Pennsylvania Department of Health
HARBORVIEW REHABILITATION AND CARE CENTER AT LANSDALE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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HARBORVIEW REHABILITATION AND CARE CENTER AT LANSDALE - 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 August 24, 2026, at Harborview Rehabilitation and Care Center at Lansdale, 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# 140502

Component 01

Main Building

Based on a Medicare/Medicaid Recertification Survey completed on August 24, 2026, it was determined that Harborview Rehabilitation and Care Center at Lansdale 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 three-story, Type III (211), protected ordinary building, with a basement, 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

28 Pa. Code 553.3(1) GOVERNING BODY RESPONSIBILITIES
Governing body responsibilities include:
(1) Conforming to applicable Federal, State, and local law. 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 observation, document review, and interview, it was determined the following items did not conform to applicable Federal, State, and local laws and regulations:

Findings include:

1. Document review and observation on August 24, 2026, at 10:00 a.m., revealed the facility failed to secure plan approval by the Department of Health prior to installing a new emergency generator.

Exit Interview with the Administrator and Maintenance Director on August 24, 2026, at 1:15 p.m., confirmed that the facility failed to obtain Occupancy after the new generator installation.

28 Pa Code 51.3. Notification (d)

Plan of Correction - To be completed: 09/26/2026

-Facility will apply to Plan review for the replacement generator within 60 days of the visit and inform the field office once it is done.
- Facility will make sure the correspondence with Plan Review is kept on file throughout the duration of this process.

NFPA 101 STANDARD Building Construction Type and Height:

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.

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 document review and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire facility. Findings include: Document review on August 24, 2026, at 9:30 a.m., revealed the building exceeded the maximum allowable story height for protected ordinary construction by one story. Exit Interview with the Administrator and Maintenance Director on August 24, 2026, at 1:15 p.m., confirmed the building story height deficiency.

Plan of Correction - To be completed: 09/26/2026

-Facility requests a time-limited waiver to contact an engineering or architectural firm to evaluate the current building construction within 60 days of the visit and determine the necessary corrective action required to meet or exceed the Life Safety Code.

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 01 - Component: 01 - Tag: 0225 Based on observation and interview, it was determined that the facility failed to maintain stairways, affecting two of three stairways. Findings include: 1. Observation on August 24, 2026, revealed stairway deficiencies in the following locations: a. 11:00 a.m., basement West stairway had boxes and a trash can stored under the landing. b. 11:05 a.m., basement West stairway door had open holes around the handle. c. 11:30 a.m., on the third floor, the front hall stairway had a chair stored on the landing. Exit Interview with the Administrator and Maintenance Director on August 24, 2026, at 1:15 p.m., confirmed the stairway deficiencies.

Plan of Correction - To be completed: 09/26/2026

- Facility immediately removed boxes and trash under the landing of the basement west stairways.
- Facility immediately repaired the open holes with steel screws and plates.
- Facility immediately removed the chair found during the visit on the third-floor front hallway stair landing.
- Facility educated Director of maintenance and Maintenance technician about importance of preventive maintenance of the doors in the facility.
- Facility educated the Director of Maintenance, Director of Environmental Services and Maintenance Technician about maintaining stairways, and exit doors free of storage items.
- Facility will do audits of the stairways, and exit doors free of clutter, weekly * 4 then monthly *2 and the results of the audits will be reviewed and discussed in monthly QAPI meetings.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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 01 - Component: 01 - Tag: 0345 Based on observation, document review, and interview, it was determined the facility failed to maintain Fire Alarm components, affecting the entire facility. Findings include: 1. Document review on August 24, 2026, at 9:30 a.m., revealed June 2026, Semi-Annual Fire Alarm Inspection Report noted the following deficiencies, which remained uncorrected at time of survey: a. Sprinkler tampers and waterflow in the side D outside sprinkler room did not report to the fire alarm panel. Exit Interview with the Administrator and Maintenance Director on August 24, 2026, at 1:15 p.m., confirmed the listed deficiencies remained uncorrected at time of survey. 2. Observation on August 24, 2026, at 10:45 a.m., revealed the facility fire alarm panel was in trouble mode at time of survey. Exit Interview with the Administrator and Maintenance Director on August 24, 2026, at 1:15 p.m., confirmed the fire alarm panel trouble status.

Plan of Correction - To be completed: 09/26/2026

-Facility contracted the vendor and the repair work is done for the issues related to Sprinkler Tampers in the side D outside sprinkler room and now it is reporting to the fire alarm panel.
- Facility immediately inspected the fire alarm panel and fixed the trouble status.
- Facility re-educated Director of Maintenance and Maintenance Technician regarding importance of inspection of fire alarm panel and immediate actions to fix the trouble status.
- Facility will do audit weekly*4 and monthly*2 of inspection of fire alarm panel to see for any trouble status and if immediate actions to fix the trouble status needed or not. Results of these audits will be reviewed in monthly QAPI meeting.

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

Plan of Correction - To be completed: 09/26/2026

- Facility contracted the vendor and the repair work is done for the issues related to Sprinkler Tampers in the side D outside sprinkler room and now it is reporting to the fire alarm panel.
- Facility contracted the vendor and replaced the corroded pipe with new pipe located on Room 312 and also checked for any other sections are corroded or not.
- Facility checked the pipe for dry valve connection.
- Facility contracted vendor and conducted main drain testing for the fire pump.
- Facility contracted the vendor and the Fire pump is tied into the FACP.
- Facility re-educated Director of Maintenance and Maintenance Technician regarding importance of Sprinkler System- Maintenance and Testing and timely doing preventive maintenance and repairs if needed.
- Facility will do monthly*2 audits of preventive maintenance and repairs of the sprinkler system and results of these audits will be reviewed in monthly QAPI meeting.

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, observation, and interview, it was determined the facility failed to maintain the emergency generator, affecting the entire facility. Findings include: 1. Document review on August 24, 2026, at 9:30 a.m., revealed the facility lacked documentation showing the following required emergency generator maintenance items had been conducted: a. monthly battery conductance testing. b. annual 90-minute load testing. c. 3-year 4-hour exercise. d. annual fuel quality report. Exit Interview with the Administrator and Maintenance Director on August 24, 2026, at 1:15 p.m., confirmed the missing documentation. 2. Observation on August 24, 2026, at 9:15 a.m., revealed facility emergency generator exhaust pipe was disconnected. The generator resides directly below the second and third floor windows. Exit Interview with the Administrator and Maintenance Director on August 24, 2026, at 1:15 p.m., confirmed the disconnected exhaust pipe. 3. Observation on August 24, 2026, at 12:15 p.m., the facility failed to provide a remote annunciator for its newly installed emergency generator. Exit Interview with the Administrator and Maintenance Director on August 24, 2026, at 1:15 p.m., confirmed the missing remote annunciator.

Plan of Correction - To be completed: 09/26/2026

- Facility will request a time-limited waiver for items 1a. monthly battery conductance testing, 1 b. annual 90-minute load testing, 1 c. the 3-year 4-hour exercise, and 1 d.- Annual Fuel Quality Report.
- Facility will request a time-limited for exhaust pipe attachment to the generator.
- Facility will request a time-limited waiver for connection of the remote annunciator panel to the emergency generator
- Facility got the permit from local borough after third party inspection to make sure the generator can be used when needed and there will be no adverse effect on patient health or safety while corrective action is taking place.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923 Based on observation and interview, it was determined the facility failed to maintain oxygen cylinder storage affecting one of four levels. Findings include: 1. Observation on August 24, 2026, at 12:15 p.m., revealed an unsecured oxygen cylinder, on the ground floor Physical Therapy. Exit Interview with the Administrator and Maintenance Director on August 24, 2026, at 1:15 p.m., confirmed the freestanding oxygen cylinder.

Plan of Correction - To be completed: 09/26/2026

- Facility immediately secured the oxygen cylinder safely that was found on the floor in physical therapy.
- Facility re-educated Nursing and Therapy staff on importance of secure storage of the oxygen cylinder.
- Facility will do weekly * 4 and monthly *2 audits of the secure storage of the oxygen cylinder and results of the audits will be reviewed during the monthly QAPI meeting.

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