Nursing Investigation Results -

Pennsylvania Department of Health
LANDIS HOMES
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

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LANDIS HOMES
Inspection Results For:

There are  38 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.
LANDIS HOMES - 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 January 30, 2020, at Landis Homes, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: EPHRATA - Component: 03 - Tag: 0000


Facility ID# 120602
Component 03
Building 03 (Ephrata)

Based on a Medicare/Medicaid Recertification Survey completed on January 30, 2020, it was determined that Landis Homes 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 V (000), unprotected wood frame structure, with a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type: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.
Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: EPHRATA - Component: 03 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain common wall doors to be within the allowed gap margins, and to positively latch, on one of two floors within the component.

Findings include:

1. Observation on January 30, 2020, at 12:40 PM revealed the 1st floor double corridor fire rated doors, separating 03 Ephrata House from 04 Lancaster House, had gaps, greater than 1/8 inch, between the door and frame.

Interview with the Director of Maintenance on January 30, 2020, at 12:40 PM confirmed the doors exceeded the allowed gap margins.


2. Observation on January 30, 2020, at 1:10 PM revealed the 1st floor double corridor fire rated doors, separating 03 Ephrata House from Cedar House, would not close and latch in the frame.

Interview with the Director of Maintenance on January 30, 2020, at 1:10 PM confirmed the doors failed to positively latch.


3. Observation on January 30, 2020, at 1:25 PM revealed the 1st floor double corridor fire rated doors, separating 03 Ephrata House from 04 Lancaster House, at the Rehab Suite, had gaps, greater than 1/8 inch, between the door and frame.

Interview with the Director of Maintenance on January 30, 2020, at 1:25 PM confirmed the doors exceeded the allowed gap margins.




 Plan of Correction - To be completed: 03/30/2020

Preparation and/or implementation of this plan of correction does not constitute admission or agreement by Landis Homes, set forth in the statement of deficiencies. This plan of correction is prepared and implemented solely because it is required by the provisions of federal and state law.

K 0133
1.) A gap 90 seal will be installed on the door identified in observation number one (1). A new 7-foot wood door vertical system will be installed on the door identified in observation number two (2). The hinges will be replaced and a gap 90 seal will be installed on the door identified in observation number three (3).
2.) Ongoing monitoring and quality assurance will be accomplished via continued annual fire door inspections. Results of the inspections will be reported to the QAPI/QAA committee. A Time-Limited Waiver is requested with a corrective action completion date of 05/24/2020.
Update per request - 03/04/2020 TLW will be sent 03/04/2020. We plan to use National Guard Products (Product number NGP-FDA-gap-pcs-0919-A)gap guard which is an intumescent seal fire. This product is approved to eliminate gap clearance in fire rated doors.

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: EPHRATA - Component: 03 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain stairtower doors to be within the allowed gap margins, on one of two floors within the component.

Findings include:

1. Observation on January 30, 2020, at 1:20 PM revealed Ephrata House, 1st floor stairtower door, by Resident Room 10, had gaps, greater than 3/16 inch.

Interview with the Director of Maintenance on January 30, 2020, at 1:20 PM confirmed the stairtwoer door exceeded the allowed gap margins.




 Plan of Correction - To be completed: 03/30/2020

Preparation and/or implementation of this plan of correction does not constitute admission or agreement by Landis Homes, set forth in the statement of deficiencies. This plan of correction is prepared and implemented solely because it is required by the provisions of federal and state law.

K 0225
1.) The hinges will be replaced and a 7-foot steel door vertical system will be installed on the door identified in observation one (1).
2.) Ongoing monitoring and quality assurance will be accomplished via continued annual fire door inspections. Results of the inspections will be reported to the QAPI/QAA committee. A Time-Limited Waiver is requested with a corrective action completion date of 05/24/2020.
Update request- 03/04/2020 - TLW will be emailed 03/04/2020

Initial comments:Name: MAIN BUILDING - Component: 04 - Tag: 0000


Facility ID# 120602
Component 04
Building 04( Conestoga, Lititz, Lancaster, Oregon, Manheim, Rehab, Laundry)

Based on a Medicare/Medicaid Recertification Survey completed on January 30, 2020, it was determined that Landis Homes 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, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type: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.
Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: MAIN BUILDING - Component: 04 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain common wall doors to be within the allowed gap margins, on one of two floors within the component.

Findings include:

1. Observation on January 30, 2020, at 1:30 PM revealed the 1st floor double corridor fire rated doors, separating 04 Lancaster House, at the Rehab Fitness Room, from Assistive Living, had gaps, greater than 1/8 inch, between the door and frame.

Interview with the Director of Maintenance on January 30, 2020, at 1:30 PM confirmed the doors exceedec the allowed gap margins.



 Plan of Correction - To be completed: 03/30/2020

Preparation and/or implementation of this plan of correction does not constitute admission or agreement by Landis Homes, set forth in the statement of deficiencies. This plan of correction is prepared and implemented solely because it is required by the provisions of federal and state law.

K 0133
1.) A gap 90 seal will be installed on the door identified in observation number one (1).

Update per request - 03/04/2020 We plan to use National Guard Products (Product number NGP-FDA-gap-pcs-0919-A)gap guard which is an intumescent seal fire. This product is approved to eliminate gap clearance in fire rated doors.

2.) Ongoing monitoring and quality assurance will be accomplished via continued annual fire door inspections. Results of the inspections will be reported to the QAPI/QAA committee. A Time-Limited Waiver is requested with a corrective action completion date of 05/24/2020.

Initial comments:Name: DAYCARE - Component: 05 - Tag: 0000


Facility ID# 120602
Component 05
Building 05 ( Adult Daycare)

Based on a Medicare/Medicaid Recertification Survey completed on January 30, 2020, at Landis Homes, it was determined there were no deficiencies identified under the 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 V (111), protected wood frame structure, without a basement, which is fully sprinklered.



 Plan of Correction:


Initial comments:Name: CONNECTING CORRIDOR - Component: 06 - Tag: 0000


Facility ID# 120602
Component 06
Connecting Corridor

Based on a Medicare/Medicaid Recertification Survey completed on January 30, 2020, it was determined that Landis Homes was not in compliance with the following requirements of the Life Safety Code for a new 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, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type: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.
Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a two hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
*The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
*The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: CONNECTING CORRIDOR - Component: 06 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain common wall doors to be within the allowed gap margins, for one of two sets of doors for this component.

Findings include:

1. Observation on January 30, 2020, at 12:30 PM revealed the double corridor fire rated doors, separating the corridor from Ephrata House Nursing Care, had gaps greater than 1/8 inch between the door and frame and had an under cut greater than 3/4 inch.

Interview with the Director of Maintenance on January 30, 2020, at 12:30 PM confirmed the doors exceeded the allowed gap margins.




 Plan of Correction - To be completed: 03/30/2020

Preparation and/or implementation of this plan of correction does not constitute admission or agreement by Landis Homes, set forth in the statement of deficiencies. This plan of correction is prepared and implemented solely because it is required by the provisions of federal and state law.
K 0133
1.) A gap 90 seal and top and bottom fire door extensions will be installed on the door identified in observation number one (1).

Update per request 03/04/2020 - We plan to use National Guard Products (Product number NGP-FDA-gap-pcs-0919-A)gap guard which is an intumescent seal fire. This product is approved to eliminate gap clearance in fire rated doors.

2.) Ongoing monitoring and quality assurance will be accomplished via continued annual fire door inspections. Results of the inspections will be reported to the QAPI/QAA committee. A Time-Limited Waiver is requested with a corrective action completion date of 05/24/2020.


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

Visit the PA Power Port