at 1:30 PM, confirmed the facility could not provide Kitchen ductwork had been cleaned, semi-annually.



 Plan of Correction - To be completed: 06/25/2024

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.

K 0324 NFPA 101 Cooking Facilities
1) Kitchen exhaust contractor will be scheduled to complete the maintenance and inspection of the kitchen hoods on 6/5/2024.
2) The NHA or designee will provide education to the maintenance director or designee on this inspection needed to be completed per regulation.
3) Maintenance director or designee will confirm annually when the semi-annual hood cleaning should be scheduled and that the last completed hood cleaning report is filed in the life safety book.
4) Findings of the audit will be reported to the facility quality assurance performance improvement committee to determine the need for additional actions and or monitoring.
5) Date of compliance _6/25/24.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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 AND THERAPY ADDITION - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to maintain the fire alarm system, affecting nine of nine floors within the component.

Findings include:

1. Review of documentation on May 6, 2024, between 9:40 AM and 9:48 AM, revealed the facility lacked documentation verifying the following inspections were performed:

a. 9:40 AM, annual Carbon Monoxide Detector functional test;
b. 9:44 AM, annual Fire Alarm inspection;
c. 9:46 AM, semi-annual Fire Alarm visual inspection;
b. 9:48 AM, two-year Sensitivity Smoke detector test.

Interview at the time of the exit conference with the Director of Operation Consultant, Administrator, Property Management Consultant, Director of Maintenance and Maintenance Tech on May 7, 2024, at 1:30 PM, confirmed the Fire alarm inspections had not been performed.



 Plan of Correction - To be completed: 06/25/2024

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.

K 0345 NFPA 101 Fire Alarm system – Testing and Maintenance
1) Fire alarm system contractor will be scheduled to complete the maintenance and inspection of the fire alarm system on 5/24/24, 5/28-5/31/2024
2) The NHA or designee will provide education to the maintenance director or designee on this inspection needed to be completed per regulation.
3) Maintenance director or designee will confirm annually when the annual carbon monoxide functional test, annual fire alarm inspection, semi-annual visual inspection and two-year sensitivity smoke detector should be scheduled and that the last completed hood cleaning report is filed in the life safety book.
4) Findings of the audit will be reported to the facility quality assurance performance improvement committee to determine the need for additional actions and or monitoring.
5) Date of compliance 6/25/24.

NFPA 101 STANDARD Sprinkler System - Installation: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.
Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)
Observations:
Name: MAIN BUILDING AND THERAPY ADDITION - Component: 01 - Tag: 0351

Based on observation and interview, it was determined the facility failed to maintain sprinkler heads to be installed, per manufacturer's specifications, in one of nine floors within the component.

Findings include:

1. Observation on May 6, 2024, at 1:00 PM, revealed the sprinkler heads, in the ground floor Kitchen Refrigerator Unit 1, were placed with less than six feet of each other, due to the removal of a mechanical unit separating the installed sprinkler heads.

Interview at the time of the exit conference with the Director of Operation Consultant, Administrator, Property Management Consultant, Director of Maintenance and Maintenance Tech on May 7, 2024, at 1:30 PM, confirmed the sprinkler head separation was less than six feet.



 Plan of Correction - To be completed: 06/25/2024

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.

K0351 NFPA 101 sprinkler system - Installation
1) Sprinkler contractor will be scheduled to inspect the sprinkler heads in kitchen refrigerator unit one to determine what needs completed since the sprinkler heads are less than six feet from each other.
2) House wide audit off all kitchen refrigerator units to ensure no sprinkler heads are within 6 feet of each other.
3) Maintenance Director or designee will complete random audits of the kitchen refrigerator units quarterly.
4) Findings of the audit will be reported to the facility quality assurance performance improvement committee to determine the need for additional actions and or monitoring.
5) Date of compliance 6/25/24.

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 AND THERAPY ADDITION - Component: 01 - Tag: 0353

Based on document review, observation and interview, it was determined the facility failed to provide quarterly sprinkler reports, and maintain the automatic sprinkler piping system, to be free of extraneous weight, affecting nine of nine floors within the component.

Findings include:

1. Review of documentation and observation on May 6, 2024, between 9:30 AM and 11:15 AM, revealed the facility lacked documentation verifying the sprinkler system had been inspected, during the 3rd and 4th quarter of 2023.

Interview at the time of the exit conference with the Director of Operation Consultant, Administrator, Property Management Consultant, Director of Maintenance and Maintenance Tech on May 7, 2024, at 1:30 PM, confirmed the 3rd and 4th quarter inspections were not performed.


2. Observation on May 7, 2024, between 9:05 AM and 11:55 AM, revealed items were being supported by the sprinkler piping system, at the following locations:

a. 9:05 AM, 8th floor, Southwest Hall, above smoke doors, above ceiling, multiple wires;
b. 9:10 AM, 8th floor, above Nurses' Station, above ceiling, multiple green wires;
c. 10:15 AM, 4th floor, above Nurses' Station, above ceiling, multiple green wires;
d. 11:55 AM, 1st floor, Administration Hall, above ceiling by Security Office, multiple wires.

Interview at the time of the exit conference with the Director of Operation Consultant, Administrator, Property Management Consultant, Director of Maintenance and Maintenance Tech on May 7, 2024, at 1:30 PM, confirmed various items laying across sprinkler pipes.




 Plan of Correction - To be completed: 06/25/2024

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.

K 0353 NFPA 101 sprinkler System – Maintenance and testing
1) Sprinkler system contractor system will be scheduled to complete the maintenance and inspection of the sprinkler system.
2) The NHA or designee will provide education to the maintenance director or designee on this inspection needed to be completed per regulation.
3) Maintenance director or designee will confirm the quarterly sprinkler system should be scheduled and that the last completed sprinkler system report is filed in the life safety book.
4) Findings of the audit will be reported to the facility quality assurance performance improvement committee to determine the need for additional actions and or monitoring.
5) Date of compliance 6/25/24.

1) The wires over the sprinkler pipes on, 8th floor southwest hall, 8 & 4th floor nurses station, 1st administration hall, will be removed and bundled so that the wires will no longer come in contact with the sprinkler pipes.
2) The maintenance director or designee will provide re-education to the facility maintenance team that nothing can be in contact with the sprinkler pipes.
3) Maintenance director will complete random audits in random locations of units weekly for 4 weeks and then monthly for 2 months to ensure that the sprinkler pipes are free of anything laying on them.
4) Findings of the audit will be reported to the facility quality assurance performance improvement committee to determine the need for additional actions and or monitoring.
5) Date of compliance 6/25/24


NFPA 101 STANDARD Portable Fire Extinguishers: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.
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: MAIN BUILDING AND THERAPY ADDITION - Component: 01 - Tag: 0355

Based on document review and interview, it was determined the facility failed to provide a certificate for the Fire Extinguisher Technician, affecting nine of nine floors within the component.

Findings include:

1. Review of documentation on May 6, 2024, between 9:30 AM and 11:15 AM, revealed the facility lacked documentation of the annual inspection being completed, by a certified Fire Extinguisher Technician.

Interview at the time of the exit conference with the Director of Operation Consultant, Administrator, Property Management Consultant, Director of Maintenance and Maintenance Tech on May 7, 2024, at 1:30 PM, confirmed the facility could not provide a certificate for the Fire Extinguisher Technician.



 Plan of Correction - To be completed: 06/25/2024

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.

K 0355 NFPA 101 Portable Fire extinguishers
1) The fire extinguishers will be inspected by a certified extinguisher technician this is scheduled on 5/21/2024. A record of the inspector's certification will be kept on record.
2) The maintenance director or designee will provide education to the facility maintenance team that annual fire extinguisher inspection is completed by a certified fire extinguisher technician.
3) Maintenance director or designee will confirm annually when annual fire extinguisher inspection is completed by a certified fire extinguisher technician and that we have the certification of that person and the report and certification are filed in the life safety book.
4) Findings of the audit will be reported to the facility quality assurance performance improvement committee to determine the need for additional actions and or monitoring.
5) Date of compliance 6/25/24



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