Pennsylvania Department of Health
 CLEPPER MANOR
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
CLEPPER MANOR
Inspection Results For:

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.
CLEPPER MANOR - 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 April 8, 2025, it was determined that Clepper Manor was not in compliance with the requirements of 42 CFR 483.73.




 Plan of Correction:


403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually: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.
§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.
Observations:
Name: - Component: -- - Tag: 0004

Based on document review and interview, the facility failed to meet emergency preparedness guidelines for one of one program.

Findings include:

Document review on April 8, 2025, at 8:29 a.m., revealed the last annual review date for the emergency preparedness plan occurred January 17, 2019.

Interview with the maintenance director on April 8, 2025, at 8:29 a.m., confirmed the facility was unable to provide documentation for an updated annual review date at the time of the survey.







 Plan of Correction - To be completed: 05/14/2025

1. Administrator and Maintenance Director conducting review and updates for emergency preparedness plan.
2. Emergency preparedness plan will be updated by 5/12/2025
3. Administrator and Maintenance Director will provide all staff education on emergency preparedness plan.
4. All staff education will be completed by 5/14/2025.

403.748(a)(1)-(2), 416.54(a)(1)-(2), 418.113(a)(1)-(2), 441.184(a)(1)-(2), 482.15(a)(1)-(2), 483.475(a)(1)-(2), 483.73(a)(1)-(2), 484.102(a)(1)-(2), 485.542(a)(1)-(2), 485.625(a)(1)-(2), 485.68(a)(1)-(2), 485.727(a)(1)-(2), 485.920(a)(1)-(2), 486.360(a)(1)-(2), 491.12(a)(1)-(2), 494.62(a)(1)-(2) STANDARD Plan Based on All Hazards Risk Assessment: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.
§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)

[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*

(2) Include strategies for addressing emergency events identified by the risk assessment.

* [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.

*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.
Observations:
Name: - Component: -- - Tag: 0006

Based on document review and interview, the facility failed to meet emergency preparedness guidelines for one of one program.

Findings include:

Document review on April 8, 2025, at 8:31 a.m., revealed the facility was unable to provide a documented risk assessment that utilized an all-hazard approach.

Interview with the maintenance director on April 8, 2025, at 8:31 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.




 Plan of Correction - To be completed: 05/01/2025

risk assessment was completed for the facility in our company's electronic system. The facility printed the assessment and has placed in our life safety binder.
maintenance director and administrator will ensure that when the risk assessment is completed it is printed and placed in the life safety binder at the time of completion.
Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID #032902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 8, 2025, it was determined that Clepper Manor 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 two-story, Type III (211), protected, ordinary building, with a basement and unoccupied attic, that is fully sprinklered.




 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 - Component: 01 - Tag: 0100

Document review on April 8, 2025, at 8:45 a.m., revealed the facility failed to provide a set of accurate, portable floor plans. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site, to be used during the Life Safety Code Survey.

Observation on April 8, 2025, at 9:01 a.m., revealed there were multiple areas without doors and smoke detection leading to the corridor. The facility was also unable to provide accurate rating information for the dining room doors leading to the entertainment area.

The Life Safety Code Floor Plan shall include the following:
a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls (1-2 hour walls);
c. Horizontal exits;
d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls;
g. Door schedule.

Interview with the maintenance director on April 8, 2025, at 8:45 a.m., confirmed the facility's Life Safety Code Floor Plan was not accurate at the time of the survey.







 Plan of Correction - To be completed: 05/13/2025

Maintenance Director and Administrator will update floor plan with clear description of
a. smoke barrier walls (outside wall to outside wall)
b. fire barrier walls (1-2 hour walls)
c. horizontal exits
d. rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms)
e. exits noted
f. shaft walls
g door schedule
this will be completed by 5/13/2025
NFPA 101 STANDARD Building Rehabilitation: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.
Building Rehabilitation
Repair, Renovation, Modification, or Reconstruction
Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following:
* Requirements of Chapter 18 and 19
* Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6
18.1.1.4.3, 19.1.1.4.3, 43.1.2.1
Change of Use or Change of Occupancy
Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2
18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7)
Additions
Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition.
Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8.
18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0111

Based on observation and interview, the facility failed to comply with building rehabilitation requirements for one of one facility.

Findings include:

Observation on April 8, 2025, between 8:45 a.m. and 10:20 a.m., revealed the following projects had been completed without plans submitted to State Plan Review and a granted occupancy from the Division of Safety Inspection;
A. (8:45 a.m.) Outside generator was installed in November 2023. The facility did not provide plans or an H number;
B. (10:20 a.m.) Fire alarm panel was replaced.

Interview with the maintenance director on April 8, 2025, at 10:20 a.m., confirmed the facility was unable to provide plans documentation at the time of the survey.





 Plan of Correction - To be completed: 05/13/2025

maintenance director and administrator will obtain the appropriate plans and H nyumber for the outside generator installation from the contractor and submit to the state by 5/13/2025

maintenance director and administrator will obtain plans for the fire alarm panel that was replaced from the contractor and submit to the state by 5/13/2025
NFPA 101 STANDARD Building Construction Type and Height: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.
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, the facility failed to comply with building contruction type requirements for two of two components.

Findings include:

Observation on April 8, 2025, at 9:00 a.m., revealed the fire door separating component 01 from component 02, located next to the resident entertainment room, failed to positively close or latch when released.

Interview with the maintenance director on April 8, 2025, at 9:00 a.m., confirmed the door failed to latch at the time of the inspection.






 Plan of Correction - To be completed: 04/12/2025

Maintenance Director has replaced latch on fire door separating component 01 from component 02, located next to the resident entertainment room on 4/12/2025. The door now properly latches when released.

Maintenance director will audit twice a week Monday through Friday - ongoing
The results of the audit will be reviewing in quality assurance committee monthly to determine if quality assurance plan is required.
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 01 - Component: 01 - Tag: 0345

Based on observation and interview, the facility failed to meet fire alarm system maintenance and testing requirements for one of one panel.

Findings include:

Observation on April 8, 2025, at 10:45 a.m., revealed the fire alarm panel had a trouble signal listed for a communication error at the time of the survey.

Interview with the maintenance director on April 8, 2025, at 10:45 a.m., confirmed the communication error.





 Plan of Correction - To be completed: 05/12/2025

Maintenance director contacted summit fire regarding the trouble signal listed for communication error.
summit came out on 4/29/2025, reset the panel and the issue was temporarily corrected.
Summit ordered part needed to repair completely and it is scheduled to be in and repaired at the latest 5/12/2025
NFPA 101 STANDARD Sprinkler System - Installation: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.
Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0351

Based on observation and interview, the facility failed to maintain sprinkler system requirements for one of two components.

Findings include:

Observation on April 8, 2025, at 12:00 p.m., revealed the hydraulic elevator pit did not have a sidewall sprinkler installed within two feet of the floor.

Interview with the maintenance director on April 8, 2025, at 12:00 p.m., confirmed the elevator pit did not have a sidewall sprinkler installed.




 Plan of Correction - To be completed: 05/15/2025

Maintenance Director to contact Mike at the department of labor elevator division and tony from schindler elevator to determine/obtain documentation of the requirement needed for the elevator sprinkler.
Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000


Facility ID #032902
Component 02
Building 02

Based on a Medicare/Medicaid Recertification Survey completed on April 8, 2025, it was determined that Clepper Manor 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 II (000), unprotected, non-combustible building, with a basement, that is fully sprinklered.




 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: BUILDING 02 - Component: 02 - Tag: 0100

Document review on April 8, 2025, at 8:45 a.m., revealed the facility failed to provide a set of accurate, portable floor plans. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site, to be used during the Life Safety Code Survey.

The Life Safety Code Floor Plan shall include the following:
a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls (1-2 hour walls);
c. Horizontal exits;
d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls;
g. Door schedule.

Interview with the maintenance director on April 8, 2025, at 8:45 a.m., confirmed the facility's Life Safety Code Floor Plan was not accurate at the time of the survey.




 Plan of Correction - To be completed: 05/14/2025

Maintenance director and Administrator will update the portable floor plan to keep in life safety manual to include:
a. smoke barrier walls (outside wall to outside wall)
b. fire barrier walls (1-2 hour walls)
c. Horizontal exits
d. rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) and they will be clearly designated
e. required exits clearly noted
f. shaft walls
g. door schedule
this will be completed by 5/14/2025
NFPA 101 STANDARD Building Rehabilitation: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.
Building Rehabilitation
Repair, Renovation, Modification, or Reconstruction
Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following:
* Requirements of Chapter 18 and 19
* Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6
18.1.1.4.3, 19.1.1.4.3, 43.1.2.1
Change of Use or Change of Occupancy
Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2
18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7)
Additions
Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition.
Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8.
18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8)
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0111

Based on observation and interview, the facility failed to comply with building rehabilitation requirements for one of one facility.

Findings include:

Observation on April 8, 2025, between 8:45 a.m. and 11:00 a.m., revealed the following projects had been installed without plans submitted to State Plan Review and a granted occupancy from the Division of Safety Inspection:
A. (8:45 a.m.) Outside generator was installed in November 2023. The facility did not provide plans or an H number;
B. (10:20 a.m.) Fire alarm panel was replaced;
C. (11:00 a.m.) The automatic fire detection system and sprinkler head were removed from the elevator pit.

Interview with the maintenance director on April 8, 2025, confirmed the facility was unable to provide plans documentation at the time of the survey.





 Plan of Correction - To be completed: 05/15/2025

 maintenance director and administrator will obtain the appropriate plans and H nyumber for the outside generator installation from the contractor and submit to the state by 5/13/2025

maintenance director and administrator will obtain plans for the fire alarm panel that was replaced from the contractor and submit to the state by 5/13/2025
NFPA 101 STANDARD Building Construction Type and Height: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.
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: BUILDING 02 - Component: 02 - Tag: 0161

Based on observation, document review, and interview, the facility failed to comply with building contruction type requirements for two of two building components.

Findings include:

1. Observation on April 8, 2025, at 9:00 a.m., revealed the fire door separating component 01 from component 02, located next to the resident entertainment room, failed to positively close or latch when released.

Interview with the maintenance director on April 8, 2025, at 9:00 a.m., confirmed the door failed to latch at the time of the inspection.

2. Document review on April 8, 2025, at 11:45 a.m., revealed the facility lacked documentation that the discharge exit canopy, located near room 112, was flame retardant. This canopy extends over four feet from the building, is attached to the building, and does not have sprinkler coverage. Therefore, the canopy should be inherently flame retardant.

Interview with the maintenance director on April 8, 2025, at 11:45 a.m., confirmed the flame retardant documentation was unavailable at the time of the survey.
.









 Plan of Correction - To be completed: 05/15/2025

Maintenance Director has replaced latch on fire door separating component 01 from component 02, located next to the resident entertainment room on 4/12/2025. The door now properly latches when released.

Maintenance director will audit twice a week Monday through Friday - ongoing
The results of the audit will be reviewing in quality assurance committee monthly to determine if quality assurance plan is required.
NFPA 101 STANDARD Alcohol Based Hand Rub Dispenser (ABHR):This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0325

Based on observation and interview, the facility failed to meet alcohol-based hand rub dispenser requirements in one of over three smoke compartments.

Findings include:

Observation on April 8, 2025, at 10:42 a.m., revealed the basement electric control room had over 10 gallons of alcohol-based hand rub stored outside of a storage cabinet and located within feet of an ignition source. There was approximately 40, 40-ounce full containers being stored.

Interview with the maintenance director on April 8, 2025, at 10:42 a.m., confirmed the deficiency.




 Plan of Correction - To be completed: 04/30/2025

Regional Maintenance Director educated administrator on the regulation pertaining to storage of alcohol based hand rub.
Administrator will educate housekeeping director and housekeeping staff of the regulation.
education will be completed by 4/30/2025
Excess hand rub was removed from electric control room on 4/8/2025. There now is less than 10 gallons stored in the control room in storage cabinet

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: BUILDING 02 - Component: 02 - Tag: 0345

Based on observation and interview, the facility failed to meet fire alarm system maintenance and testing requirements for one of one panel.

Findings include:

Observation on April 8, 2025, at 10:45 a.m., revealed the fire alarm panel had a trouble signal listed for a communication error at the time of the survey.

Interview with the maintenance director on April 8, 2025, at 10:45 a.m., confirmed the communication error.




 Plan of Correction - To be completed: 05/25/2025

maintenance director contacted summit fire to come out and correct fire panel communication error.

summit came out and ordered new part to fix the issue on April 31,2025.

Once the part arrives summit will be out to replace the part.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
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: BUILDING 02 - Component: 02 - Tag: 0353

Based on observation and interview, the facility failed to meet sprinkler system maintenance and testing requirements for one of over ten rooms.

Findings include:

Observation on April 8, 2025, at 10:30 a.m., revealed the basement electric control room had a fictional character figure (minion) taped to the sprinkler line.

Interview with the maintenance director on April 8, 2025, at 10:30 a.m., confirmed the deficiency.






 Plan of Correction - To be completed: 05/14/2025

Fictional character was removed immediately when noted by life safety surveyor.
Regional maintenance director educated administrator on regulation on sprinkler system maintenance and testing requirements on 4/15/2025.
Administrator will educate housekeeping director and all housekeeping staff on sprinkler system maintenance and testing requirements by 5/14/2025.
Maintenace director/designee will round weekly for the next four weeks to ensure compliance.
results of audit will be reviewed with administrator weekly.
NFPA 101 STANDARD Portable Fire Extinguishers:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0355

Based on observation and interview, the facility failed to meet portable fire extinguisher requirements for two of over six portable fire extinguishers.

Findings include:

Observation on April 8, 2025, between 11:00 a.m. and 11:06 a.m., revealed the following portable fire extinguisher deficiencies:
A. (11:00 a.m.) Basement washing room had a portable fire extinguisher blocked by a janitor cart;
B. (11:06 a.m.) Basement elevator control room had an outdated fire extinguisher with a November 2023 date.

Interview with the maintenance director on April 8, 2025, at 11:06 a.m., confirmed the deficiencies at the time of the survey.



 Plan of Correction - To be completed: 05/13/2025

Housekeeping Director immediately removed the janitor cart away from the portable fire extinguisher in the basement washing room.
regional director of maintenance educated administrator on the portable fire extinguishers on 4/14/2025
administrator will educate housekeeping director and all housekeeping staff of the regulation pertaining to the portable fire extinguishers
education will be completed by 5/13/2025
administrator/designee will audit weekly for four weeks to ensure that fire extinguisher regulation is followed.
NFPA 101 STANDARD Electrical Systems - Other:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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 - Component: 02 - Tag: 0911

Based on observation and interview, the facility failed to maintain electrical system requirements in one of over three smoke compartments.

Findings include:

Observation on April 8, 2025, at 10:55 a.m., revealed the basement electric control room had a desk blocking access to the electric panels at the time of the survey.

Reference: NFPA 70-110.26(a)

Interview with the maintenance director on April 8, 2025, at 10:55 a.m., confirmed the deficency.




 Plan of Correction - To be completed: 05/14/2025

Housekeeping director immediately moved the desk that was blocking the electric panel when surveyor observed.
regional director of maintenance educated the administrator and maintenance director on the electrical system requirements on 4/14/2025.
Administrator will educate housekeeping director and all housekeeping staff.
education will be completed by 5/14/2025
administrator/designee will audit for compliance weekly for 4 weeks to ensure compliance

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