Pennsylvania Department of Health
NEWPORT MEADOWS HEALTH 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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NEWPORT MEADOWS HEALTH 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 September 23, 2025, at Newport Meadows Health 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: 'A' BLDG - Component: 01 - Tag: 0000
Facility ID# 080502

Component 01

"A" Building

Based on a Medicare/Medicaid Recertification Survey completed on September 23, 2025, it was determined that Newport Meadows Health 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 V (000), unprotected wood frame 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: 'A' BLDG - 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 September 23, 2025, between 8:45 AM and 10:30 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 at the time of the exit conference with the Administrator and Director of Maintenance on September 23, 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: 12/15/2025

Facility unable to correct deficiency retroactively.

FSES Floor plans have been updated and will be kept on file with the plant operations manager and a copy kept in the life safety binder.

FSES Floor plans will be submitted to QAPI for review.

FSES Floor plans will be reviewed annually with the Emergency preparedness plan

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: 'A' BLDG - Component: 01 - 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 September 23, 2025, at 10:30 AM, revealed the building is a two-story, unprotected wood frame structure, with a basement, which is fully sprinklered. The building exceeds the maximum allowable story height for this type of construction. Interview at the time of the exit conference with the Administrator and Director of Maintenance on September 23, 2025, at 2:00 PM, confirmed the construction type is not allowed in health care.

Plan of Correction - To be completed: 12/15/2025

The facility requests FSES be conducted for "A" building

The facility has submitted a Time Limited Wavier to the Division of Safety Inspection.

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: 'A' BLDG - Component: 01 - Tag: 0241 Based on observation and interview, it was determined the facility failed to provide at least two exits, remote from each other, on each floor or fire section, affecting two of three floors within the component. Findings include: 1. Observation on September 23, 2025, between 11:00 AM and 11:30 AM, revealed the facility lacked two acceptable means of egress, from the 2nd floor and the basement. Interview at the time of the exit conference with the Administrator and Director of Maintenance on September 23, 2025, at 2:00 PM, confirmed the facility failed to provide two exits, remote from each other, from each story.

Plan of Correction - To be completed: 12/15/2025

The facility requests FSES be conducted for "A" Building

Initial comments:Name: B & C BLDG - Component: 02 - Tag: 0000
Facility ID #080502

Component 02

"B" and "C" Buildings

This is a three-story, Type II (222), fire resistive structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

Observations:
Name: B & C BLDG - Component: 02 - 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 September 23, 2025, between 8:45 AM and 10:30 AM, revealed the facility lacked portable, accurate life safety drawings of the facility. Interview at the time of the exit conference with the Administrator and Director of Maintenance on September 23, 2025, at 2:00 PM, confirmed the lack of portable, accurate life safety drawings of the facility.

Plan of Correction - To be completed: 12/15/2025

Facility unable to correct deficiency retroactively.

Floor plans have been updated and will be kept on file with the plant operations manager and a copy kept in the life safety binder.

Floor plans will be submitted to QAPI for review.

Floor plans will be reviewed annually with the Emergency preparedness plan

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: B & C BLDG - Component: 02 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintain hazardous area doors, to be within the allowed gap margins, affecting one of three levels within the component. Findings include: 1. Observation on September 23, 2025, between 12:30 PM and 12:36 PM, revealed hazardous area doors exceeded the allowed gap margins, at the following locations: a. 12:30 PM, Main Kitchen, right door, gaps exceeding 3/16 inch, latch side and top; b. 12:33 PM, Main Kitchen, left door, gaps exceeding 3/16 inch, latch side and top; c. 12:36 AM, Kitchen, Storage Room door, gaps exceeding 3/16 inch, latch top. Interview at the time of the exit conference with the Administrator and Director of Maintenance on September 23, 2025, at 2:00 PM, confirmed the doors exceeded gap requirements.

Plan of Correction - To be completed: 12/15/2025

Kitchen doors could not be repaired or adjusted to original function to ensure positive latch and gap.

The facility has submitted a Time Limited Wavier to the Division of Safety Inspection; new doors ordered for the dry storage room and left and right Kitchen entrances. Delivery from vendor expected January 29, 2026

New doors to be installed by the maintenance department and ensure correct function of door closure, positive latch and gap.

Plant Operations Director/designee will audit the Kitchen and dry storage room doors weekly x 4 weeks and then monthly to ensure correct function of door closure, positive latch and gap. Results of the audits will be forwarded to facility QAPI for review.

NFPA 101 STANDARD Smoking Regulations:

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.

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: B & C BLDG - Component: 02 - Tag: 0741 Based on observation and interview, it was determined the facility lacked ashtrays of noncombustible material and a metal container with a self-closing device, affecting the entire component. Findings include: 1. Observation on September 23, 2025, between 1:10 PM and 1:12 PM, revealed the Designated Smoking Area lacked the following: a. 1:10 PM, noncombustible ashtray; b. 1:12 PM, self-closing metal container. Interview at the time of the exit conference with the Administrator and Director of Maintenance on September 23, 2025, at 2:00 PM, confirmed the lack of required ashtray and containers.

Plan of Correction - To be completed: 12/15/2025

Facility unable to correct deficiency retroactively.

A new steel ashtray and a self-closing metal container that contains sand to extinguish smoldering cigarette butts have been purchased and put into place in the designated smoking area.

Signage has been added to the area designating it as an acceptable smoking area.

Plant Operations Director/designee will monitor the staff designated smoking area to ensure cigarette butts are disposed of properly daily x 14 then weekly x 4 then monthly ongoing. Results will be forwarded to facility QAPI for review.

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