Pennsylvania Department of Health
AVALON SPRINGS CARE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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AVALON SPRINGS CARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Based on an Onsite Revisit to an Emergency Preparedness Survey completed on December 23, 2025, at Avalon Springs Care 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 01 - Component: 01 - Tag: 0000

Facility ID #132402
Component 01
Main Building

Based on an Onsite Revisit to a Medicare/Medicaid Recertification Survey completed on December 23, 2025, it was determined that Avalon Springs Care Center was not in compliance with the following requirements of the Life Safety Code for an existing nursing 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 (000), unprotected, non-combustible building, with a ground floor, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

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 01 - Component: 01 - Tag: 0100

Based on observation and interview, it was determined the facility failed to maintain general requirements not addressed by the provided K-tags, but are deficient, affecting two of three building levels.
Findings include:
Observation on December 23, 2025, at 11:30 a.m., revealed the facility failed to obtain required approval from the Department of Health State Plan Review and a granted occupancy from the Life Safety Division for the following projects:
A. (11:30 a.m.) First floor North Hall had recent flood damage. There was remediation work being completed from the floor up approximately three feet of the corridor walls. The residents were evacuated and relocated from this area as a result of the event;
B. (11:30 a.m.) Ground floor North Hall dementia unit had recent flood damage, resulting in total remediation of the partitioning studs;
C. (11:30 a.m.) The facility is currently using various rooms throughout the facility to provide item storage due to the recent flood event.
Interview with the facility administrator on December 23, 2025, at 11:30 a.m., confirmed the deficiencies.

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Based on an interview with the maintenance supervisor during an Onsite Revisit Survey conducted on February 18, 2026, at 9:00 a.m., the facility failed to obtain approval for items A, B, and C from the Department of Health State Plan Review and to receive a granted occupancy from the Life Safety Division. The facility did not prepare drawings and applications for submission at the time of the Revisit Survey.
Interview with the maintenance supervisor on February 18, 2026, at 9:00 a.m., confirmed items A, B, and C were not corrected.

Plan of Correction - To be completed: 03/20/2026

The facility will submit for a time limited waiver for the ground floor dementia unit, facility storage and the first-floor north hall. The waiver will provide the facility with needed time to plan for the renovation of the flooded areas.

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 01 - Component: 01 - Tag: 0161

Based on observation and interview, the facility failed to maintain the roofing system and construction type of the building, affecting the rated assemblies and structural integrity throughout one of three building levels.

Findings include:

Observation on December 23, 2025, at 1:00 p.m., revealed the facility had a leaking roof throughout the building. The facility has deployed ceiling-mounted leak diverters and positioned collection buckets to manage and contain water intrusion.

Interview with the facility administrator on December 23, 2025, at 1:00 p.m., confirmed the deficiency.

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Based on an interview with the maintenance supervisor during an Onsite Revisit Survey conducted on February 18, 2026, at 9:15 a.m., the facility failed to obtain approval from the Department of Health State Plan Review and to receive a granted occupancy from the Life Safety Division to correct the deficiency. The facility did not prepare drawings and applications for submission at the time of the Revisit Survey.
Interview with the maintenance supervisor on February 18, 2026, at 9:15 a.m. confirmed the deficiency was not corrected.

Plan of Correction - To be completed: 03/20/2026

Roof replacement plans are in progress. Plans will be submitted to plan review when completed.

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