Pennsylvania Department of Health
ALPINE VALLEY POST ACUTE AND HEALTHCARE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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ALPINE VALLEY POST ACUTE AND HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Facility ID #193602
Component 01
Main Building and New Addition

Based on a Relicensure Survey completed on December 3, 2025, it was determined that Alpine Valley Post Acute and Healthcare Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a three-story, Type II (222), fire resistive structure, with a basement and a penthouse, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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 S-tags, but are deficient.

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, observation 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 December 3, 2024, between 8:45 AM and 10:45 AM, revealed the facility portable life safety drawings lacked compartment labeling, resident room capacities, fire wall boundaries, smoke wall boundaries, hazardous areas, length and width of zones and travel distances. This information is required by the active FSES used to meet compliance with NFPA 101A. Facility provided two sets of drawings which were inconsistent, which need to be updated and merged into a complete and accurate set of floor drawings.

Interview at the time of the exit conference with the Administrator, VP Of Plant Operations and Director of Maintenance on December 3, 2025, at 1:45 PM, confirmed the portable life safety drawings lacked the required information for a facility with an active FSES.

2. Observation and interview on December 3, 2025, between 8:45 AM and 10:45 AM, revealed the facility had ongoing finish changes and lacked notification to plan review.

Interview at the time of the exit conference with the Administrator, VP Of Plant Operations and Director of Maintenance on December 3, 2025, at 1:45 PM, confirmed the facility failed to contact plan review of changes.

3. Observation and interview on December 3, 2025, between 8:45 AM and 10:45 AM, revealed the facility lacked temporary evacuation plans to reflect egress paths.

Interview at the time of the exit conference with the Administrator, VP Of Plant Operations and Director of Maintenance on December 3, 2025, at 1:45 PM, confirmed the facility lacked revised evacuation plans.

Plan of Correction - To be completed: 01/20/2026

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.

1. The facility will have appropriate life safety drawings, submit documentation to plan review, and updated temporary evacuation plans
2. NHA and Maintenance Director educated that life safety drawings need to increase compartment labeling, resident room capacities, fire wall boundaries, smoke wall boundaries, hazardous areas, length and width of zones and travel distances. NHA and Maintenance Director educated that plan review should be notified when any changes are made to floor plan or material used within facility. NHA and Maintenance Director re-educated that when there is needed adjustments to evacuations plans, a temporary evacuation plan to reflect egress paths needs to be developed and posted accordingly.
3. Maintenance Director or designee will complete random audits monthly for 2 months and then quarterly for 12 months to ensure drawings are accurate, plan review notified when changes are made, and if evacuation plans are adjusted the facility has temporary egress paths. Audit findings will be reported to the monthly QAA for review and recommendations

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN - Component: 01 - Tag: 0291

Based on document review, observation and interview, it was determined the facility failed to provide documentation, verifying monthly and annual inspections of battery back-up emergency lighting fixtures and lacked a battery back-up light, at the emergency generator, affecting the entire component.

Findings include:

1. Review of documentation on December 3, 2025, between 8:45 A.M. and 10:45 AM, revealed the facility failed to provide documentation, verifying a monthly and a 90-minute test of the battery back-up lighting fixtures were performed.

Interview at the time of the exit conference with the Administrator, VP Of Plant Operations and Director of Maintenance on December 3, 2025, at 1:45 PM, confirmed the lack of documentation verifying monthly and a 90-minute test of the battery back-up lighting fixture had occurred, within the previous twelve months.

2. Observation and interview on December 3, 2025, at 12:25 PM, revealed the facility lacked a battery back-up lighting fixture, at the emergency generator, which is in an enclosure.

Interview at the time of the exit conference with the Administrator, VP Of Plant Operations and Director of Maintenance on December 3, 2025, at 1:45 PM, confirmed the facility lacked a battery back-up lighting fixture, at the emergency generator.

Plan of Correction - To be completed: 01/20/2026

1. The facility will have 90-minute test of battery backup lighting fixtures and battery backup light fixtures at emergency generator.
2. NHA and Maintenance Director educated that the facility must conduct annual testing of battery back up lighting fixtures and one must be located at emergency generator.
3. Maintenance Director or designee will complete random audits monthly for 2 months and then quarterly for 12 months to ensure annual testing of battery backup lighting fixtures testing was completed and that battery backup lighting fixture is location at emergency generator. Audit findings will be reported to the monthly QAA for review and recommendations

NFPA 101 STANDARD Exit Signage:

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN - Component: 01 - Tag: 0293

Based on document review and interview, it was determined the facility failed to provide documentation, verifying exit signage had been subjected to monthly visual inspections, within the previous twelve months, affecting the entire component.

Findings include:

1. Review of documentation on December 3, 2025, at 1:45 PM, revealed the facility failed to provide documentation, verifying exit signage had been subjected to monthly visual inspections, within the previous twelve months.

Interview at the time of the exit conference with the Administrator, VP Of Plant Operations and Director of Maintenance on December 3, 2025, at 1:45 PM, confirmed the lack of documentation, verifying exit signage had been subjected to monthly visual inspections, within the previous twelve months.

Plan of Correction - To be completed: 01/20/2026

1. The facility will have monthly visual inspections of exit signage.
2. NHA and Maintenance Director educated that the facility must conduct monthly visual inspections of exit signage to verify illumination.
3. Maintenance Director or designee will complete random audits of documentation monthly for 2 months and then quarterly for 12 months to ensure visual inspection of exit signage and documentation is completed. Audit findings will be reported to the monthly QAA for review and recommendations

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to provide documentation verifying a visual inspection of the fire alarm system had occurred within the previous twelve months, and a sensitivity report had been performed within 24 months, affecting the entire component.

Findings include:

1. Review of documentation on December 3, 2025, between 8:45 AM and 10:45 AM, revealed the facility failed to provide documentation verifying a visual inspection of the fire alarm system had occurred within the previous twelve months.

Interview at the time of the exit conference with the Administrator, VP Of Plant Operations and Director of Maintenance on December 3, 2025, at 1:45 PM, confirmed the lack of documentation verifying a visual inspection of the fire alarm system had occurred within the previous twelve months.

2. Review of documentation on December 3, 2025, between 8:45 AM and 10:45 AM, revealed the facility failed to provide documentation verifying a sensitivity test had occurred within the past two years.

Interview at the time of the exit conference with the Administrator, VP Of Plant Operations and Director of Maintenance on December 3, 2025, at 1:45 PM, confirmed the lack of documentation verifying a sensitivity test had occurred with the past two years

Plan of Correction - To be completed: 01/20/2026

1. The facility will annual visual inspection of fire alarm system and sensitivity testing every 2 years.
2. NHA and Maintenance Director educated that the facility must complete annual visual inspection and sensitivity testing every 2 years of the fire alarm system.
3. Maintenance Director or designee will complete random audits monthly for 2 months and then quarterly for 12 months to ensure annual visual inspection and every 2 year sensitivity testing of fire alarm system is completed. Audit findings will be reported to the monthly QAA for review and recommendations

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, observation and interview, it was determined the facility failed to provide quarterly maintenance/maintenance documentation, the sprinkler piping system to be free of extraneous weight and free of obstructions, in six of six smoke zones within the component.

Findings include:

1. Review of documentation on December 3, 2025, between 8:45 AM and 10:45 AM, revealed the facility lacked documentation, verifying the 3rd quarter wet sprinkler system was performed.

Interview at the time of the exit conference with the Administrator, VP Of Plant Operations and Director of Maintenance on December 3, 2025, at 1:45 PM, confirmed the facility could not provide documentation of 3rd quarter wet sprinkler inspection.

2. Observation on December 3, 2025, at 12:10 PM, revealed the Laundry Room, Dryer Chase Area, 2 sprinkler heads were subject to a load.

Interview at the time of the exit conference with the Administrator, VP Of Plant Operations and Director of Maintenance on December 3, 2025, at 1:45 PM, confirmed sprinkler heads were subject to load.

3. Observation on December 3, 2025, between 12:50 PM and 1:26 PM revealed items were being supported by the sprinkler system, at the following locations:

a. 12:50 PM, 1st floor, above Nurses' Station, above ceiling, multiple wires;
b. 12:52 PM, 1st floor, above ceiling, by Resident Room 123, wires and flex ducting;
c. 1:00 PM, 2nd floor, above East Stairtower door, above ceiling, multiple wires and rigid pipe;
d. 1:05 PM, 2nd floor, South Hall, above ceiling, by Resident Room 212, multiple wires wire-tied to system;
e. 1:12 PM, 2nd floor, Day Lounge, above elevator door, above ceiling, multiple wires wire tied to sprinkler system;
f. 1:20 PM, 3rd floor, above South Stairtower door, above ceiling, multiple wires and rigid pipe;
g. 1:26 PM, 3rd floor, above North Stairtower door, above ceiling, multiple wires and rigid pipe.

Interview at the time of the exit conference with the Administrator, VP Of Plant Operations, and Director of Maintenance on December 3, 2025, at 1:45 PM, confirmed various items supported by the sprinkler system.

Plan of Correction - To be completed: 01/20/2026

1. The facility will have quarterly sprinkler inspections. Sprinkler heads at laundry room and dryer chase area will be free of load. The sprinkler system at first floor nursing station, resident room 123, 2nd floor east stairtower door, 2nd floor south hall near resident room 212, 2nd floor day lounge above elevator door, 3rd floor south stairtower door, and 3rd floor north stairtower door will be free of support to wires, ducts, and rigid pipes.
2. NHA or designee will provide education to facility maintenance team that the sprinkler system is to be inspected quarterly, and sprinkler system can not support wires, ducts, or rigid pipes. The NHA or designee will provide education to facility maintenance staff, laundry and kitchen staff that sprinkler heads need to be free of loads and not obstructed.
3. Maintenance Direction or designee will complete random audits of monthly for 12 months to ensure sprinkler inspection is done quarterly, sprinkler system not supporting wires, ducts, rigid pipes, and that sprinkler heads are free of loads. Audit findings will be reported to the monthly
QAA for review and recommendations.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:

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 the facility failed to provide at least two smoke compartments on each resident sleeping floor, and to maintain travel distance to a door within a smoke barrier wall as not exceeding 200 feet, affecting three of four floors within the component.

Findings include:

1. Observation on December 3, 2025, between 8:45 AM and 12:00 PM, revealed the facility lacked at least two smoke compartments on the 2nd and 3rd floors.

Interview at the time of the exit conference with the Administrator, VP Of Plant Operations and Director of Maintenance on December 3, 2025, at 1:45 PM, confirmed the 2nd and 3rd floors did not have smoke barrier walls.

2. Review of documentation on December 3, 2025, at 9:30 AM, revealed the 1st floor travel distance, from the Chapel to the Smoke Barrier Wall, is 222 feet, exceeding the minimum of 200 feet.

Interview at the time of the exit conference with the Administrator, VP Of Plant Operations and Director of Maintenance on December 3, 2025, at 1:45 PM, confirmed the smoke compartment travel distance exceeded 200 feet.

Plan of Correction - To be completed: 01/20/2026

FSES completed on 10/31/23 by Shiela Osborne (Safety Inspection Supervisor) to comply with adoption of 2012 edition of National Fire Protection Association's (NFPA) Life Safety Code.

NFPA 101 STANDARD Operating Features - Other:

Operating Features - Other
List in the REMARKS section any LSC Section 18.7 and 19.7 Operating Features requirements that are not addressed by the provided S-tags, but are deficient.

Observations:
Name: MAIN - Component: 01 - Tag: 0700

Based on document review and interview, it was determined the facility failed to provide documentation, verifying fire doors had been inspected, within the previous twelve months, in four of four smoke zones.

Findings include:

1. Review of documentation on December 3, 2025, between 8:45 AM and 10:45 AM, revealed the facility failed to provide documentation, verifying fire doors, had been inspected in the last 12 months.

Interview at the time of the exit conference with the Administrator, VP Of Plant Operations and Director of Maintenance on December 3, 2025, at 1:45 PM, confirmed the facility could not provide documentation, verifying fire doors had been inspected, within the previous twelve months.

Plan of Correction - To be completed: 01/20/2026

1. The facility will inspect fire doors will be inspected and tested annually.
2. NHA and Maintenance Director educated that the facility must complete annual fire door inspection and complete documentation.
3. Maintenance Director or designee will complete random audits monthly for 2 months and then quarterly for 12 months to ensure annual fire door inspection is completed. Audit findings will be reported to the monthly QAA for review and recommendations

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 and readily identifiable. 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 - Component: 01 - Tag: 0918

Based on document review, observation and interview, it was determined the facility failed to provide required maintenance and testing documentation, and lacked emergency signage, for the emergency generator, which serves the entire component.

Findings include:

1. Review of documentation on December 3, 2025, between 9:20 AM and 9:24 AM, revealed the facility lacked documentation, for the following:

a. 9:20 AM, one full year, weekly maintenance;
b. 9:24 AM, one full year, monthly maintenance, 30-minute load w/transfer switch.

Interview at the time of the exit conference with the Administrator, VP Of Plant Operations, and Director of Maintenance on December 3, 2025, at 1:45 PM, confirmed the lack of documentation, for emergency generator.2. Observation on December 3, 2025, at 12:30 PM, revealed the emergency generator did not have a remote manual stop, outside the exterior enclosure.Interview at the time of the exit conference with the Administrator, VP Of Plant Operations, and Director of Maintenance on December 3, 2025, at 1:45 PM, confirmed the lack of an emergency generator stop button.

Plan of Correction - To be completed: 01/20/2026

1. The facility will conduct weekly maintenance on emergency generator and monthly 30min load with transfer switch. The facility will have a remote manual stop for the emergency generator outside the exterior enclosure.
2. NHA and Maintenance Director educated that the facility must complete weekly maintenance and 30min load with transfer switch on emergency generator, documentation must be completed. NHA and Maintenance Director educated that the facility must have a remote manual stop for the emergency generator outside the exterior enclosure.
3. Maintenance Director or designee will complete random audits monthly for 2 months and then quarterly for 12 months to ensure weekly maintenance and monthly 30min load with transfer switch is conducted on emergency generator and to verify the remote manual stop is outside the exterior enclousre. Audit findings will be reported to the monthly QAA for review and recommendations

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