Pennsylvania Department of Health
LOCK HAVEN REHABILITATION AND SENIOR LIVING
Building Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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LOCK HAVEN REHABILITATION AND SENIOR LIVING - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Facility ID #710802
Component 01
Main Building 01

Based on a Relicensure Survey completed on October 29, 2025, it was determined that Lock Haven Rehabilitation and Senior Living, 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 483.70(a).

This is a three story, Type II (000) unprotected, noncombustible building, with a basement that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

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 failed to maintain building construction requirements in two locations, affecting seven of seven smoke compartments.

Findings include:

1. Observation on October 29, 2025, between 10:00 am, and 11:30 am, revealed the building, a Type II (000), unprotected, noncombustible building, exceeds the maximum allowable story height by one story.

Exit interview with the Administrator and Facilities Maintenance on October 29, 2025, at 11:45 am, confirmed the building construction deficiencies.

Plan of Correction - To be completed: 12/01/2025

The facility requests a continuation of the previously accepted FSES, or a new FSES evaluation be completed by the Division of Safety Inspection

NFPA 101 STANDARD Doors with Self-Closing Devices:

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: MAIN BUILDING 01 - Component: 01 - Tag: 0223
Based on observation and interview, it was determined the facility failed to maintain four doors with self-closing devices, affecting three of four floors.

Findings include:

1. Observation on October 29, 2025, between 10:05 am, and 10:58 am, revealed the following:

a. At 10:05 am, Basement Level, Employee break room door failed to positively latch into frame when tested.
b. At 10:27 am, Basement Level, Janitors closet door failed to positively latch into frame when tested.
c. At 10:32 am, 3rd floor, Unit 3 nurses station door to Unit 4 nurses station failed to close into frame when tested.
d. At 10:58 am, 2nd floor, Apartment side, Sitting room door failed to positively latch into frame when tested.

Exit interview with the Administrator and Facilities Maintenance on October 29, 2025, at 11:45 am, confirmed the self-closing door deficiencies.

Plan of Correction - To be completed: 12/01/2025

1. (a) The Basement Level, Employee Break Room door was immediately repaired so that the door positively latched into the frame when tested.
(b) The Basement Level Janitors closet door was immediately repaired so that the door positively latched into the frame when tested.
(c) The 3rd floor Unit 3 nurses station door to Unit 4 was immediately repaired so that the door positively latched into the frame when tested.
(d) The 2nd Floor, Apartment side, sitting room door was immediately repaired so that the door positively latched into the frame when tested.

2. A facility-wide audit was conducted by the Director of Maintenance/Designee to ensure doors with self-closing devices close and positively latch into frames when tested. The Director of Maintenance was educated on the requirement to maintain doors with self-closing devices.

3. Monthly audits will be conducted by the Director of Maintenance/Designee x3 months to ensure doors with self-closing devices close and positively latch into frames when tested. Any concerns will be corrected immediately.

4. Audit findings will be given to the Administrator and reviewed at the monthly QAPI meeting

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 documentation review, observation, and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of four floors.

Findings include:

1. Observation on October 29, 2025, at 10:17 am, Basement Level, revealed equipment storage room in D-stairwell exit corridor had an unsealed penetration of the wall, within the room.

Exit interview with the Administrator and Facilities Maintenance on October 29, 2025, at 11:45 am, confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 12/01/2025

1. The penetration in the wall of Basement Level Equipment Storage room on D stairwell exit corridor was immediately repaired.

2. A facility-wide audit was conducted by the Director of Maintenance/Designee to ensure storage rooms were free of unsealed penetrations. The Director of Maintenance was educated on the NFPA 25 requirements to maintain the automatic sprinkler systems.

3. Monthly audits will be conducted by the Director of Maintenance/Designee x3 months to ensure storage rooms are free of unsealed penetrations. Any concerns will be corrected immediately.

4. Audit findings will be given to the Administrator and reviewed at the monthly QAPI meeting.

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 - Component: 01 - Tag: 0521
Based on observation, documentation review, and interview it was determined the facility failed to maintain key components of the heating, ventilation and cooling (HVAC) system, affecting seven of seven smoke compartments within the facility.

Findings include:

1. Review of documentation on October 29, 2025, between 9:00 am, and 10:00 am, revealed the facility lacked documentation for the required four-year testing and inspection of HVAC fire/smoke dampers. (Lasted documented on June 1, 2021).

Exit interview with the Administrator and Facilities Maintenance on October 29, 2025, at 11:45 am, confirmed the lack of documentation

Plan of Correction - To be completed: 12/01/2025

1. The facility cannot retroactively complete the 4-year testing and inspections of the HVAC fire/smoke dampers that were due. The required test and inspection are scheduled and will be completed on November 17, 2025.

2. The Director of Maintenance was educated on the requirement for the facility to have documentation of testing and inspections of the HVAC fire/smoke dampers every 4 years.

3. Annual audits will be conducted by the Director of Maintenance/Designee to ensure the facility has documentation of testing and inspections of the HVAC fire/smoke dampers completed every 4 years. Any concerns will be addressed immediately.

4. Audit findings will be given to the Administrator and reviewed at the monthly QAPI meeting.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu:

Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0541
Based on observation and interview, it was determined the facility failed to maintain linen chute doors, on one of four floors.

Findings include:

1. Observation on October 29, 2025, at 10:24 am, Basement Level, revealed the linen chute discharge door failed to fully positive latch and was not smoke tight into frame when tested.

Exit interview with the Administrator and Facilities Maintenance on October 29, 2025, at 11:45 am, confirmed the chute door failed to fully latch and was not smoke tight.

Plan of Correction - To be completed: 12/01/2025

1. The basement level linen chute discharge door was immediately repaired so that it fully positively latches and is smoke tight in the frame when it closes.

2. A facility-wide audit of linen chute doors was conducted by the Director of Maintenance/Designee to ensure they fully positively latch and are smoke tight in the frame when they close. The Director of Maintenance was educated on the NFPA 82 requirements to maintain linen chute doors.

3. Monthly audits will be conducted by the Director of Maintenance/Designee x3 months to ensure linen chute doors fully positively latch and are smoke tight in the frame when they close. Any concerns will be addressed immediately.

4. Audit findings will be given to the Administrator and reviewed at the monthly QAPI meeting.

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, it was determined the facility failed to properly secure oxygen cylinders in one location, affecting one of seven smoke compartments within the facility.

Findings include:

1. Observation on October 29, 2025, at 10:41 am, revealed an unsecured "E" sized oxygen cylinder being stored on the floor, located at the 3rd floor, Unit 4 Nurses station.

Exit interview with the Administrator and Facilities Maintenance on October 29, 2025, at 11:45 am, confirmed the unsecured cylinder.

Plan of Correction - To be completed: 12/01/2025

1. The unsecured "E" sized oxygen cylinder being stored on the floor located at the 3rd floor unit 4 nurses' station was immediately secured.

2. A facility-wide audit was conducted by the Director of Maintenance/Designee to ensure oxygen cylinders were being stored securely. All Maintenance and Nursing staff were educated on the NFPA 99 requirements to properly secure oxygen cylinders.

3. Monthly audits will be conducted by the Director of Maintenance/Designee x3 months to ensure oxygen cylinders are properly secured in storage locations. Any concerns will be addressed immediately.

4. Audit findings will be given to the Administrator and reviewed at the monthly Quality Assurance and Performance Improvement meeting.

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