Pennsylvania Department of Health
YORK SOUTH SKILLED NURSING AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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YORK SOUTH SKILLED NURSING AND REHABILITATION CENTER - 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 June 13, 2024, at York South Skilled Nursing and Rehabilitation, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

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

Facility ID #280402
Component 01
Main Building and Arcadia

Based on a Medicare/Medicaid Recertification Survey completed on June 13, 2024, it was determined that York South Skilled Nursing and Rehabilitation, 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 (000), unprotected noncombustible structure, with a basement, which 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 - Component: 01 - Tag: 0100

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. 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 document review and interview, it was determined the facility failed to meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents, within the component.

Findings include:

1. Review of documentation and interview on June 13, 2024, between 8:15 AM and 10:30 AM, revealed the facility lacked portable, accurate life safety drawings of the facility with an FSES. Floor plans lacked resident room capacities, hazardous areas, travel distance from the furthest point in the zone to the exit, travel distance from the furthest point in the zone to the smoke barrier doors, length & width of zone and labeled use of spaces.

Interview with the Administrator and Director of Maintenance on June 13, 2024, at 2:45 PM, confirmed the lack of portable, accurate life safety drawings of the facility.

Plan of Correction - To be completed: 08/07/2024

Portable, Accurate Life Safety Drawings of the facility will be available for review to include room capacities, hazardous areas, travel distance from the furthest point in the zone to the exit, travel distance from the furthest point in the zone to the smoke barrier doors, length and wide of zone and labeled use.

The Maintenance Director/designee will monitor/audit any building changes and update the drawings monthly as needed.

Drawings will be reviewed by QAPI for continued compliance and discontinuation.

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 - Component: 01 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain the rated horizontal fire doors, to close and latch within the frame, in three of twelve smoke compartments within the component.
Findings include:
1. Observation on June 13, 2024, between 11:50 AM and 1:10 PM, revealed multiple horizontal fire-rated access doors, failed to self-close and latch in the frame, at the following locations:
a. 11:50 AM, 1st floor, Admin Hall, by smoke doors;
b. 11:55 AM, 1st 1st floor, Bethany Nurses' Station;
c. 12: 20 PM, 1st floor, by Resident Room 407;
d. 1:10 PM, 1st floor, by Conference Room.

Interview with the Administrator and Director of Maintenance on June 13, 2024, at 2:45 PM, confirmed the horizontal fire-rated access doors would not self-close and latch.

Plan of Correction - To be completed: 08/07/2024

Multiple horizontal fire-rated access doors, have been repaired to self-close and latch in the frame, at the following locations:
1st floor, Admin Hall, by smoke doors
1st floor, Bethany Nurses station
1st floor, by Resident Room 407
1st floor, by Conference Room

The Maintenance Director/designee will conduct audits on 2 random horizontal fire-rated access doors quarterly for the rest of the year with the results reviewed by the QAPI Committee to determine continued compliance and discontinuation.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

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 - Component: 01 - Tag: 0225
Based on observation and interview, it was determined the facility failed to maintain stairtower doors, to close and latch in frame, and horizontal access doors failed to latch in frame, on two of five stairtowers within the component.

Findings include:

1. Observation on June 13, 2024, at 11:35 AM, revealed 1st floor, 200 Hall door, stairtower left leaf, failed to positively close and latch in frame, due to an inoperable coordinator.

Interview with the Administrator and Director of Maintenance on June 13, 2024, at 2:45 PM, confirmed the stairtower door failed to latch.
2. Observation on June 13, 2023, at 12:45 PM, revealed 2nd floor, Stairtower #7, attic horizontal access hatch, within the stairtower, failed to self-close and latch in frame, due to detached springs.

Interview with the Administrator and Director of Maintenance on June 13, 2024, at 2:45 PM, confirmed the horizontal hatch failed to close and latch.

Plan of Correction - To be completed: 08/07/2024

The following doors will positively close and latch in the frame:
1st floor, 200 hall door, stairtower left leaf will have the coordinator fixed/replaced
2nd floor, stairtower #7, attic horizontal access hatch, within the stairtower, will have the springs re-attached/fixed

The Maintenance Director/designee will conduct audits on 2 random stairtower and/or horizontal access doors quarterly for the rest of the year with the results reviewed by the QAPI Committee to determine continued compliance and discontinuation.

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: MAIN - Component: 01 - 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 close and latch in frame, in three of twelve smoke compartments within the component.

Findings include:

1. Observation on June 13, 2024, between 10:17 AM and 12:48 PM, revealed hazardous area doors exceeded minimum gap margins, at the following locations:

a. 10:17 AM, basement, Dietary Cart Storage, top exceeded 3/16th inch;
b. 10:58 AM, basement, Central Supply Room, top exceeded 3/16th inch;
c. 12:48 PM, 2nd floor, 700 Hall, Soiled Utility Room, top exceeded 3/16th inch.

Interview with the Administrator and Director of Maintenance on June 13, 2024, at 2:45 PM, confirmed hazardous area doors exceeded the allowed gap margins.

2. Observation on June 13, 2024, at 11:10 AM, revealed the Soiled Laundry door failed to positively latch in the frame, due to door rubbing on latch plate.

Interview with the Administrator and Director of Maintenance on June 13, 2024, at 2:45 PM, confirmed the hazardous area doors failed to positively latch.

Plan of Correction - To be completed: 08/07/2024

The following hazardous area doors will have appropriate gap margins and positively latch in the frame.
Basement, Dietary Cart Storage-gap
Basement, Central Supply Room-gap
2nd floor, 700 Hall, Soiled Utility Room-gap
Basement Soiled Laundry-positive latch in the frame

The Maintenance Director/designee will conduct audits on 2 random hazardous area doors quarterly for the rest of the year with the results reviewed by the QAPI Committee to determine continued compliance and discontinuation.

NFPA 101 STANDARD Cooking Facilities:

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN - Component: 01 - Tag: 0324

Based on document review, observation and interview, it was determined the facility failed to provide documentation for the cooking fire equipment hood exhaust/duct system, semi-annually, in one of twelve smoke compartments within the component.

Findings include:

1. Review of documentation and observation on June 13, 2024, between 8:15 AM and 10:30 AM, revealed the facility lacked documentation as to whether the kitchen hood exhaust/duct system was being maintained and inspected, on a semi-annual basis. Facility lacked documentation, prior to May 29, 2024.

Interview with the Administrator and Director of Maintenance on June 13, 2024, at 2:45 PM, confirmed the facility could not provide documentation for semi-annual cleaning, for exhaust hood system.

Plan of Correction - To be completed: 08/07/2024

Documentation of semi-annual Kitchen Hood/Duct System maintenance and inspection will be available and will occur on a semi-annual basis from May 29, 2024 on as due.

Education provided to the Maintenance Director and Assistant in regards to timeliness of inspections and importance of keeping appropriate records.

Safety/Maintenance reports will be reviewed during QAPI meetings.

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 - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to provide quarterly sprinkler maintenance documentation, affecting the entire component.

Findings include:

1. Review of documentation on June 13, 2024, between 8:15 AM and 10:30 AM, revealed the facility lacked documentation for the 2023 3rd quarter Wet/Dry Sprinkler Maintenance Inspection.

Interview with the Administrator and Director of Maintenance on June 13, 2024, at 2:45 PM, confirmed the facility could not provide documentation for quarterly inspection of the Wet/Dry Sprinkler System.

Plan of Correction - To be completed: 08/07/2024

Documentation of the quarterly Wet/Dry Sprinkler Maintenance Inspection will be available and inspection will occur quarterly as due moving on.

Education provided to the Maintenance Director and Assistant in regards to timeliness of inspections and importance of keeping appropriate records.

Safety/Maintenance reports will be reviewed during QAPI meetings.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN - Component: 01 - Tag: 0355

Based on document review and interview, it was determined the facility failed to provide documentation of annual fire extinguisher inspections, affecting the entire component.

Findings include:

1. Review of documentation on June 13, 2024, between 8:15 AM and 10:30 AM, revealed the facility lacked documentation of the annual inspection being completed.

Interview with the Administrator and Director of Maintenance on June 13, 2024, at 2:45 PM, confirmed the facility could not provide documentation as to whether the annual fire extinguisher inspections were performed.

Plan of Correction - To be completed: 08/07/2024

Documentation of the annual Fire Extinguisher Inspection will be available and the inspection will occur annually moving forward.

Education provided to the Maintenance Director and Assistant in regards to timeliness of inspections and importance of keeping appropriate records.

Safety/Maintenance reports will be reviewed during QAPI meetings.

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 - Component: 01 - Tag: 0371

Based on observation and interview, it was determined the facility failed to provide at least two smoke compartments on every sleeping floor, for more than 30 residents, and to maintain travel distances to doors within a smoke barrier, on two of three floors within the component.

Findings include:

1. Observation on June 13, 2024, at 1:00 PM, revealed the facility lacked a smoke barrier wall, on the 2nd floor of the original building.

Interview with the Administrator and Director of Maintenance on June 13, 2024, at 2:45 PM, confirmed the lack of a smoke barrier wall, on the 2nd floor.

2. Observation on June 13, 2024, between 1:00 PM and 1:30 PM, revealed smoke compartments were extended zones, on the 1st and 2nd floors.

Interview with the Administrator and Director of Maintenance on June 13, 2024, at 2:45 PM, confirmed the extended smoke zones.

Plan of Correction - To be completed: 08/07/2024

The facility request DSI conduct an FSES survey.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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.

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: MAIN - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain the smoke barrier doors, to resist the passage of smoke, affecting two of twelve smoke compartments within the component.

Findings include:

1. Observation on June 13, 2024, at 11:29 AM, revealed the basement smoke barrier doors, by Therapy, did not fully close and latch within the frame, due to an inoperable coordinator.

Interview with the Administrator and Director of Maintenance on June 13, 2024, at 2:45 PM, confirmed the rated door did not fully close and latch in frame.

Plan of Correction - To be completed: 08/07/2024

Inoperable coordinator will be fixed on the basement smoke barrier door, by therapy, to allow for the door to fully close and latch within the frame.

The Maintenance Director/designee will conduct audits on 2 random smoke barrier doors quarterly through the rest of the year with the results reviewed by the QAPI Committee to determine continued compliance and discontinuation.

NFPA 101 STANDARD Fire Drills:

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 - Component: 01 - Tag: 0712
Based on document review and interview, it was determined the facility failed to conduct and perform fire drills (one per shift, per quarter), which affects the entire component.

Findings include:

1. Review of documentation on June 13, 2024, between 8:15 AM and 10:30 AM, revealed the facility did not perform fire drills, during the following:

a. 3rd quarter 2023, 1st shift;
b. 4th quarter 2023, 1st shift, 2nd shift and 3rd shift.

Interview with the Administrator and Director of Maintenance on June 13, 2024, at 2:45 PM, confirmed the lack of documentation, the fire drills were not performed.

Plan of Correction - To be completed: 08/07/2024

Fire Drills will be conducted at expected and unexpected times to include a fire alarm signal and simulation of emergency fire conditions. This will be done at a minimum of one per shift, per quarter moving forward.

Education provided to the Maintenance Director and Assistant in regards to timeliness of inspections and importance of keeping appropriate records.

Safety/Maintenance reports will be reviewed during QAPI meetings.

Initial comments:Name: BUILDING 03 - Component: 03 - Tag: 0000

Facility ID #280402
Component 03
New Addition

Based on a Medicare/Medicaid Recertification Survey completed on June 13, 2024, it was determined that York South Skilled Nursing and Rehabilitation, had deficiencies that have the potential for minimal harm as related to 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 (111), protected noncombustible structure, with a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0100

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. 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 document review and interview, it was determined the facility failed to meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents, within the component.

Findings include:

1. Review of documentation and interview on June 13, 2024, between 8:15 AM and 10:30 AM, revealed the facility lacked portable, accurate life safety drawings of the facility with an FSES. Floor plans lacked resident room capacities, hazardous areas, travel distance from the furthest point in the zone to the exit, travel distance from the furthest point in the zone to the smoke barrier doors, length & width of zone and labeled use of spaces.

Interview with the Administrator and Director of Maintenance on June 13, 2024, at 2:45 PM, confirmed the lack of portable, accurate life safety drawings of the facility.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0353

Based on document review and interview, it was determined the facility failed to provide quarterly sprinkler maintenance documentation, affecting the entire component.

Findings include:

1. Review of documentation on June 13, 2024, between 8:15 AM and 10:30 AM, revealed the facility lacked documentation for the 2023 3rd quarter Wet/Dry Sprinkler Maintenance Inspection.

Interview with the Administrator and Director of Maintenance on June 13, 2024, at 2:45 PM, confirmed the facility could not provide documentation for quarterly inspection of the Wet/Dry Sprinkler System.

NFPA 101 STANDARD Portable Fire Extinguishers:

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0355

Based on document review and interview, it was determined the facility failed to provide documentation of annual fire extinguisher inspections, affecting the entire component.

Findings include:

1. Review of documentation on June 13, 2024, between 8:15 AM and 10:30 AM, revealed the facility lacked documentation of the annual inspection being completed.

Interview with the Administrator and Director of Maintenance on June 13, 2024, at 2:45 PM, confirmed the facility could not provide documentation as to whether the annual fire extinguisher inspections were performed.

NFPA 101 STANDARD Fire Drills:

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0712

Based on document review and interview, it was determined the facility failed to conduct and perform fire drills (one per shift, per quarter), which affects the entire component.

Findings include:

1. Review of documentation on June 13, 2024, between 8:15 AM and 10:30 AM, revealed the facility did not perform fire drills, during the following:

a. 3rd quarter 2023, 1st shift;
b. 4th quarter 2023, 1st shift, 2nd shift and 3rd shift.

Interview with the Administrator and Director of Maintenance on June 13, 2024, at 2:45 PM, confirmed the lack of documentation, the fire drills were not performed.

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