Pennsylvania Department of Health
LAUREL LAKES REHABILITATION AND WELLNESS CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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LAUREL LAKES REHABILITATION AND WELLNESS CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: 00 - Tag: 0000
Based on an Emergency Preparedness Survey completed on July 16, 2025, at Laurel Lakes Rehabilitation and Wellness 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 #061302

Component 01

Building 01

Based on a Medicare/Medicaid Recertification Survey completed on July 16, 2025, it was determined that Laurel Lakes Rehabilitation and Wellness 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 noncombustible structure, with a basement, 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 July 16, 2025, between 9:15 AM and 11:00 AM, revealed the facility portable life safety drawings lacked compartment labeling, resident room capacities, fire wall boundaries, smoke wall boundaries, hazardous areas, length and width of zones and travel distances. This information is required by the active FSES used to meet compliance with NFPA 101A. Interview with the Administrator and Director of Operations on July 16, 2025, at 2:00 PM, confirmed the portable life safety drawings lacked the required information for a facility with an active FSES.

Plan of Correction - To be completed: 09/16/2025

1. Portable life safety drawings have been corrected to include the required information.
2. NHA or designee will provide re-education to the facility maintenance personnel on Portable life safety drawings requirements. Monthly audit of life safety facility binder will be done to ensure life safety plans are filed in the life safety book annually and whenever changes are made to the floor plans.
3. Maintenance director or designee will complete random audits monthly for two months to ensure drawings have required information present. An audit will be conducted annually to confirm that no changes to the Facility have been made, or all changes that have been made have been noted on the floorplans. Audit findings will be reported to the QAPI meeting for review and recommendations.

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 - Component: 01 - Tag: 0225 Based on observation and interview, it was determined the facility failed to maintain stairtower doors to close and latch in frame, affecting one of six compartments within the component. Findings include: 1. Observation on July 16, 2025, at 11:35 AM, basement, D Wing, revealed stairtower left leaf door failed to properly close and latch in frame, due to faulty coordinator. Interview with the Administrator and Director of Operations on July 16, 2025, at 2:00 PM, confirmed the door would not close and latch in frame.

Plan of Correction - To be completed: 09/14/2025

1. Basement D Wing door has been corrected.
2. NHA or designee will provide re-education to the facility maintenance personnel and employees who use this door how to report a needed repair and that doors must properly close and latch in frame.
3. Maintenance director or designee will complete random audits monthly for two months to ensure doors properly close and latch in frame. Maintenance director will audit stair tower doors on a quarterly basis to ensure doors close and latch in frame. Audit findings will be reported to the QAPI meeting for review and recommendations.

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: MAIN BUILDING - Component: 01 - Tag: 0241 Based on observation and interview, it was determined the facility failed to provide two required exits, remote from one another, for one of six smoke compartments within the component. Findings include: 1. Observation on July 16, 2025, at 11:05 AM, revealed the D-Wing basement had only one approved exit. Interview with the Administrator and Director of Plan Operations on July 16, 2025, at 2:00 PM, confirmed the D-Wing basement had only one approved exit.

Plan of Correction - To be completed: 09/14/2025

Facility requests FSES.

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 close and latch in frame affecting one of six zones within the component. Findings include: 1. Observation on July 16, 2025, between 11:55 AM and 11:59 AM, revealed double fire rated doors failed to latch, at the following locations: a. 11:55 AM, Main Laundry, Soiled side, right leaf, faulty latch; b. 11:57 AM, Main Laundry, Clean Laundry, left leaf, faulty latch; c. 11:58 PM, Main Laundry, Clean/Soiled Separation door, left leaf, faulty coordinator; d. 11:59 PM, Main Corridor Housekeeper Storage door missing panic hardware. Interview with the Administrator and Director of Operations on July 16, 2025, at 2:00 PM, confirmed the doors did not positively latch in frame.

Plan of Correction - To be completed: 09/14/2025

1. Main Laundry, Soiled side, right leaf, faulty latch; Main Laundry, Clean/Soiled Separation door, left leaf, faulty coordinator doors have been corrected to properly latch. Main Corridor Housekeeper Storage door panic hardware has been corrected.
2. NHA or designee will provide re-education to the facility maintenance personnel, laundry and housekeeping that doors must positively latch in frame. Education will include reporting doors that need repair.
3. Maintenance director or designee will complete random audits monthly for two months to ensure doors must positively latch in frame. Maintenance director or designee will complete audits for all hazardous area doors to be conducted quarterly to ensure doors close and latch in frame. Audit findings will be reported to the QAPI meeting for review and recommendations.

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 - Component: 01 - Tag: 0324 Based on document review and interview, it was determined the facility failed to provide semi-annual hood cleanings documentation, in one of six smoke zones within the component. Findings include: 1. Review of documentation on July 16, 2025, between 9:15 AM and 11:00 AM, revealed the facility could not provide documentation, verifying the Kitchen exhaust ductwork had been cleaned, on a semi-annual basis. Interview with the Administrator and Director of Operations on July 16, 2025, at 2:00 PM confirmed the facility could not provide Kitchen ductwork had been cleaned, semi-annually.

Plan of Correction - To be completed: 09/14/2025

1. Kitchen exhaust ductwork has been cleaned semi-annually and documented.

2. NHA or designee will provide re-education to the facility maintenance personnel on documented kitchen exhaust ductwork cleaning, on a semi-annual basis.

3. Maintenance director or designee will complete audits semi-annually to ensure kitchen exhaust ductwork cleaning is scheduled and the certificate or report has been filed in the life safety book semi-annually. Audit findings will be reported to the QAPI meeting for review and recommendations.

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 - Component: 01 - Tag: 0345 Based on observation and interview, it was determined the facility failed to inspect and test the installed residential smoke detector system installed an independent smoke detection system, affecting all resident rooms within the component. Findings include: 1. Observation and interview on July 16, 2025, between 9:00 AM and 11:00 AM, revealed the facility failed to inspect and test the residential local smoke alarm detectors. Smoke detectors are not installed on the fire alarm system. Interview at the time of the exit conference with the Environmental Services Director on July 16, 2025, at 2:00 PM,confirmed smoke detectors were not being tested and inspected.

Plan of Correction - To be completed: 09/14/2025

1. Smoke alarm detectors have been inspected and tested. Smoke detectors do not report to an audible device when activated. Policy has been developed that when smoke detectors are activated staff call 911.

2. NHA or designee will provide re-education to the facility maintenance personnel on inspecting and testing the residential local smoke alarm detectors monthly. General staff have been educated that if smoke detectors sound, they must call 911 upon activation.

3. Maintenance director or designee will complete random audits monthly for two months to ensure that smoke alarm detectors have been inspected and tested monthly. Audit findings will be reported to the QAPI meeting for review and recommendations.

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: MAIN BUILDING - Component: 01 - Tag: 0371 Based on observation and interview, it was determined the facility failed to maintain travel distance requirements, for two of six smoke compartments within the component. Findings include: 1. Observation on July 16, 2025, between 11:30 AM and 1:00 PM, revealed the travel distance to reach a smoke barrier door exceeded two hundred feet, within the A and D Wing smoke compartments. Interview with the Administrator and Director of Operations on July 16, 2025, at 2:00 PM, confirmed the travel distance to reach a smoke barrier door exceeded two hundred feet, within the A and D Wing smoke compartments.

Plan of Correction - To be completed: 09/14/2025

Facility requests FSES.

NFPA 101 STANDARD Smoking Regulations:

Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0741 Based on observation and interview, it was determined the facility failed to inspect the installed fire extinguisher and failed to enforce the documented smoking policy, affecting the entire component. Findings include: 1. Observation on July 16, 2025, between 12:25 PM and 12:27 PM, revealed discarded cigarette butts, at the following locations: a. 12:25 PM, Rear Parking Area, by Smoking Shed, cigarettes on the ground; b. 12:26 PM, Rear Parking Area, in Smoking Shed, cigarettes on the ground; c. 12:27 PM, Rear Parking Area, by Smoking Shed, cigarettes in garbage can. Interview with the Administrator and Director of Operations on July 16, 2025, at 2:00 PM, confirmed discarded cigarette butts on the ground and in the garbage can. 2. Observation on July 16, 2025, at 12:31 PM, revealed the fire extinguisher, located in the Smoking Shed, was lacking monthly and annual inspection. Interview with the Administrator and Director of Operations on July 16, 2025, at 2:00 PM, confirmed the extinguisher was lacking monthly and annual inspection.

Plan of Correction - To be completed: 09/14/2025

1. Cigarette butts removed from ground and garbage can. Fire extinguisher has been inspected.
2. NHA or designee will provide re-education to general staff on placement of cigarette butts and fire extinguisher monthly and annual inspections.
3. Maintenance Director/designee/shift supervisors will complete random audits daily on all shifts to ensure that the smoking area has proper cigarette butts placement. Maintenance Director/designee will complete audits of fire extinguishers on a quarterly basis. This audit will be done by a staff member who does not conduct the monthly owner's quick checks to confirm that they are being looked at a minimum of every 30 days per NFPA 10. Audit findings will be reported to the monthly QAPI for review and recommendations.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0918 Based on document review and interview, it was determined the facility failed to provide required maintenance and testing documentation, which serves the entire component. Findings include: 1. Review of documentation on July 16, 2025, between 10:03 AM and 10:05 AM, revealed the facility lacked documentation, for the following: a. 10:03 AM, gas reliability letter; b. 10:05 AM, annual, 90-minute load bank; Interview with the Administrator and Director of Operations on July 16, 2025, at 2:00 PM, confirmed the lack of documentation for the emergency generator.

Plan of Correction - To be completed: 09/14/2025

1. Gas reliability letter and annual 90-minute load bank have been completed.
2. NHA or designee will provide re-education to the facility maintenance personnel on gas reliability letter and annual 90-minute load bank requirements.
3. Maintenance director or designee will complete random audits monthly for two months to ensure that the gas reliability letter and annual 90-minute load bank documentation has been completed. Audit findings will be reported to the QAPI meeting for review and recommendations.

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