Pennsylvania Department of Health
LUTHER CREST NURSING FACILITY
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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LUTHER CREST NURSING FACILITY - 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 19, 2026, at Luther Crest Nursing Facility, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000
Facility ID# 125502

Component 01

Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 19, 2026, it was determined that Luther Crest Nursing Facility 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 (111), protected, wood frame building, with basement, that is fully sprinklered.

Plan of Correction:

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 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of two floors.

Findings include:
1. Observation on May 19, 2026, at 11:52 a.m., revealed the Housekeeping Storage Room door, located at the basement level, required adjustment to fully latch.
Exit interview on May 19, 2026, between 12:25 p.m., and 12:30 p.m., with the Executive Director, Facility Administrator, and Facilities Manager, confirmed the hazardous area enclosure deficiency.

Plan of Correction - To be completed: 06/05/2026

1. The Housekeeping storage room door was adjusted to fully latch by the maintenance director on 5/19/2026.

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 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of two floors.

Findings include:
1. Observation on May 19, 2026, at 11:40 a.m., revealed storage items located within eighteen inches of an adjacent sprinkler head assembly, located within the Central Supply closet.
Exit interview on May 19, 2026, between 12:25 p.m., and 12:30 p.m., with the Executive Director, Facility Administrator, and Facilities Manager, confirmed the automatic sprinkler system deficiency.

Plan of Correction - To be completed: 06/05/2026

1. The items located within eighteen inches of an adjacent sprinkler head assembly in the Central supply closet were corrected by the maintenance director on 5/19/2026.
2. Central supplies staff was educated on the storage of the items within proper distance from the sprinkler head assembly.
3. Maintenance staff have marked the eighteen-inch line in all of central supply area walls to remain compliant by making a visual level for storage.
4. Maintenance director/ designee will inspect the central supply area weekly x 4 weeks and then monthly x 2 months.

NFPA 101 STANDARD Fire Drills:

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.

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712 Based on documentation review and interview, it was determined the facility failed to maintain fire drills in one instance, affecting two of two floors. Findings include: 1. Observation on May 19, 2026, at 12:10 p.m., revealed the facility lacked a second quarter, second shift fire drill for the preceding twelve-month period. Exit interview on May 19, 2026, between 12:25 p.m., and 12:30 p.m., with the Executive Director, Facility Administrator, and Facilities Manager, confirmed the fire drill deficiency.

Plan of Correction - To be completed: 06/05/2026

1. The second quarter, second shift fire drill for the preceding twelve - month period of 4/25/25 at 1535 was located at the facility that was completed by Fire Life Safety Solutions.
2. Maintenance Director/designee will ensure all the required fire drills paperwork are maintained at the facility post each completed fire drill to ensure compliance.

NFPA 101 STANDARD Electrical Systems - Other:

Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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.
Chapter 6 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain electrical systems in one location, affecting one of two floors.

Findings include:
1. Observation on May 19, 2026, at 11:22 a.m., revealed a junction box, located within Activities Storage, was not fully enclosed.
Exit interview on May 19, 2026, between 12:25 p.m., and 12:30 p.m., with the Executive Director, Facility Administrator, and Facilities Manager, confirmed the electrical deficiency.

Plan of Correction - To be completed: 06/05/2026

1. The junction box located within activities storage was corrected by the maintenance director on 5/19/2026 and is now enclosed properly.
2. The maintenance director/designee will monitor the junction box located in the activities storage to ensure it is properly covered monthly x 3 months.

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 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the generator set in one instance, affecting two of two floors.

Findings include:
1. Observation on May 19, 2026, at 12:14 p.m., revealed the diesel generator lacked a fuel quality sample for the preceding twelve-month period.
Exit interview on May 19, 2026, between 12:25 p.m., and 12:30 p.m., with the Executive Director, Facility Administrator, and Facilities Manager, confirmed the generator set deficiency.

Plan of Correction - To be completed: 06/05/2026

1. Curtis Power Solutions, the contractor performing facility generator p.m.'s, has been notified to take a fuel quality sample during the next scheduled maintenance/filter change that is pending completion June 2026.

2. Maintenance Director/Designee will ensure that the diesel generator has a fuel quality sample done and recorded for the preceding twelve-month period.

Initial comments:Name: COUNTRY KITCHEN - Component: 03 - Tag: 0000
Facility ID# 125502

Component 03

Country Kitchen

Based on a Medicare/Medicaid Recertification Survey completed on May 19, 2026, at Luther Crest Nursing Facility, 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 building, that is fully sprinklered.

Plan of Correction:

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