Pennsylvania Department of Health
SPRING CREEK REHABILITATION AND NURSING CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 67 surveys for this facility. Please select a date to view the survey results.

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SPRING CREEK REHABILITATION AND NURSING CENTER - 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 29, 2025, at Spring Creek Rehabilitation and Nursing Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MCBRIDE - Component: 02 - Tag: 0000

Facility ID #040202
Component 02
McBride Building

Based on a Medicare/Medicaid Recertification Survey conducted on April 28 & April 29, 2025, it was determined that Spring Creek Rehabilitation and Nursing Center 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 (222), fire resistive structure, without a basement, which 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: MCBRIDE - Component: 02 - 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 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 and interview on April 28, 2025, between 9:15 AM and 11:10 AM, revealed the facility life safety drawings lacked resident room capacities, fire wall boundaries, smoke wall boundaries, hazardous areas and compartment designation.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the life safety drawings of the facility lacked required information.

2. Review of documentation on April 28, 2025, between 9:15 AM and 11:10 AM, revealed the facility lacked documentation, verifying the installation and location of installed Carbon Monoxide Alarms.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the lack of documentation.

Plan of Correction - To be completed: 05/28/2025

1. The facility will develop life safety drawings will include resident room capacities, fire wall boundaries, smoke wall boundaries, hazardous areas and compartment designation.
2. The facility will develop documentation to verify the installation and location of the installed Carbon Monoxide Alarm.

These items will be placed in the life safety book, and an annual audit will be done to confirm they are still in the life safety book.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

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.

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: MCBRIDE - Component: 02 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of exit stairtower enclosures, affecting one of five floors within the component.

Findings include:

1. Observation on April 29, 2025, at 11:45 AM, revealed the Stairtower 06 door, exceeded minimum gap requirements, of 1/8-inch, on the latch side.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the stairtower door exceeded minimum gap requirements.

Plan of Correction - To be completed: 05/28/2025

The stairtower 06 door will be adjusted to not exceeded minimum gap requirements, of 1/8-inch, on the latch side and positively latch within the door frame.
The Nursing Home Administrator will educate the Maintenance Director and Maintenance team on latching for door gaps.
Random monthly audits will be done by the Maintenance Director/designee to ensure all compliance.
Results of the audits will be reviewed/reported to the monthly QAPI committee to determine trends/compliance. QAPI committee will determine the need for continuance of audits.

NFPA 101 STANDARD Emergency Lighting:

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.

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: MCBRIDE - Component: 02 - Tag: 0291

Based on document review, observation and interview, it was determined the facility lacked documentation, verifying the annual maintenance of battery-powered emergency lighting sources and installed battery back-up lighting failed to illuminate, affecting the entire component.

Findings include:

1. Review of documentation on April 28, 2025, between 9:15 AM and 11:10 AM, it was revealed the facility failed to perform annual testing of battery powered emergency lighting sources.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the facility failed to perform annual testing of battery powered lighting sources.

2. Observation on April 28, 2025, at 11:50 AM, revealed the installed battery back-up emergency lighting failed to illuminate, when tested, at the transfer switch.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the installed battery back-up emergency lighting failed to illuminate, when tested, at the transfer switch.

Plan of Correction - To be completed: 05/28/2025

The Maintenance Director/Designee will perform annual testing of battery powered emergency lighting sources and will maintain documentation.
The Nursing Home Administrator will educate the Maintenance Director and Maintenance team to confirm that the battery backup lighting functions on a monthly test. The testing form will be in writing and will be placed in the life safety book.
Random monthly audits will be done by the Maintenance Director/designee to ensure all compliance.
Random monthly audits will be done by the Maintenance Director/designee to ensure all compliance.

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: MCBRIDE - Component: 02 - Tag: 0293

Based on document review and interview, it was determined the facility failed to provide documentation, verifying monthly inspections of exit signs for one full year, affecting the entire component.

Findings include:

1. Review of documentation on April 28, 2025, between 9:15 AM and 11:10 AM, revealed the facility failed to provide documentation, verifying exit signs within the facility had been visually inspected for one full year.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the lack of documentation, verifying exit signs for one full year.

Plan of Correction - To be completed: 05/28/2025

The Maintenance Director will visually inspect the exit signs within the facility and keep documentation.
The Nursing Home Administrator will educate the maintenance team to ensure that all exit signs are visually inspected.
Random monthly audits will be done by Nursing Home Administrator/designee monthly to maintain exit signage are visually inspected and the inspections are filed in the safety book.
Results of the audits will be reviewed/reported to the monthly QAPI committee to determine trends/compliance. QAPI committee will determine the need for continuance of audits.

NFPA 101 STANDARD Smoke Detection:

Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2

Observations:
Name: MCBRIDE - Component: 02 - Tag: 0347

Based on document review and interview, it was determined the facility failed to maintain the battery-operated smoke detectors in all patient rooms, on one of five floors within the component.

Findings include:

1. Review of documentation and interview on April 28, 2025, between 9:15 AM and 11:10 AM, revealed the battery-operated smoke detectors, in the McBride resident rooms, 1st floor, were not being maintained or tested.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the battery-operated smoke detectors were not being maintained or tested.

Plan of Correction - To be completed: 05/28/2025

The Maintenance Director/Designee will perform an audible test on the battery-operated smoke detectors on a monthly basis in the McBride resident rooms, 1st floor and maintain documentation in the Life Safety Binder.
The Nursing Home Administrator will educate the maintenance team to ensure that all battery-operated smoke detectors in residents' rooms are tested monthly for an audible test.
Random monthly audits will be done by Nursing Home Administrator/designee monthly to ensure battery-operated smoke detectors are inspected and the inspections are filed in the safety book.
Results of the audits will be reviewed/reported to the monthly QAPI committee to determine trends/compliance. QAPI committee will determine the need for continuance of audits.

NFPA 101 STANDARD Smoking Regulations:

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.

Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MCBRIDE - Component: 02 - Tag: 0741

Based on observation and interview, it was determined the facility lacked ashtrays of noncombustible material and metal containers, with a self-closing device, affecting the entire component.
Findings include:
1. Observation on April 29, 2025, between 12:55 PM and 12:56 PM, revealed designated smoking area lacked:
a. 12:55 PM, noncombustible ashtray;
b. 12:56 PM, self-closing metal container.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the lack of required ashtrays and self-closing metal containers.

Plan of Correction - To be completed: 05/28/2025

The facility has placed noncombustible ashtrays and self-closing metal containers in the designated smoking area.
The Nursing Home Administrator will educate the maintenance team to ensure the designated smoking area has noncombustible ashtrays and self-closing metal containers.
Random monthly audits will be done by Nursing Home Administrator/designee to ensure compliance.
Results of the audits will be reviewed/reported to the monthly QAPI committee to determine trends/compliance. QAPI committee will determine the need for continuance of audits.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Observations:
Name: MCBRIDE - Component: 02 - Tag: 0761

Based on document review and interview, it was determined the facility lacked documentation of annual inspections of the fire door assemblies, in five of five floors the entire component.

Findings include

1. Review of documentation on April 28, 2025, between 9:15 AM and 11:10 AM, revealed the facility lacked documentation of annual door inspection of rated doors.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the facility lacked documentation of annual door inspection of rated doors.

Plan of Correction - To be completed: 05/28/2025

The facility will maintain documentation of annual inspections of the fire door assemblies.
The Nursing Home Administrator will educate the maintenance team to ensure the fire doors are inspected annually and documentation are maintained in Life Safety binder.
Random monthly audits will be done by Nursing Home Administrator/designee to ensure compliance.
Results of the audits will be reviewed/reported to the monthly QAPI committee to determine trends/compliance. QAPI committee will determine the need for continuance of audits.

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, 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: MCBRIDE - Component: 02 - Tag: 0918
Based on document review, observation and interview, it was determined the facility failed to perform testing and inspections, and an exterior emergency shut off switch required for the Essential Electrical System, which serves the entire component.

Findings include:

1. Review of documentation and interview on April 28, 2025, between 10:00 AM and 10:05 AM, revealed the facility failed to perform annual inspections and testing of the generator, including the following:
a. 10:00 AM, full year weekly battery voltage;b. 10:03 AM, annual 90-minute load bank;
c. 10:05 AM, annual fuel quality test.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the facility failed to perform required maintenance and testing.

2. Observation and interview on April 28, 2025, at 11:50 AM, revealed the lack of an installed exterior emergency generator shut off switch.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the facility lacked an exterior emergency shut off switch.

Plan of Correction - To be completed: 05/28/2025

The facility maintenance director will perform inspection and testing of the generator battery voltage weekly.
The facility will contact Penn Power (an Outside Vendor) to conduct 90-minute load bank testing of the generator and annual quality fuel test for the generator on May 23, 2025.
The Nursing Home Administrator will educate the Maintenance team on weekly voltage testing for the generator
The Nursing Home Administrator/Designee will conduct random audits on the generator and the life safety book on a monthly basis to ensure compliance.
Results of the audits will be reviewed/reported to the monthly QAPI committee to determine trends/compliance. QAPI committee will determine the need for continuance of audits.

Initial comments:Name: SOUTH BUILDING, BUILDING 04 - Component: 06 - Tag: 0000

Facility ID #040202
Component 06
South Pavilion Building

Based on a Medicare/Medicaid Recertification Survey conducted on April 28 & April 29, 2025, it was determined that Spring Creek Rehabilitation and Nursing Center 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 four-story, Type II (222), fire resistive structure, with a penthouse, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

Observations:
Name: SOUTH BUILDING, BUILDING 04 - Component: 06 - 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 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 and interview on April 28, 2025, between 9:15 AM and 11:10 AM, revealed the facility life safety drawings lacked resident room capacities, fire wall boundaries, smoke wall boundaries, hazardous areas and compartment designation.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the life safety drawings of the facility lacked required information.

2. Review of documentation on April 28, 2025, between 9:15 AM and 11:10 AM, revealed the facility lacked documentation, verifying the installation and location of installed Carbon Monoxide Alarms.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the facility failed to provide documentation, verifying carbon monoxide detectors were installed.

NFPA 101 STANDARD Means of Egress - General:

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: SOUTH BUILDING, BUILDING 04 - Component: 06 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain the maximum force required to operate exit discharge doors, affecting one of four floors within the component.

Findings include:

1. Observation on April 28, 2025, at 1:25 PM, revealed the exit discharge door, to the ground floor Trash Room, required a force of more than 30 pounds and failed to open.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the door failed to open.

Plan of Correction - To be completed: 05/28/2025

The Maintenance Director has fixed the exit discharge door, to the ground floor Trash Room, to open within the required force of 30 pounds.
The Nursing Home Administrator will educate the Maintenance team that exit discharge door must be able to open easily.
The Nursing Home Administrator/Designee will conduct random monthly audits to ensure exit discharge doors can be open to ensure compliance.
Results of the audits will be reviewed/reported to the monthly QAPI committee to determine trends/compliance. QAPI committee will determine the need for continuance of audits.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: SOUTH BUILDING, BUILDING 04 - Component: 06 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the stairtower doors, to be within the allowed gap margins, affecting two of four floors within the component.

Findings include:

1. Observation on April 28, 2025, between 12:15 PM and 12:50 PM, revealed the stairtower doors exceeded minimum gap requirements, at the following locations:

a. 12:15 PM, 4th floor, Stairtower A, 1/8 inch, top;
b. 12:50 PM, 3rd floor, Stairtower A, 1/8 inch, top.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the stairtower doors exceeded allowed gap margins.

Plan of Correction - To be completed: 05/28/2025

1. The 4th Floor stairtower A door will be adjusted to not exceeded minimum gap requirements, of 1/8-inch, on the latch side and positively latch within the door frame.
2. The 3rd Floor stairtower A door will be adjusted to not exceeded minimum gap requirements, of 1/8-inch, on the latch side and positively latch within the door frame
The Nursing Home Administrator will educate the Maintenance Director and Maintenance team to ensure all doors gaps are meeting the gap requirements.
Random monthly audits will be done by the Maintenance Director/designee to ensure all compliance.
Results of the audits will be reviewed/reported to the monthly QAPI committee to determine trends/compliance. QAPI committee will determine the need for continuance of audits.

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: SOUTH BUILDING, BUILDING 04 - Component: 06 - Tag: 0291

Based on document review, observation and interview, it was determined the facility lacked documentation, verifying the annual maintenance of battery-powered emergency lighting sources and installed battery back-up lighting failed to illuminate, affecting the entire component.

Findings include:

1. Review of documentation on April 28, 2025, between 9:15 AM and 11:10 AM, it was revealed the facility failed to perform annual testing of battery powered emergency lighting sources.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the facility failed to perform annual testing of battery powered lighting sources.

2. Observation on April 28, 2025, at 11:50 AM, reveled the installed battery back-up emergency lighting failed to illuminate, when tested, at the transfer switch.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the installed battery back-up emergency lighting failed to illuminate, when tested, at the transfer switch.

NFPA 101 STANDARD Exit Signage:

Observations:
Name: SOUTH BUILDING, BUILDING 04 - Component: 06 - Tag: 0293

Based on document review and interview, it was determined the facility failed to provide documentation, verifying monthly inspections of exit signs for one full year, on five of five floors within the component.

Findings include:

1. Review of documentation on April 28, 2025, between 9:15 AM and 11:10 AM, revealed the facility failed to provide documentation, verifying exit signs within the facility had been visually inspected for one full year.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the lack of documentation, verifying exit signs for one full year.

NFPA 101 STANDARD Smoke Detection:

Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2

Observations:
Name: SOUTH BUILDING, BUILDING 04 - Component: 06 - Tag: 0347

Based on document review and interview, it was determined the facility failed to maintain the battery-operated smoke detectors in all patient rooms, on the 1st floor within the component.

Findings include:

1. Review of documentation and interview on April 28, 2025, between 9:15 AM and 11:10 AM, revealed the battery-operated smoke detectors, in the South Pavilion Building resident rooms, 1st floor were not being maintained or tested.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the battery-operated smoke detectors were not being maintained or tested.

Plan of Correction - To be completed: 05/28/2025

The Maintenance Director/Designee will perform an audible test on the battery-operated smoke detectors on a monthly basis in the McBride resident rooms, 1st floor and maintain documentation in the Life Safety Binder.
The Nursing Home Administrator will educate the maintenance team to ensure that all battery-operated smoke detectors in residents' rooms are tested monthly for an audible test.

The Nursing Home Administrator will educate the maintenance team to ensure that all battery-operated smoke detectors in residents' rooms are tested.
Random monthly audits will be done by Nursing Home Administrator/designee monthly to ensure battery-operated smoke detectors are inspected and the inspections are filed in the safety book.
Results of the audits will be reviewed/reported to the monthly QAPI committee to determine trends/compliance. QAPI committee will determine the need for continuance of audits.

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: SOUTH BUILDING, BUILDING 04 - Component: 06 - Tag: 0353

Based on document review, observation and interview, it was determined the facility failed to perform weekly tests, maintain the automatic sprinkler system, to be free of excessive weight and sprinkler heads covered with debris, affecting the entire component.

Findings include:

1. Review of documentation and interview on April 28, 2025, at 9:30 AM, revealed the facility failed to perform weekly 10-minute run of electric fire pump.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the facility failed to perform weekly fire pump runs.

2. Observation on April 28, 2025, between 12:22 PM and 12:50 PM, revealed various items being supported by sprinkler piping system, at the following locations:

a. 12:22 PM, 4th floor, by Stairtower A, above ceiling, flex ducting across sprinkler piping;b. 12:50 PM, 3rd floor, by Stairtower A, above ceiling, numerous wires across sprinkler piping.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed there were various items supported by the sprinkler pipe system.

3. Observation on April 28, 2025, between 12:33 PM and 1:06 PM, revealed sprinkler heads covered with debris, at the following locations:

a. 12:33 PM, 3rd floor, by elevators, 3 sprinkler heads;b. 1:06 PM, 2nd floor, Front Hall, between Resident Room 207-211, 3 sprinkler heads.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the sprinkler heads were subject to load.

Plan of Correction - To be completed: 05/28/2025

1. The Maintenance Director will perform weekly 10-minute run of electric fire pump and will maintain documentation in the Life Safety Binder.
2. a. The flex ducting across sprinkler piping above the ceiling on the 4th floor by Stairtower A will be cleaned.
b. The numerous wires across sprinkler piping above the ceiling on the 3rd floor by Stairtower A will be organized and tied.
3. a. The 3 sprinkler heads on the 3rd floor by the elevator has been cleaned.
b. The sprinkler heads on the 2nd floor Front Hall between resident's room 207-211 has been cleaned.
The Nursing Home Administrator will educate the maintenance team to ensure that all sprinkler heads to be free from debris and excessive weights
Random monthly audits will be done by Nursing Home Administrator/designee monthly sprinkler heads are free from debris and excessive weights.
Results of the audits will be reviewed/reported to the monthly QAPI committee to determine trends/compliance. QAPI committee will determine the need for continuance of audits.

NFPA 101 STANDARD Elevators:

Elevators
2012 EXISTING
Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter's Service is operated monthly with a written record.
Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter's Service Requirements of ASME/ANSI A17.3. (Includes firefighter's service Phase I key recall and smoke detector automatic recall, firefighter's service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.)
19.5.3, 9.4.2, 9.4.3

Observations:
Name: SOUTH BUILDING, BUILDING 04 - Component: 06 - Tag: 0531

Based on observation and interview, it was determined the facility failed to maintain the Elevator Machine Room door, to be free of combustible materials, affecting one of two elevator machine rooms within the component.

Findings include:

1. Observation on April 28, 2025, at 1:00 PM, revealed storage in the Elevator Machine Room, 2nd floor, of various combustible materials, which did not service the elevator.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the 2nd floor Elevator Machinery Room contained various flammable materials.

Plan of Correction - To be completed: 05/28/2025

The Maintenance Director/Designee will clean the Elevator Machine Room, to be free of combustible materials.
The Nursing Home Administrator will educate the maintenance team to ensure that the elevator machine room will be free of combustible materials.
Random monthly audits will be done by Nursing Home Administrator/designee to ensure compliance.
Results of the audits will be reviewed/reported to the monthly QAPI committee to determine trends/compliance. QAPI committee will determine the need for continuance of audits.

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: SOUTH BUILDING, BUILDING 04 - Component: 06 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain rated Chute Room doors, to be within allowed gap margins and to positively latch in the frame, on two of four floors within the component.

Findings include:

1. Observation on April 28, 2025, between 1:05 PM and 1:20 PM, revealed the rated doors to Chute Rooms exceeded minimum gap requirements at the following locations:

a. 1:05 PM, 2nd floor, 3/16 inch, latch side;
b. 1:20 PM, 1st floor, 3/16 inch, top and failed to latch in frame.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the chute room rated door failed to latch and gaps exceeded the allowed margin.

Plan of Correction - To be completed: 05/28/2025

1. a. The rated door to the chute room on the 2nd floor will be adjusted to automatically close and positively latch within the door frame.
2. b. The rated door to the chute room on the 1st floor will be adjusted to automatically close and positively latch within the door frame.
The Nursing Home Administrator will in-service the Maintenance Director, Maintenance team to ensure the door to the chute room will automatically close and positively latch within the frame. Floor staff will be educated to place a work order in TELS if the latch is not working properly.
Random monthly audits will be done by the Maintenance Director/designee to ensure compliance.
Results of the audits will be reviewed/reported to the monthly QAPI committee to determine trends/compliance. QAPI committee will determine the need for continuance of audits.

NFPA 101 STANDARD Smoking Regulations:

Observations:
Name: SOUTH BUILDING, BUILDING 04 - Component: 06 - Tag: 0741

Based on observation and interview, it was determined the facility lacked ashtrays of noncombustible material and metal containers, with self-closing device, affecting the entire component.
Findings include:
1. Observation on April 29, 2025, between 12:55 PM and 12:56 PM, revealed designated smoking area lacked:
a. 12:55 PM, noncombustible ashtrays;
b. 12:56 PM, self-closing metal containers.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the lack of required ashtrays and containers.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

Observations:
Name: SOUTH BUILDING, BUILDING 04 - Component: 06 - Tag: 0761

Based on document review and interview, it was determined the facility lacked documentation of annual inspections of the fire door assemblies, on five of five floors within the component.

Findings include

1. Review of documentation on April 28, 2025, between 9:15 AM and 11:10 AM, revealed the facility lacked documentation of annual door inspection of rated doors.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the facility lacked documentation of annual door inspection of rated doors.

NFPA 101 STANDARD Electrical Systems - Receptacles:

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: SOUTH BUILDING, BUILDING 04 - Component: 06 - Tag: 0912

Based on observation and interview, it was determined the facility failed to maintain power receptacles, to be Ground Fault Interruption (GFI) protected, within six feet of a water source, in three of five floors within the component.

Findings include:

1. Observation on April 28, 2025, between 12:43 PM and 1:17 PM, revealed various outlets were not GFI protected but were within six feet of a water source, at the following locations:

a. 12:43 PM, 3rd floor, Residential Laundry Room, 1 outlet;
b. 1:08 PM, 2nd floor, Residential Laundry Room, 1 outlet;
c. 1:17 PM, 1st floor, Residential Laundry Room, 1 outlet.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the outlets were not GFI protected.

Plan of Correction - To be completed: 05/28/2025

The Maintenance Director has installed power receptacles, to be Ground Fault Interruption (GFI) protected, within six feet of a water source at the following locations.
a. 1 outlet on the 3rd floor, Residential Laundry Room,
b. 1 outlet on the 2nd floor, Residential Laundry Room,
c. 1 outlet on the 1st floor, Residential Laundry Room.
The Nursing Home Administrator will educate the maintenance team to ensure the installation of power receptacles to be Ground Fault Interruption (GFI) protected, within six feet of a water source.
Random monthly audits will be done by Nursing Home Administrator/designee to ensure compliance.
Results of the audits will be reviewed/reported to the monthly QAPI committee to determine trends/compliance. QAPI committee will determine the need for continuance of audits.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: SOUTH BUILDING, BUILDING 04 - Component: 06 - Tag: 0918

Based on document review, observation and interview, it was determined the facility failed to perform testing and inspections, and an exterior emergency shut off switch required for the Essential Electrical System, which serves the entire component.

Findings include:

1. Review of documentation and interview on April 28, 2025, between 10:00 AM and 10:05 AM, revealed the facility failed to perform annual inspections and testing of the generator, including the following:
a. 10:00 AM, full year weekly battery voltage;b. 10:03 AM, annual 90-minute load bank;
c. 10:05 AM, annual fuel quality test.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the facility failed to perform required maintenance and testing.

2. Observation and interview on April 28, 2025, at 11:50 AM, revealed the lack of an installed exterior emergency generator shut off switch.

Interview at the time of the exit conference with the Administrator and Senior Plant Ops Director on April 29, 2025, at 1:45 PM, confirmed the facility lacked an exterior emergency shut off switch.

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