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 May 19, 2025, 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 May 19, 2025, 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 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 self-closing doors to be free of obstruction from closing, in one of four smoke zones within the component.

Findings include:

1. Observation on May 19, 2025 at 2:10 PM, revealed a filled trash bag was placed in the swing path of the Dishwashing Room door, in the basement, preventing it from self-closing.

Interview at the time of the exit conference with the Administrator and the Maintenance Director on May 19, 2025, at 2:45 PM, confirmed the door was obstructed from closing.

Plan of Correction - To be completed: 06/24/2025

Trash Bag removed from swing path of Dish washing Room door enabling door to self close and be fully operational.
Education with Dietary Staff in regards to deficient practice as well as random audits to kitchen area will be conducted daily for 7 days, then weekly for 4 weeks, then monthly and forwarded to QAPI for review.
Date of Compliance: June 24, 2025

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 the rating of hazardous areas, in one of four smoke zones within the component.

Findings include:

1. Observation on May 19, 2025, at 2:20 PM, revealed an unsealed penetration in the Boiler Room corridor wall, where new sprinkler pipes had been installed at the water heaters.

Interview at the time of the exit conference with the Administrator and the Maintenance Director on May 19, 2025, at 2:45 PM, confirmed there was a penetration.

Plan of Correction - To be completed: 06/24/2025

Unsealed penetration in the Boiler Room Corridor Wall has been repaired using an approved through penetration fire stop system and facility will maintain a 1 hour fire resistance rating.
Weekly Random Audits (5 areas x 5 weeks, then monthly of 5 areas x 1) of the facility are logged for Quality Assurance and reviewed by the QAPI Committee as needed.
Date of Compliance: June 24, 2025

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors to positively latch, in one of four smoke zones within the component.

Findings include:

1. Observation on May 19, 2025, at 1:17 PM, revealed the 2nd floor Linen Closet door was not latching, due to the inactive leaf being bypassed, by Room 501. Testing revealed the latch on the inactive leaf was broken.

Interview at the time of the exit conference with the Administrator and the Maintenance Director on May 19, 2025, at 2:45 PM, confirmed the door failed to positively latch.

Plan of Correction - To be completed: 06/24/2025

2nd Floor Linen Closet door was put back into proper operation by activating the leaf that staff had bypassed. Latch itself has been fixed.
Education with floor staff was conducted in regards to the deficient practice of bypassing the leaf and safety concerns.
Random audits are done weekly to ensure smoke doors are latched properly and forwarded to QAPI for review.

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 document review, observation and interview, it was determined that the facility failed to provide a minimum of one smoke barrier on the second floor, and had an extended smoke zone on the first floor, affecting two of four smoke zones within the component.

Findings include:

1. Observation and interview, on May 19, 2025, between 1:17 and 1:30 PM, it was determined that the 2nd floor lacked a smoke barrier, complete from the attic deck to the floor of the 2nd floor.

Interview at the time of the exit conference with the Administrator and the Maintenance Director on May 19, 2025, at 2:45 PM, confirmed the 2nd floor had no smoke barrier.

2. Review of documentation and interview, on May 19, 2025, between 11:00 AM and 12:30 PM, revealed the 1st floor was documented as an extended zone.

Interview at the time of the exit conference with the Administrator and the Maintenance Director on May 19, 2025, at 2:45 PM, confirmed that the 1st floor had been documented as an extended zone, during prior surveys.

Plan of Correction - To be completed: 06/24/2025

The facility request DSI conduct an FSES survey.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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 hardware on the smoke barrier doors to function, per manufacturer specifications, affecting two of four smoke zones within the component.

Findings include:

1. Observation on May 19, 2025, at 2:00 PM, revealed the latching mechanism, on the smoke barrier door to Arcadia, was broken and would not allow the door to fully close.

Interview at the time of the exit conference with the Administrator and the Maintenance Director on May 19, 2025, at 2:45 PM, confirmed the door hardware failed to function, per manufacturer specifications.

Plan of Correction - To be completed: 06/24/2025

Latching mechanism on the smoke barrier door to Arcadia has been addressed to allow the door to fully close.
Education and random weekly (x4 week) audit of smoke barrier door latching mechanism will be conducted in addition to the regulatory quarterly audits consistently being done, to ensure continued compliance with review by QAPI.

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 May 19, 2025, at York South Skilled Nursing and Rehabilitation, it was determined there were no deficiencies identified under the 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:

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