Pennsylvania Department of Health
LEBANON VALLEY BRETHREN HOME
Building Inspection Results

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LEBANON VALLEY BRETHREN HOME
Inspection Results For:

There are  46 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
LEBANON VALLEY BRETHREN HOME - 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 January 22, 2024, at Lebanon Valley Brethren Home, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


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


Facility ID #380602
Component 02
Leffler Building

Based on a Medicare/Medicaid Recertification Survey completed on January 22, 2024, it was determined that Lebanon Valley Brethren Home 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 structure, without 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: LEFFLER - Component: 02 - Tag: 0223
Based on observation and interview, it was determined the facility failed to maintain self-closing doors to self close and positively latch, to resist the passage of smoke, and to be free of obstructions from closing, in one of five smoke zones within the component.

Findings include:

1. Observation on January 22, 2024, at 12:40 PM, revealed the Leffler Kitchen doors failed to close and positively latch in frame, due to failed coordinator.

Interview at the time of the exit conference with the Administrator, Maintenance Director and Security and Transportation Supervisor on January 22, 2024, at 2:00 PM, confirmed the Kitchen doors failed to close and positively latch.


2. Observation on January 22, 2024, at 12:42 PM, revealed several penetrations in the Leffler Kitchen doors, where magnetic hardware was removed.

Interview at the time of the exit conference with the Administrator, Maintenance Director and Security and Transportation Supervisor on January 22, 2024, at 2:00 PM, confirmed the door could not resist the passage of smoke.


3. Observation on January 22, 2024, at 12:45 PM, revealed the Leffler Kitchen doors, which were equipped with self-closing devices, were held open with rubber door chocks.

Interview at the time of the exit conference with the Administrator, Maintenance Director and Security and Transportation Supervisor on January 22, 2024, at 2:00 PM, confirmed the doors were obstructed from closing.



 Plan of Correction - To be completed: 02/16/2024

The facility submits this plan of correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal regulations relating to long-term care. This plan of correction should not be construed as either a waiver of the facility's right to appeal and to challenge the accuracy of the alleged deficiencies or an admission of past or ongoing violations of State or Federal regulatory requirements.


1)
a. The Leffler Kitchen door will be repaired to be able to close and positively latch in the frame.
b. Magnetic hardware will be put back on the doors which will eliminate the penetrations from it being removed.
c. The rubber door chocks were removed so the doors could self- close.
2) Dietary staff that work in the Leffler kitchen and the maintenance department will be educated on the deficiency and how it related to the regulation
3) Audits will be done by the dietary manager or designee weekly x 8 weeks. Results of the audit will taken to the Quality Assurance committee for further recommendations.
4) Date of Completion: Feb. 16th.


Initial comments:Name: UNIT 1 - Component: 03 - Tag: 0000


Facility ID #380602
Component 03
Hostetter House (12 Greenhouse Lane)

Based on a Medicare/Medicaid Recertification Survey completed on January 22, 2024, it was determined that Lebanon Valley Brethren Home 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 structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
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: UNIT 1 - Component: 03 - Tag: 0161
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, on one of two smoke compartments within the component.
Findings include:
1. Observation on January 22, 2024, at 12:15 PM, revealed horizontal fire-rated access door, by the garage entrance, failed to self close and latch. This is a Type V (111), protected wood frame structure.
Interview at the time of the exit conference with the Administrator, Maintenance Director and Security and Transportation Supervisor on January 22, 2024, at 2:00 PM, confirmed the horizontal fire-rated access door would not self close and latch.



 Plan of Correction - To be completed: 02/16/2024

1) The horizontal fire-rated access door in Hostetter House will be repaired to self-close and latch.
2) Maintenance will be educated on the deficiency and how it relates to the regulation
3) Audits will be done on the fire rated access doors in Hostetter Green house weekly x 8. Results of the audit will be taken to the Quality Assurance committee for further recommendations.
4) Date of Completion: Feb. 16th.


Initial comments:Name: UNIT 2 - Component: 04 - Tag: 0000


Facility ID #380602
Component 04
Castagna Cottage (11 Greenhouse Lane)

Based on a Medicare/Medicaid Recertification Survey completed on January 22, 2024, at Lebanon Valley Brethren Home, 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 one-story, Type V (111), protected wood frame structure, without a basement, which is fully sprinklered.



 Plan of Correction:


Initial comments:Name: UNIT 3 - Component: 05 - Tag: 0000


Facility ID #380602
Component 05
Fake Cottage (8 Greenhouse Lane)

Based on a Medicare/Medicaid Recertification Survey completed on January 22, 2024, at Lebanon Valley Brethren Home, 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 one-story, Type V (111), protected wood frame structure, without a basement, which is fully sprinklered.



 Plan of Correction:


Initial comments:Name: UNIT 4 - Component: 06 - Tag: 0000


Facility ID #380602
Component 06
Royer Cottage (7 Greenhouse Lane)

Based on a Medicare/Medicaid Recertification Survey completed on January 22, 2024, at Lebanon Valley Brethren Home, 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 one-story, Type V (111), protected wood frame structure, without a basement, which is fully sprinklered.



 Plan of Correction:


Initial comments:Name: RECREATION ROOM 103 - Component: 07 - Tag: 0000


Facility ID #380602
Component 07
Recreation Room

Based on a Medicare/Medicaid Recertification Survey completed on January 22, 2024, at Lebanon Valley Brethren Home, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for 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 structure, without a basement, which is fully sprinklered.



 Plan of Correction:


Initial comments:Name: UNIT 5 - Component: 08 - Tag: 0000


Facility ID #380602
Component 08
Stoneback Haven (16 Greenhouse Court)

Based on a Medicare/Medicaid Recertification Survey completed on January 22, 2024, at Lebanon Valley Brethren Home, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for a new 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 structure, without a basement, which is fully sprinklered.



 Plan of Correction:


Initial comments:Name: UNIT 6 - Component: 09 - Tag: 0000


Facility ID# 380602
Component 09
Sweigert (20 Greenhouse Court)

Based on a Medicare/Medicaid Recertification Survey completed on January 22, 2024, at Lebanon Valley Brethren Home, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for a new 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 structure, without a basement, which is fully sprinklered.



 Plan of Correction:



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