Pennsylvania Department of Health
LEBANON VALLEY HOME, THE
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 48 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


LEBANON VALLEY HOME, THE - 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 September 17, 2025, at The Lebanon Valley Home, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000
Facility ID #730602Component 01Main BuildingBased on a Medicare/Medicaid Recertification Survey completed on September 17, 2025, it was determined that the Lebanon Valley Home 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 III (200), unprotected ordinary structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Fire Alarm System - Installation:

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 - Installation
A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity.
18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0341 Based on document review and interview, it was determined the facility failed to obtain plan approval for the installation of a new fire alarm panel and components and entered the system into service without notifying the Division of Life Safety, which serves the entire component. Findings include: 1. Review of documentation and interview on September 17, 2025, between 9:15 AM and 11:15 AM, revealed the facility failed to follow up on a citation issued on October 22, 2024, to which the facility installed a new fire alarm system on June 17, 2024, but could not provide a Department of Health approved plan. Interview at the time of the exit conference with the Executive Director, Director of Nursing and Maintenance Assistant on September 17, 2025, at 1:45 PM, confirmed facility failed to follow up on the previous citation for the installation of a new fire alarm system, without prior approval from the Pennsylvania Department of Health. 2. Review of documentation and interview on September 17, 2025, between 9:15 AM and 11:15 AM, revealed the facility failed to follow up on a citation issued on October 22, 2024, to which the facility entered a new fire alarm system into service on July 30, 2024, without notifying the Division of Safety Inspection. Interview at the time of the exit conference with the Executive Director, Director of Nursing and Maintenance Assistant on September 17, 2025, at 1:45 PM, confirmed facility failed to follow up on the previous citation for the installation of a new fire alarm system, without notifying the Division of Life Safety Division.

Plan of Correction - To be completed: 11/01/2025

1. The facility had submitted the documents for plan approval for the installation of the fire alarm panel, however, did not receive verification that the documents had been received. The facility will retroactively submit the appropriate documentation to the Division of Life Safety for plan review and approval for the installed fire alarm panel. The facility will verify that the documents submitted to the Division of Life Safety Plan Review Office have been received.
2.The NHA has provided education to the Maintenance Department/Designee regarding the requirements for submission of work to the Division of Life Safety Plan Review.
3.The NHA/Designee and Maintenance Director will review projects in advance of completion to determine if a plan is required to be submitted to the Division of Life Safety prior to initiation of the work.
4. The Maintenance Director/Designee will submit plans to the Division of Life Safety plan review office and obtain verification of receipt from the department prior to beginning future work.
5. The NHA/Designee will complete audits of documentation on an as needed basis to ensure that work/projects scheduled for the facility have been submitted for plan approval and that there is documentation of approval from the Department of Life Safety prior to initiation of any future work/projects. This information will be reviewed at the monthly QAPI meeting when there are projects planned or in progress for further review and/or recommendations.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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 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 - Component: 01 - Tag: 0345 Based on document review and interview, it was determined the facility failed to provide documentation verifying the sensitivity of smoke detectors installed throughout the facility had been tested within the previous two years, affecting the entire component. Findings include: 1. Review of documentation on September 17, 2025, between 9:15 AM and 11:15 AM, revealed the facility failed to provide documentation, verifying the sensitivity of smoke detectors installed throughout the facility had been tested, since July 30, 2024, when a new system was put into service. Interview at the time of the exit conference with the Executive Director, Director of Nursing and Maintenance Assistant on September 17, 2025, at 1:45 PM, confirmed the lack of documentation, verifying the sensitivity of smoke detectors installed throughout the facility had been tested, within the previous two years.

Plan of Correction - To be completed: 11/01/2025

1. The Maintenance Department/Designee has received a copy of and reviewed the requirements for sensitivity testing.
2.The Maintenance Director/Designee will engage a qualified professional to conduct smoke detector sensitivity testing and obtain documentation verifying that the system is performing within its listed range and testing of the system will be scheduled in accordance with NFPA standards.
3.The Maintenance Director/Designee will maintain a written record of all inspections, testing, and maintenance.
4. Results of Fire Alarm System testing, including documentation of smoke head sensitivity will be reviewed in Monthly QA 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 - Component: 01 - Tag: 0353 Based on document review and interview, it was determined the facility failed to perform monthly tests of the installed fire pump, and sprinkler heads were covered with debris, affecting the entire component. Findings include: 1. Review of documentation and interview on September 17, 2025, between 9:15 AM and 11:15 AM, revealed the facility failed to perform one full year of weekly 30-minute run of the diesel fire pump. Interview at the time of the exit conference with the Executive Director, Director of Nursing and Maintenance Assistant on September 17, 2025, at 1:45 PM,confirmed the facility failed to perform weekly fire pump runs. 2. Observation on September 17, 2025, between 11:40 AM and 11:45 AM, revealed sprinkler heads covered with debris, at the following locations: a. 11:40 AM, Main Laundry, Dryer Room, 2 sprinkler heads; b. 11:42 AM, Main Laundry, Dryer Chase area, 1 sprinkler head; c. 11:45 AM, Main Laundry, Folding Room, 1 sprinkler head. Interview at the time of the exit conference with the Executive Director, Director of Nursing and Maintenance Assistant on September 17, 2025, at 1:45 PM,confirmed the sprinkler heads were subject to load.

Plan of Correction - To be completed: 11/01/2025

1. Education has been provided to Maintenance Director/Designee regarding requirements for testing of the fire pump.
2.Fire Pump testing will be conducted weekly for 30 minutes, and all required documentation will be kept of file.
3. Education has been provided to Maintenance Director/Designee regarding checking that all sprinkler heads are free of debris. Maintenance Director/Designee will ensure that preventative maintenance schedule is followed to ensure sprinkler heads are free of debris.
4. Sprinkler heads will be checked weekly for 4 weeks and then bi-weekly for 8 weeks and monthly thereafter.
5.Documentation of audits will be reviewed in Monthly QA to ensure a pattern of compliance has been established.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement