Pennsylvania Department of Health
VALLEY VIEW HAVEN, INC.
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 47 surveys for this facility. Please select a date to view the survey results.

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VALLEY VIEW HAVEN, INC. - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Based on an Emergency Preparedness Survey conducted on April 23, 2025, at Valley View Haven, Inc., it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000

Facility ID #220402
Component 01
Main Building (100-300 Wings)

Based on a Medicare/Medicaid Recertification Survey conducted on April 22 & 23, 2025, it was determined that Valley View Haven, Inc. 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 III (200), unprotected ordinary structure, which is fully sprinklered.

Plan of Correction:

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 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire component.

Findings include:

1. Observation of building construction on April 22, 2025, between 11:15 AM and 1:30 PM, revealed the facility is a two-story, Type III (200), unprotected ordinary structure, which is not permitted in Health Care.

Exit interview with the Chief Executive Officer and Director of Campus Services on April 23, 2025, at 1:15 PM, confirmed the facility exceeded the maximum allowable story height, for this type of construction.

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

The facility submits this Plan of Correction based on the Department of Health's identification of areas that are determined to represent deficient practice. Facility submits this Plan of Correction for the identified tag.

The facility will request Division of Safety to conduct an FSES survey.

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to maintain documentation, verifying annual inspections, affecting the entire component.

Findings include:

1. Review of documentation on April 22, 2025, between 9:30 AM and 11:15 AM, revealed the facility failed to provide documentation verifying battery back-up emergency lighting had been subjected to an annual test, for one year.

Exit interview with the Chief Executive Officer and Director of Campus Services on April 23, 2025, at 1:15 PM, confirmed the lack of documentation verifying annual battery back-up lighting tests.

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

Battery back-up emergency lighting testing will be completed.

Maintenance staff will be educated on completion of battery back up emergency light testing.

Battery back-up emergency lighting testing will be conducted and repeated annually.

Random audit will be completed quarterly to ensure that battery back-up emergency lighting testing has been completed. Results will be reported to the Quality Assurance Steering Committee.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system to be free of obstructions, in one of two smoke zones within component.

Findings include:

1. Observation on April 23, 2025, between 10:15 AM and 10:20 AM, revealed sprinkler heads covered with debris, at the following locations:

a. 10:15 AM, Laundry Room, Dryer Chase Room;
b. 10:18 AM, Laundry Room, Wash Machine Room;
c. 10:20 AM, Laundry Room, Laundry Folding Room, 4 sprinkler heads.

Exit interview with the Chief Executive Officer and Director of Campus Services on April 23, 2025, at 1:15 PM, confirmed debris covering sprinkler heads.

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

The Sprinklers in the laundry room dryer chase and wash machine room were cleaned.

Maintenance and Laundry was educated on how to complete cleaning on the sprinkler heads in the laundry room.

Sprinklers will be audited weekly for 4 weeks then monthly for 3 months and then quarterly following. Results will be reported to the Quality Assurance Steering Committee.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0371

Based on observation and interview, it was determined the facility failed to provide smoke compartments no greater than 22,500 square feet, affecting one of two smoke compartments within the component.

Findings include:

1. Observation on April 22, 2023, between 11:15 AM and 1:30 PM, revealed the 1st floor smoke compartment was greater than 22,500 square feet.

Exit interview with the Chief Executive Officer and Director of Campus Services on April 23, 2025, at 1:15 PM, confirmed the smoke compartment was in excess of 22,500 square feet.

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

The facility will request the Division of Safety to conduct an FSES Survey

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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.

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 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to perform a 3-year, 4-hour load testing required for the Essential Electrical System, which serves the entire component.

Findings include:

1. Review of documentation and interview on April 22, 2025, between 9:30 AM and 11:15 AM, revealed the facility failed to perform a tri-annual 4-hour load test. Last documented test was performed December 2021.

Exit interview with the Chief Executive Officer and Director of Campus Services on April 23, 2025, at 1:15 PM, confirmed the facility failed to perform the tri-annual 4-hour load test.

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

Facility cannot retroactively correct the missed documentation.

4-hour load test will be completed.

The maintenance director will be educated on the completion of the 4-hour load test completion.

An audit will be completed quarterly to ensure the 4 hour load test is completed as required. Results of this audit will be reported to the Quality Assurance Steering Committee.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID #220402
Component 02
Building 2 (400-500 Wings)

Based on a Medicare/Medicaid Recertification Survey conducted on April 22 & 23, 2025, it was determined that Valley View Haven, Inc. 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 II (000), unprotected noncombustible structure, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0291

Based on document review and interview, it was determined the facility failed to maintain documentation, verifying annual inspections, affecting the entire component.

Findings include:

1. Review of documentation on April 22, 2025, between 9:30 AM and 11:15 AM, revealed the facility failed to provide documentation verifying battery back-up emergency lighting had been subjected to an annual test, for one year.

Exit interview with the Chief Executive Officer and Director of Campus Services on April 23, 2025, at 1:15 PM, confirmed the lack of documentation verifying annual battery back-up lighting tests.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0918

Based on document review and interview, it was determined the facility failed to perform a 3-year, 4-hour load testing required for the Essential Electrical System, which serves the entire component.

Findings include:

1. Review of documentation and interview on April 22, 2025, between 9:30 AM and 11:15 AM, revealed the facility failed to perform a tri-annual 4-hour load test. Last documented test was performed December 2021.

Exit interview with the Chief Executive Officer and Director of Campus Services on April 23, 2025, at 1:15 PM, confirmed the facility failed to perform the tri-annual 4-hour load test.

Initial comments:Name: NEW ADDITION - Component: 04 - Tag: 0000

Facility ID #220402
Component 04
New Addition

Based on a Medicare/Medicaid Recertification Survey completed on April 23, 2025, it was determined that Valley View Haven, Inc. 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 (III), protected noncombustible structure, with a partial basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: NEW ADDITION - Component: 04 - Tag: 0291

Based on document review and interview, it was determined the facility failed to maintain documentation, verifying annual inspections, affecting the entire component.

Findings include:

1. Review of documentation on April 22, 2025, between 9:30 AM and 11:15 AM, revealed the facility failed to provide documentation verifying battery back-up emergency lighting had been subjected to an annual test, for one year.

Exit interview with the Chief Executive Officer and Director of Campus Services on April 23, 2025, at 1:15 PM, confirmed the lack of documentation verifying annual battery back-up lighting tests.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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: NEW ADDITION - Component: 04 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors, to be within the allowed gap margins and self-close, in one of five smoke zones within the component.

Findings include:

1. Observation on April 22, 2025, between 12:30 PM and 12:40 PM, revealed hazardous area doors exceeded minimum gap margins and failed to self-close, at the following locations:

a. 12:30 PM, basement, Mechanical Room door, exceeded 1/8 top and failed to self-close, due to a faulty coordinator;
b. 12:40 PM, basement, Storage Room door, exceeded 1/8 top and failed to self-close, due to a faulty coordinator.

Exit interview with the Chief Executive Officer and Director of Campus Services on April 23, 2025, at 1:15 PM, confirmed doors exceeded minimum gap margins and failed to self-close.

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

Mechanical room door coordinator was corrected and door gap are being adjusted to correct gap tolerances.

Storage room door gab adjusted to correct gap tolerances.

Maintenance staff will be educated on proper door enclosures.

An audit of hazardous area enclosures will be completed monthly for 3 months and then quarterly following. Results of the audit will be reported to the Quality Assurance Steering Committee.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: NEW ADDITION - Component: 04 - Tag: 0918

Based on document review and interview, it was determined the facility failed to perform a 3-year, 4-hour load testing required for the Essential Electrical System, which serves the entire component.

Findings include:

1. Review of documentation and interview on April 22, 2025, between 9:30 AM and 11:15 AM, revealed the facility failed to perform a tri-annual 4-hour load test. Last documented test was performed December 2021.

Exit interview with the Chief Executive Officer and Director of Campus Services on April 23, 2025, at 1:15 PM, confirmed the facility failed to perform the tri-annual 4-hour load test

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