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

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 40 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.


ORWIGSBURG 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 August 20, 2025, at Orwigsburg Nursing and Rehabilitation Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000
Facility ID #043502

Component 01

Main Building

Based on a Medicare/Medicaid Recertification Survey completed on August 20, 2025, it was determined that Orwigsburg 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 two-story, Type II (111), protected noncombustible structure, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

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 - Component: 01 - Tag: 0100 28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE (a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met. 35 P.S. 448.808. Issuance of license. (a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met: (2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered. Based on document review and interview, it was determined the facility failed to meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component. Findings include: 1. Review of documentation on August 20, 2025, between 9:30 AM and 11:30 AM, revealed the facility lacked portable, accurate life safety drawings of the facility. Interview at the time of the exit conference with the Regional Property Manager, Assistant Administrator and Maintenance Assistant on August 20, 2025, at 1:30 PM, confirmed the lack of portable, accurate life safety drawings of the facility.

Plan of Correction - To be completed: 09/30/2025

Portable accurate life safety drawings of the facility will be completed.

Maintenance Director or designee will validate the life safety drawings of the facility to meet the regulatory requirements.

NHA or designee will educate maintenance staff on K0100 and maintaining portable accurate life safety drawings of the facility.

Maintenance Director or designee will audit life safety drawings of the facility monthly X 3 months then quarterly to validate portable accurate life safety drawings of the facility are compliant.

NFPA 101 STANDARD Building Construction Type and Height:

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.

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: MAIN BUILDING - Component: 01 - Tag: 0161 Based on observation and interview, it was determined the facility failed to maintain the rated horizontal fire doors to close and latch within the frame, on one of six smoke compartments within the component. Findings include: 1. Observation on August 20, 2025, at 11:40 AM, revealed horizontal fire-rated door, on the 2nd floor, storage closet failed to self-close and latch in the frame, due to missing springs. Interview at the time of the exit conference with the Regional Property Manager, Assistant Administrator and Maintenance Assistant on August 20, 2025, at 1:30 PM, confirmed the horizontal fire-rated hatch failed to self-close and latch.

Plan of Correction - To be completed: 09/30/2025

1. Missing springs on the horizontal fire-rated door in the second-floor storage closet have been ordered, and the maintenance director will install upon arrival allowing the door to self-close. A time-limited waiver for completion has been requested.
2. Maintenance Director or designee will validate missing springs have been replaced on the horizontal fire-rated door on the second floor, storage closet allowing the door to self close.
3. NHA or designee will educate maintenance staff on K0161 and maintaining springs to the horizontal fire-rated door on the second-floor storage closet to allow door to self-close. Springs will be ordered by9/30/2025. The horizontal fire rated door will self-close and latch in compliance with regulation by December 31, 2025. In the interim, the door will remain closed and latched unless someone is in attendance ensuring no risk to residents.
4. Maintenance Director or designee will audit the horizontal fire-rated door on the second-floor storage closet monthly X 3 then quarterly X 3 to validate springs are intact allowing door to self-close with results reported to the QAPI Committee.

NFPA 101 STANDARD Means of Egress - General:

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0211 Based on observation and interview, it was determined the facility failed to maintain special locking arrangements lacked delayed egress signage, in three of six smoke zones within the component. Findings include: 1. Observation on August 20, 2025, between 12:25 PM and 12:35 PM, revealed the exit discharge doors lacked delayed egress signage, at the following locations: a. 12:25 PM, 1st floor, dock entrance; b. 12:30 PM, 1st floor, main entrance; c. 12:35 PM, 1st floor, back stairwell. Interview at the time of the exit conference with the Regional Property Manager, Assistant Administrator and Maintenance Assistant on August 20, 2025, at 1:30 PM, confirmed exit doors lacked delayed egress signage.

Plan of Correction - To be completed: 09/30/2025

1. Delayed Egress signage for the exit discharge doors located on the first floor dock entrance, main entrance, and back stairwell have been applied.
2. Maintenance Director or designee will validate delayed egress signage is present on all facility exit discharge doors.
3. NHA or designee will educate maintenance staff on K0211 and maintaining delayed egress signage for exit discharge doors.
4. Maintenance Director of designee will audit exit discharge doors monthly X 3 then quarterly X 3 to ensure delayed egress signage is in place with results reported to the QAPI Committee.

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: MAIN BUILDING - Component: 01 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintain hazardous area doors to meet minimum gap requirements, and to positively latch in frame, affecting two of six smoke zones within the component. Findings include: 1. Observation on August 20, 2025, at 11:47 AM, revealed the 1st floor, Elevator Machinery Room door exceeded minimum gap requirements, at the top and latch side, of 1/8th inch. Interview at the time of the exit conference with the Regional Property Manager, Assistant Administrator and Maintenance Assistant on August 20, 2025, at 1:30 PM, confirmed the Elevator Machinery Room door exceeded minimum gap requirements. 2. Observation on August 20, 2025, at 11:53 AM, revealed the 1st floor, Service Hall door, by Staff Locker Room, failed to positively latch, due to faulty panic hardware. Interview at the time of the exit conference with the Regional Property Manager, Assistant Administrator and Maintenance Assistant on August 20, 2025, at 1:30 PM, confirmed the Service Hall door failed to positively latch in frame.

Plan of Correction - To be completed: 09/30/2025

1. Elevator machinery door will be adjusted to ensure minimum gap requirements. Panic hardware on first floor, service hall door, by staff locker room was adjusted to allow door to positively latch.
2. The Maintenance Director or designee will audit all hazardous doors to maintain minimum gap requirements and positively latch to frame.
3. NHA or designee will educate maintenance staff on K0321 minimum gap requirements for doors and ensure panic hardware functions properly to allow doors to positively latch.
4. The Maintenance Director or designee will audit 5 hazardous doors monthly X 3 then quarterly x 3 to ensure minimum gap requirements and positively latch to frame with results reported to the QAPI Committee.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0345 Based on document review and interview, it was determined the facility failed to provide documentation verifying a semi-annual inspection of the fire alarm system had been performed, affecting the entire component. Findings include: 1. Review of documentation on August 20, 2025, between 9:30 AM and 11:30 AM, revealed the facility failed to provide documentation verifying a semi-annual visual inspection of the fire alarm system had occurred, within the previous twelve months. Interview at the time of the exit conference with the Regional Property Manager, Assistant Administrator and Maintenance Assistant on August 20, 2025, at 1:30 PM, confirmed the facility could not provide documentation of the semi-annual inspection of the fire alarm system.

Plan of Correction - To be completed: 09/30/2025

1. The annual visual inspection occurred in August 2025 performing all inspections also required semi-annually. A semi-annual visual inspection of the fire alarm system will be scheduled in February 2026 per regulation.
2. The Maintenance Director will obtain an updated contract with the fire system inspection vendor that will include annual and semi-annual inspections.

3. NHA or designee will educate maintenance staff on K0345 receiving documentation verifying a semi-annual visual inspection of the fire alarm system has been completed.
4. The Maintenance Director or designee will audit records semi-annually to ensure documentation of the visual semi-annual inspection of the fire alarm system has been received and available with results reported to the QAPI Committee.

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: MAIN BUILDING - Component: 01 - Tag: 0353 Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler heads to be free of obstructions, in one of six smoke zones within component. Findings include: 1. Observation on August 20, 2025, between 12:00 PM and 12:10 PM, revealed sprinkler heads were covered with debris, at the following locations: a. 12:00 PM, 1st floor, Main Kitchen, 6 sprinkler heads; b. 12:05 PM, 1st floor, Main Laundry Room, 4 sprinkler heads; c. 12:10 PM, 1st floor, Main Laundry Room, Dryer Chase Room, 1 sprinkler head. Interview at the time of the exit conference with the Regional Property Manager, Assistant Administrator and Maintenance Assistant on August 20, 2025, at 1:30 PM, confirmed debris was covering sprinkler heads.

Plan of Correction - To be completed: 09/30/2025

1. Sprinkler heads will be cleaned to remove debris.
2. The Maintenance Director or designee will complete a review of facility sprinkler heads validate sprinkler heads are clean and free of debris.
3. NHA or designee will educate maintenance staff on K0353 and maintaining sprinkler heads are clean and free of debris.
4. The Maintenance Director or designee will audit 5 sprinkler heads monthly X 3 then quarterly X 3 to ensure sprinkler heads are free of debris with results reported to the QAPI Committee.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement