Pennsylvania Department of Health
LAUREL RIDGE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 31 surveys for this facility. Please select a date to view the survey results.

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LAUREL RIDGE 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 July 15, 2024, at Laurel Ridge Center, 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 #381002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on July 15, 2024, it was determined that Laurel Ridge Center 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, non-combustible building, without a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Fire Drills:

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.

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 BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform one of 12 required fire drills, affecting the entire facility.

Findings include:

1. Review of documentation on July 15, 2024, at 9:20 a.m., revealed the facility lacked documentation for the first shift drill in the third quarter.

Interview with the Facility Administrator and Maintenance Director on July 15, 2024 at 1:30 p.m., confirmed the facility lacked documentation for the first shift drill in the third quarter.

Plan of Correction - To be completed: 08/21/2024

The Maintenance Director or Designee will hold Fire drills at expected and unexpected times under varying conditions, at least quarterly on each shift.

The Administrator educated the Maintenance Director on Fire Drills.

The Maintenance Director or Designee will hold Fire drills at expected and unexpected times under varying conditions, at least quarterly on each shift.
The Administrator or Designee will
audit the fire log monthly for 90 days.
Results of the audits will be reported to the Quality assurance improvement committee monthly.

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