Pennsylvania Department of Health
DEER MEADOWS 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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DEER MEADOWS 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 November 24, 2025, at Deer Meadows Rehabilitation 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 (BAIR PAVILION) - Component: 01 - Tag: 0000

Facility ID# 020202

Component 01

Bair Pavilion
Based on a Medicare/Medicaid Recertification Survey conducted on October 27, 2025, and completed on November 24, 2025, it was determined that Deer Meadows Rehabilitation Center - Bair Pavilion, was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 five-story, Type II (222), fire-resistive building, with a partial basement, that is fully sprinklered.
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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 BUILDING 01 (BAIR PAVILION) - Component: 01 - Tag: 0100 28 Pa. Code 553.3(1) GOVERNING BODY RESPONSIBILITIES Governing body responsibilities include: (1) Conforming to applicable Federal, State and local law. 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 observation, document review, and interview, it was determined the following items did not conform to applicable Federal, State and local laws and regulations. Findings include: 1. Observation and document review on October 27, 2025, at 9:30 a.m., revealed the facility failed to notify Department of Health that the Emergency Generator was rendered inoperable due to an October 25, 2025 flood event. Exit Interview with the Administrator and Maintenance Director on October 27, 2025, at 1:45 p.m., confirmed the facility failed to notify the Department.

Plan of Correction - To be completed: 01/12/2026

The provider submits the following plan of correction in good faith and to comply with Federal regulation. This plan is not admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the statement deficiencies.
Department of health notified 10/27/2025 of generator out of service due to mechanical room flood on 10/25/25
Corporate Director of nursing educated NHA about K0100
Temporary generator installed on 10/25/2025 but not put into operation until completion and installation of transfer shift on 10/31/2025
Weekly audit of generator for operational will be completed weekly x 4 weeks by director of maintenance or designee, and then monthly x3 months. Any deficient will be corrected at the time of audit
Result of audit will be presented at monthly QAPI until substantial compliance is achieved

NFPA 101 STANDARD Multiple Occupancies:

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.

Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:
Name: MAIN BUILDING 01 (BAIR PAVILION) - Component: 01 - Tag: 0131 Based on observation and interview, it was determined the facility failed to ensure common wall fire separations maintained a fire resistance rating affecting one of two levels. Findings include: 1. Observation on October 27, 2025, at 12:15 p.m., revealed double fire doors that separate the Walton Component from the Bair Component, failed to fully close, positively latch and had multiple penetrations in the doors and frame, on the first floor leading to the connecting bridge. Exit Interview with the Administrator and Maintenance Director on October 27, 2025, at 1:45 p.m., confirmed the deficient fire doors.

Plan of Correction - To be completed: 01/12/2026

Double doors that separate Walton component from Bair component cannot be repaired New double fire doors replacement quote received. New double fire doors will be installed immediately it is received
All fire rated double doors in Walton and Bair checked for penetrations and that they are positively latched by maintenance director October 27, and none found
Director of maintenance will educate maintenance staff about K0131 and auditing of fire rated double doors for penetrations and that they are closing and positively latching
Maintenance director or designee will audit fire rated double doors for penetration and positive latching weekly x4 weeks, then monthly x3 months. Any deficiency will be corrected at the time of the audit
Results of audits will be presented at monthly QAPI until substantial compliance is achieved

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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.

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 (BAIR PAVILION) - Component: 01 - Tag: 0345 Based on observation review and interview, it was determined the facility failed to maintain the fire alarm system in proper operating condition, affecting the entire facility. Findings Include: 1. Observation on October 27, 2025, at 1:30 p.m., revealed the facility fire alarm panel was in trouble mode at the time of survey. Exit Interview with the Administrator and Maintenance Director on October 27, 2025, at 1:45 p.m., confirmed the fire alarm panel was in trouble mode.

Plan of Correction - To be completed: 01/12/2026

K0345
Alarm panel monitor repaired on 10/31/2025 after installation and completion of transfer shift to the generator
Fire watch rounds were completed while alarm panel monitor was in trouble mode
Maintenance staff will be educated about K0345 by maintenance director
Weekly audit of the alarm panel monitor will be completed weekly x4 weeks for functioning by director of maintenance/designee, and then monthly x3 months. Any deficiency will be corrected at the time of audit
Director of maintenance will present weekly audit reports monthly at QAPI until substantial compliance is achieved

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 BUILDING 01 (BAIR PAVILION) - Component: 01 - Tag: 0353 Based on document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting one of six levels. Findings include: 1. Document review on October 27, 2025, at 9:30 a.m., revealed September 2025, annual sprinkler inspection report listed the following deficiency: Antifreeze failed to meet solution requirements and freeze points. Proof of corrective action was not available at time of survey. Exit Interview with the Administrator and Maintenance Director on October 27, 2025, at 1:45 p.m., confirmed the sprinkler system deficiency.

Plan of Correction - To be completed: 01/12/2026

K0353
Contracted provider will flush and correct solution requirement and bring sprinkler inspection to code and provide facility with a report
NHA will educate Director of maintenance about K0345 and NFPA 25 standards for inspection that maintenance and testing report includes; testing and maintaining of water-based fire protection systems, records of systems design, maintenance, inspection testing to ensure that report is detailed, accurate and all necessary repair is completed
Director of maintenance will review yearly testing report to ensure that it contained antifreeze requirements, that solution meets solution requirement and freeze point
Maintenance director will present report at QAPI until substantial compliance is achieved

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: MAIN BUILDING 01 (BAIR PAVILION) - Component: 01 - Tag: 0521 Based on document review and interview, it was determined the facility did not properly maintain HVAC systems, affecting one of two levels. Findings include: 1. Observation on October 27, 2025, at 12:00 p.m., revealed a portable air conditioning unit ducted into the ceiling, on the first floor Walton Infectious Control Office. Exit Interview with the Administrator and Maintenance Director on October 27, 2025, at 1:45 p.m., confirmed the portable AC unit being ducted into the ceiling.

Plan of Correction - To be completed: 01/12/2026

Portable air conditioning unit ducted to the ceiling on the first floor Walton Infection control office was removed on 10/27/2025
Maintenance director completed audit of all offices in Walton for vented air conditioning ducted to ceiling and none found
Maintenance director/designee will educate maintenance staff about K0521 and not venting portable air conditioning into the ceiling
Maintenance director/designee will complete audit of all Walton offices monthly for portable air condition vented into the ceiling weekly for 4 weeks and then monthly for 3 months. Any deficiency will be corrected at the time of audit
Results of audits will be presented at monthly QAPI until substantial compliance is achieved

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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 01 (BAIR PAVILION) - Component: 01 - Tag: 0918 Based on observation and interview, it was determined the facility failed to maintain the emergency generator, affecting the entire facility. Findings include: 1. Observation on October 27, 2025, at 10:00 a.m. revealed the facility's emergency generator and transfer switches had been damaged from a flooding event on 10/25/2025. The emergency generator remained non-functional at time of survey. Exit Interview with the Administrator and Maintenance Director on October 27, 2025, at 1:45 p.m., confirmed the emergency generator condition.

Plan of Correction - To be completed: 01/12/2026

Transfer switch for emergency generator repair completed on 10/31/2025 and now operational
Maintenance director will educate maintenance staff about k0918
Emergency generator is now being inspected and tested weekly according to K0918
Director of maintenance will provide inspection and testing report at monthly QAPI until substantial compliance is achieved

Initial comments:Name: BUILDING 02 (WALTON CENTER) - Component: 02 - Tag: 0000
Facility ID# 020202

Component 02

Walton Center Building

Based on a Medicare/Medicaid Recertification Survey conducted on October 27, 2025, and completed on November 24, 2025, it was determined that Deer Meadows Rehabilitation Center - Walton Center Building, was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 non-combustible building, that is fully sprinklered.

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Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: BUILDING 02 (WALTON CENTER) - Component: 02 - Tag: 0211 Based on observation and interview, it was determined the facility failed to maintain means of egress free of obstructions to full use, affecting one of two floors. Findings include: 1. Observation on October 27, 2025, at 11:50 a.m., revealed on the ground floor, C-hall FT-5 stair exit door was required excessive force to open. Exit Interview with the Administrator and Maintenance Director on October 27, 2025, at 1:45 p.m., confirmed the stuck door.

Plan of Correction - To be completed: 01/12/2026

Ground floor, C Hall FT-5 stair exit door repaired and does not require excessive force to open
Director of maintenance audited all exit doors on the ground floor on Walton for needing excessive force to open and none found
Director of maintenance or designee will complete weekly audit of ground floors exit doors for maintenance and repair x 4 weeks and monthly x 3 months. Repair will be completed at the time of audit
Report of audit will be presented at monthly QAPI until substantial compliance is achieved.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: BUILDING 02 (WALTON CENTER) - Component: 02 - Tag: 0372 Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting one of two levels. Findings include: 1. Observation on October 27, 2025, at 11:40 a.m., revealed, on the first floor above smoke doors by room 147, an unsealed 1-1/2 " conduit end. Exit Interview with the Administrator and Maintenance Director on October 27, 2025, at 1:45 p.m., confirmed the penetration.

Plan of Correction - To be completed: 01/12/2026

First floor above smoke doors by room 147 unsealed 1-1/2 "conduit end sealed with 3M UL approved WL 2002 Through wall penetrations
Maintenance director will educate maintenance staff about K0372
Maintenance director/designee will complete above smoked door audit for penetrations; any penetrations will be corrected at the time of the audit. Audit will be completed weekly x 4 weeks and monthly x 3 months
Result of audit will be presented at monthly QAPI until substantial compliance is achieved

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: BUILDING 02 (WALTON CENTER) - Component: 02 - Tag: 0521 Based on document review and interview, it was determined the facility did not properly maintain HVAC systems, affecting one of two levels. Findings include: 1. Observation on October 27, 2025, at 12:20 p.m., revealed a portable air conditioning unit being ducted into the ceiling, on the first floor Bair Dining Room. Exit Interview with the Administrator and Maintenance Director on October 27, 2025, at 1:45 p.m., confirmed the portable AC unit ducted into the ceiling.

Plan of Correction - To be completed: 01/12/2026

Portable air condition unit ducted to ceiling in Bair 1 dining room removed
Director of maintenance completed audit of Bair 1 and Bair 2 and no other air condition ducted to ceiling found
Director of maintenance will educate maintenance staff about K0521
Weekly audit of Bair 1 and 2 will be completed for air condition ducted to the ceiling by maintenance director or designee weekly x4 weeks and monthly x3, and deficiency will be corrected at the time of the audit
Director of maintenance will present audit reports at monthly QAPI until substantial compliance is achieved.

NFPA 101 STANDARD Electrical Systems - Other:

Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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.
Chapter 6 (NFPA 99)

Observations:
Name: BUILDING 02 (WALTON CENTER) - Component: 02 - Tag: 0911 Based on observation and interview, it was determined the facility failed to protect electrical system wiring in accordance with NFPA 99 2012 Edition, 6.3.2.1 Electrical Installation, affecting one of two levels. Findings include: 1. Observation on October 27, 2023, at 1:00 p.m., revealed a wire above ceiling tiles that was not terminated in a junction box, on the first floor, at the double doors of the Bair Bridge that leads to Walton. Exit Interview with the Administrator and Maintenance Director on October 27, 2025, at 1:45 p.m., confirmed the wire was not terminated in a junction box.

Plan of Correction - To be completed: 01/12/2026

Wire above ceiling tiles that was not terminated in a junction box, on the first floor Bair building now in a junction box
Audit of ceiling above double doors in Bair1 and Bair 2 checked for wire not terminated in a junction box completed, and no other found
Maintenance director will educate maintenance staff about K0911
Maintenance director or designee will complete audit of ceiling above double doors in Bair 1 and Bair 2 for wires not terminated in a junction box weekly x 4 weeks and monthly x3 months. Any deficiency will be corrected at the time of the audit
Maintenance director will present audit reports at monthly QAPI until substantial compliance is achieved.

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