Pennsylvania Department of Health
LAKEVIEW HEALTHCARE AND REHAB
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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LAKEVIEW HEALTHCARE AND REHAB - 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 22, 2025, at Lakeview Healthcare and Rehab, 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 #194802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 22, 2025, it was determined that Lakeview Healthcare and Rehab 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 two partial basements, that 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: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on observation and interview, the facility failed to maintain accurate, portable floor plans that outlined designated rated partitions, affecting the entire facility.

Findings include:

Document review on May 22, 2025, at 11:20 a.m., revealed the facility failed to provide a set of accurate, portable floor plans. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site, to be used during the Life Safety Code Survey.

The Life Safety Code Floor Plan shall include the following:
a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls (1-2 hour walls);
c. Horizontal exits;
d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls.

The facility floor plans that were provided were not accurate. Observation revealed a set of smoke barrier doors and a wall near the laundry that was not listed on the drawings. The push bar was not listed as fire exit hardware. The facility was unable to provide documentation for fire exit hardware.

Interview with the maintenance director on May 22, 2025, at 11:20 a.m., confirmed the facility's Life Safety Code Floor Plan was inaccurate at the time of the survey.

Plan of Correction - To be completed: 06/03/2025

1. The Maintenance Director will correct the Floor Plans of the facility by ensuring a.) Smoke Barrier Walls; b.) Fire Barrier Walls; c.) Horizontal Exits; d.) Rated Rooms; e.) Required Exits; & f.) Shaft Walls are all clearly marked on the drawings for an accurate set of portable floor plans.

2. Push bars on fire doors will be verified by the manufacturer and will be indicated on the floor plan as fire exit hardware.

3. Results to be reviewed at the next QA meeting.

4. Date of Compliance 6/3/2025

NFPA 101 STANDARD Doors with Self-Closing Devices:

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.

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, the facility failed to meet doors with self-closing device requirements in one of over two storage rooms.

Findings include:

Observation of May 22, 2025, at 10:55 a.m., revealed the PC storage room, a room measuring larger than 50 square feet, had combustibles stored. The door's self-closing device was also removed.

Interview with the maintenance supervisor on May 22, 2025, at 10:55 a.m., confirmed the deficiencies.

Plan of Correction - To be completed: 05/27/2025

1. The Maintenance Director corrected the PC storage room by installing an automatic door closure.

2. Educated PC staff that the storage room is now on an automatic door closure.

3. Results to be reviewed at the next QA meeting.

4. Date of Compliance 5/27/2025

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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.

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 and interview, the facility failed to meet fire alarm system maintenance requirements at one of over five pull stations.

Findings include:

Observation of May 22, 2025, at 10:20 a.m., revealed the pull station in the large lounge, near the exit door, was not mounted securely. The pull station was attached by wires only.

Interview with the maintenance supervisor on May 22, 2025, at 10:20 a.m., confirmed the deficiency.

Plan of Correction - To be completed: 05/27/2025

1. The Maintenance Director corrected the mounted fire alarm pull station near the exit door in the large lounge by mounting it securely to the wall.

2. Results to be reviewed at the next QA meeting.

3. Date of Compliance 5/27/2025

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