Pennsylvania Department of Health
ELAN SKILLED NURSING AND REHAB, A JEWISH SENIOR LIFE COMMUNI
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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ELAN SKILLED NURSING AND REHAB, A JEWISH SENIOR LIFE COMMUNI - 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 December 3, 2025, at Elan Skilled Nursing and Rehab, a Jewish Senior Life Community, 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 #360402
Component 01
Main Building 01

Based on a Medicare/Medicaid Recertification Survey completed on December 3, 2025, it was determined the Elan Skilled Nursing and Rehab, a Jewish Senior Life Community, 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 five story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

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.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility exceeded the maximum allowable story height for this type of construction, affecting six of six floors.

Findings include:

1. Observation on December 3, 2025, between 10:45 am and 11:15 am, revealed the facility exceeded the maximum allowable story height for an unprotected, noncombustible building by three stories.

Exit interview on December 3, 2025, with the Facility Administrator and the Facilities Manager, at 12:45 pm, confirmed the building construction deficiency.

NFPA 101 STANDARD Vertical Openings - Enclosure:

Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation, documentation review, and interview, it was determined the facility failed to maintain multiple vertical enclosures, affecting six of six floors.

Findings include:

1. Observation on December 3, 2025, at 11:00 am, revealed the following:

a. Vertical enclosures protecting heating, cooling, and ventilation (HVAC) shafts, adjacent to the exit stair towers, lacked the required two-hour fire resistance rating.

b. The fourth and fifth floor construction of the Clay Street exit stair tower consisted of two sheets of drywall on the inside and one sheet of drywall on the corridor and resident room side of metal studs, as well as unprotected steel beams included as part of the enclosure.

Exit interview on December 3, 2025, with the Facility Administrator and the Facilities Manager, at 12:45 pm, confirmed the vertical openings deficiency.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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.

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 BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain three hazardous area enclosures, affecting two of six floors.

Findings include:

1. Observation on December 3, 2025, between 11:10 am, and 11:29 am, revealed the following:

a. At 11:10 am, Basement Level, laundry distribution room door failed to latch into frame when tested.
b. At 11:24 am, 5th floor, Soiled Utility room door near Resident Room 516 failed to latch into frame when tested.
c. At 11:29 am, 5th floor, Storage room door near Resident Room 512 failed to latch into frame when tested.

Exit interview on December 3, 2025, with the Facility Administrator and the Facilities Manager, at 12:45 pm, confirmed the hazardous area enclosure deficiencies.

Plan of Correction - To be completed: 01/13/2026

Elan Skilled Nursing & Rehab (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 or an admission of past or ongoing violations of State and Federal regulatory requirements.
K0321 NFPA 101 Hazardous Areas-Enclosures
The latches to Basement Level laundry distribution room, 5th Floor Soiled Utility Room door near Resident Room 516 and 5th Floor Storage Room Door near resident room 512 were repaired by facility maintenance staff.
An initial audit will be conducted by the Maintenance Director/designee of door latches on all doors to identify improper functioning of door latches. Any latch found to be not properly functioning will be repaired.
The NHA will educate the Maintenance Director and Maintenance staff on regulation 0321 Hazardous Areas-Enclosures
Random Audits will be conducted by the Maintenance Director/designee of door latches throughout the facility to verify ongoing compliance. The audit of 5 random doors will be conducted weekly x 4 weeks then monthly x 3 months.
The results of the audits will be brought to QAPI monthly x 3 months for review.

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 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in five locations, affecting three of six floors.

Findings include:

1. Observation on December 3, 2025, between 10:55 am, and 12:25 pm, revealed the following:

a. At 10:55 am, Basement level, Black cooling line running from Central Supply across corridor into General Storage room, had penetrations sealed with an orange spray foam.
b. At 10:59 am, Basement level, General Storage room had sealed penetrations with an orange spray foam around copper piping.
c. At 11:04 am, Basement level, Storage room under the stairs, had 2 unsealed penetrations within the room around white camera wires.
d. At 11:27 am, 5th Floor, Resident room 513 had both sprinkler heads missing escutcheons.
e. At 12:25 pm, 1st Floor, Director of Social Services office sprinkler head was missing an escutcheon.

Exit interview on December 3, 2025, with the Facility Administrator and the Facilities Manager, at 12:45 pm, confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 01/13/2026

Elan Skilled Nursing & Rehab (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 or an admission of past or ongoing violations of State and Federal regulatory requirements.

K0353 NFPA 101 Sprinkler System-Maintenance and Testing

Penetrations sealed with orange spray foam on the basement level black cooling line running from Central Supply across corridor into General storage was removed and replaced.
Penetrations sealed with orange spray foam in the basement General Storage room was removed and replaced.
The 2 unsealed penetrations around white camera wires were sealed.
Sprinkler head escutcheons on 5th floor sprinkler head in Resident Room 513 and on 1st Floor in the Social Service Office were replaced.

An initial audit of sprinkler heads on all floors was completed to identify missing escutcheons. Areas of penetration on all floors were completed to identify unsealed or improper sealing of penetration areas.

NHA will educate the Maintenance Director and maintenance staff on regulation 0353.

Random audit of sprinkler heads on all floors will be conducted to identify missing escutcheons. Random audits of areas of penetration on all floors will be conducted to identify unsealed or improper sealing of penetration areas. Audits will be conducted by the Maintenance Director/designee of 5 random sprinkler heads and 5 areas of penetration weekly x 4 weeks then monthly x 3 weeks to verify ongoing compliance.
The results of the audits will be brought to QAPI monthly x 3 months for review.

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 BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain four sets of smoke barrier separation doors, affecting three of six floors.

Findings include:

1. Observation on December 3, 2025, between 11:15 am, and 11:40 am, revealed the following:

a. At 11:15 am, Basement Level, Cross Corridor separation doors near Receiving, failed to fully close and latch into frame when tested.
b. At 11:30 am, 5th floor, Cross Corridor separation doors near Resident Room 507, failed to fully latch into frame when tested.
c. At 11:36 am, 4th floor, Cross Corridor separation doors near Resident Room 418, failed to fully latch into frame when tested.
d. At 11:40 am, 4th floor, Cross Corridor separation doors near Resident Room 406, failed to fully latch into frame when tested.

Exit interview on December 3, 2025, with the Facility Administrator and the Facilities Manager, at 12:45 pm, confirmed the smoke barrier separation door deficiencies.

Plan of Correction - To be completed: 01/13/2026

Elan Skilled Nursing & Rehab (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 or an admission of past or ongoing violations of State and Federal regulatory requirements.
K 0374 Subdivision of Building Spaces-Smoke Barriers

The basement level cross corridor separation doors near receiving had the frame repaired and is latching properly.
The cross corridor separation doors on the 5th Floor near Room 507, 4th Floor near Room 418 and 4th Floor near Room 406 all latches were adjusted and functioning properly.

An initial audit will be conducted by the Maintenance Director/designee of all facility cross corridor separation doors to identify improper functioning and repaired if identified.

The NHA will educate the Maintenance Director and Maintenance Staff on Regulation 0374 Subdivision of Building Spaces-Smoke Barriers.

Random audits will be conducted by the Maintenance Director/designee of cross corridor separation doors throughout the facility to verify ongoing compliance. The audits of 5 random doors will be conducted weekly x 4 weeks then monthly x 3 months.

Results of the audits will be brought to the QAPI Committee monthly x 3 months for review.

NFPA 101 STANDARD Electrical Systems - Maintenance and Testing:

Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914

Based on document review and interview, it was determined the facility failed to maintain the electrical systems, affecting six of six floors.

Findings include:

1. Review of documentation on December 3, 2025, between 9:45 am, and 10:45 am, revealed the facility lacked yearly electrical receptacle testing and inspection data within the last 12 months.

Exit interview on December 3, 2025, with the Facility Administrator and the Facilities Manager, at 12:45 pm, confirmed the lack of documentation.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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.

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 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain two emergency generators which serve the entire facility.

Findings include:

1. Review of documentation on December 3, 2025, between 9:45 am and 10:45 am, revealed the facility fuel samples for both generators, taken on July 15, 2025, failed testing due to high sulfur. The facility stated they received the results with a letter dated November 19, 2025, stating the sample was in critical condition. The facility stated a vendor was going to be on-site on December 4, 2025, to drain, clean the tanks, refill the reserve diesel tanks, then resample the fuel. At the time of this survey this condition remains.

Exit interview on December 3, 2025, with the Facility Administrator and the Facilities Manager, at 12:45 pm, confirmed the failed testing of the fuel samples.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, the facility failed to properly secure oxygen cylinders in two locations, affecting two of six floors.

Findings include:

1. Observation on December 3, 2025, between 12:05 pm, and 12:25 pm, revealed the following:

a. At 12:05 pm, 2nd floor, an oxygen "E" cylinder being stored on the floor without support, inside the dialysis storage room.
b. At 12:14 pm, 1st floor, an oxygen "E" cylinder being stored on the floor without support, in the lobby near the main dining room entrance.

Exit interview on December 3, 2025, with the Facility Administrator and the Facilities Manager, at 12:45 pm, confirmed the cylinders were not supported.

Plan of Correction - To be completed: 01/13/2026

Elan Skilled Nursing & Rehab (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 or an admission of past or ongoing violations of State and Federal regulatory requirements.
Life Safety 0923 Gas Equipment-Cylinder and Container Storage

The E Cylinder in the 2nd Floor Dialysis Storage Room was properly stored.
The E Cylinder on the 1st Floor near the Main Dining Room Entrance was removed and properly stored.

An initial audit of the 2nd Floor Dialysis Den and the facility's 1st Floor was conducted with no additional improper storage of oxygen cylinders found.

The Maintenance Director/designee will educate all facility maintenance and direct care staff and DaVita Dialysis staff on the proper storing and securing of oxygen cylinders.

A random audit will be conducted by the Maintenance Director/designee weekly x 4 weeks then monthly x 3 months to verify proper oxygen cylinder storage.

Audit results will be brought to QAPI Committee for review and revision monthly x 3 months.

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