Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT LATROBE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
KADIMA REHABILITATION & NURSING AT LATROBE
Inspection Results For:

There are  46 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.
KADIMA REHABILITATION & NURSING AT LATROBE - 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 May 21, 2025, at Kadima Rehabilitation and Nursing at Latrobe, there were deficiencies identified that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.




 Plan of Correction:


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 it was determined that the facility failed to provide a written Emergency Preparedness (EP) Plan that includes a facility-based and community-based risk assessment.

Findings include:

1. Interview and documentation review of the EP plan on May 21, 2025, at 8:30 a.m., revealed the facility lacked an Emergency Preparedness Plan that includes an annually updated facility-based and community-based risk assessment, utilizing an all-hazards approach.

Interview with the Maintenance Supervisor on May 21, 2025, at 8:30 a.m., confirmed the above listed EP deficiency.





 Plan of Correction - To be completed: 06/24/2025

The facility-based and community-based risk assessment, utilizing an all-hazards approach was previously completed on 1/2/2025 with a copy located in the Emergency Preparedness Manual.
The Nursing Home Administrator and the Interdisciplinary Team, re-reviewed the facility-based and community-based risk assessment, utilizing an all-hazards approach.
The Maintenance Director was educated on the Emergency Preparedness Manual, including the location of the facility-based and community-based risk assessment, utilizing an all-hazards approach.
The Nursing Home Administrator will complete a random audit on the facility-based and community-based risk assessment, utilizing an all-hazards approach, to ensure annual and updated compliance.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

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

Facility ID# 051202
Component 01
East Building

Based on a Medicare/Medicaid Recertification Survey completed on May 21, 2025, it was determined that Kadima Rehabilitation and Nursing at Latrobe, 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, without a basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Exit Signage: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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on document review and interview, it was determined the facility failed to perform the monthly exit sign inspection for 12 of 12 months.

Findings Include:

1. Document review on May 21, 2025, at 9:00 a.m., revealed the facility lacked documentation for monthly exit sign inspections for the last 12 months.

Interview with the Facility Maintenance Director on May 21, 2025, at 9:00 a.m., confirmed the facility lacked documentation for exit sign inspections over the last 12 months at the time of the survey.







 Plan of Correction - To be completed: 06/24/2025

The Maintenance Director completed an in-house inspection on facility exit signs.
The Nursing Home Administrator will develop a monthly schedule on exit sign inspections to ensure compliance.
The Maintenance Director was educated by the Nursing Home Administrator on the requirement for monthly exit sign inspections and guidelines related to K0293.
The Nursing Home Administrator will complete a random audit on exit signage inspection to validate completion.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on observation and interview, it was determined the facility failed to maintain cooking facilities in one instance, affecting the entire facility.

Findings include:

1. Observation and document review on May 21, 2025, at 9:30 a.m., revealed the facility lacked documentation for the semiannual kitchen fire suppression system inspection at the time of the survey.

Interview with the Facility Maintenance Director on May 21, 2025, at 9:30 a.m., confirmed the cooking facility deficiency.






 Plan of Correction - To be completed: 06/24/2025

The semiannual kitchen fire suppression system inspection was completed on 4/17/2025.
The facility vendor the kitchen fire suppression system inspection is prescheduled to ensure the facility remains in compliance. The Maintenance Director will maintain a hard copy of the semiannual kitchen fire suppression system inspection to be readily accessible.
The Maintenance Director was educated by the Nursing Home Administrator on requirement of the semiannual kitchen fire suppression system inspection and guidelines related to K0324.
The Nursing Home Administrator will complete random audits of the semiannual kitchen fire suppression system to validate hard documentation and completion.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

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 documentation review and interview, it was determined the facility failed to maintain the fire alarm system in two instances, affecting the entire facility

Findings Include:

1. Review of documentation on May 21, 2025, at 9:15 a.m., revealed the following fire alarm system testing and maintenance deficiencies:

a) The facility lacked documentation for the semi-annual visual fire alarm inspection;
b) The facility lacked documentation for the biennial smoke detector sensitivity testing.

Interview with the Facility Maintenance Director on May 21, 2025, at 9:15 a.m., confirmed the fire alarm system deficiencies.






 Plan of Correction - To be completed: 06/24/2025

The semi-annual visual fire alarm inspection completed on 04/14/2025. The biennial smoke detector sensitivity testing was completed on 04/14/2025.
The facility vendor for fire alarm system and testing and maintenance is prescheduled to ensure the facility remains in compliance. The Maintenance Director will maintain a hard copy of fire alarm system testing and maintenance to be readily accessible.
The Maintenance Director was educated by the Nursing Home Administrator on the requirement of fire alarm system testing and maintenance and guidelines related to K0345.
The Nursing Home Administrator will complete random audits of the facility's fire alarm system testing and maintenance documentation to validate completion.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting the entire facility.

Findings include:

1. Review of documentation on May 21, 2025, at 9:35 a.m., revealed the facility lacked documentation verifying that any sprinkler inspections were performed since June 2024.

Interview with the Facility Maintenance Director on May 21, 2025, at 9:35 a.m., confirmed the facility lacked documentation for sprinkler inspections.





 Plan of Correction - To be completed: 06/24/2025

The facility has records for past sprinkler inspections.
The facility vendor for the sprinkler and testing and maintenance is prescheduled to ensure the facility remains in compliance. The Maintenance Director will maintain a hard copy of the sprinkler system testing and maintenance to be readily accessible.
The Maintenance Director was educated by the Nursing Home Administrator on the requirement of the sprinkler system testing and maintenance and guidelines related to K0353.
The Nursing Home Administrator will complete random audits of the facility's sprinkler system testing and maintenance documentation validate completion.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

NFPA 101 STANDARD Corridor - Doors: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.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors in one instance, affecting one of four smoke compartments.

Findings include:

1. Observation on May 21, 2025, at 10:30 a.m., revealed the door to room 35 did not self-close and latch when tested.

Interview with the Facility Maintenance Director on May 21, 2025, at 11:30 a.m., confirmed the corridor door deficiency.




 Plan of Correction - To be completed: 06/24/2025

The door to room 35 was repaired to self-close and latch when tested.
The Maintenance Director was educated by the Nursing Home Administrator on the requirement of corridor doors and doors self-closing and latching and the guidelines related to K0363.
The Maintenance Director will complete random audits on facility corridor doors and doors to ensure self-closing and latching when tested as needed to validate compliance.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.


NFPA 101 STANDARD Fire Drills: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 Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform 1 of 12 required fire drills, affecting the entire facility.

Findings include:

1. Review of documentation on May 21, 2025, at 8:45 a.m., revealed the facility lacked documentation for the second shift fire drill in the third quarter.

Interview with the Facility Maintenance Director on May 21, 2025, at 8:45 a.m., confirmed the facility lacked documentation for the drill between July and September in 2024.





 Plan of Correction - To be completed: 06/24/2025

A second shift fire drill was completed on 06/05/2025.
The Nursing Home Administrator will develop a monthly fire drill schedule to ensure completion of drills on all three shifts, every quarter.
The Maintenance Director was educated by the Nursing Home Administrator on completion of drills on all three shifts, every quarter and guidelines related to K0712.
The Nursing Home Administrator will compete random audits on monthly fire drill to validate completion.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Categories
*Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES.
*General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES.
*Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours.
3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0915

Based on observation and interview, it was determined the facility was not able to locate the remote emergency stop switch for one of one emergency generators, affecting the entire facility.

Findings include:

1. Observation on May 21, 2025, at 10:50 a.m., revealed the facility could not verify the location of the remote manual stop station located outside of the generator enclosure.

Interview with the Facility Maintenance Director on May 21, 2025, at 11:30 a.m., confirmed the location of the remote manual stop station was unknown.




 Plan of Correction - To be completed: 06/24/2025

The remote manual stop station for the generator is labeled and located in the facility electrical room.
The Maintenance Director was educated by the Nursing Home Administrator on the location of the remote manual stop station for the generator and the guidelines related to K0915.
The Nursing Home Administrator will complete random audits to ensure the remote manual stop station for the generator remains labeled.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to perform emergency generator maintenance and testing in two instances, affecting the entire facility.

Findings include:

1. Review of documentation on May 21, 2025, at 8:45 a.m., revealed the facility lacked documentation verifying the following items were performed in the last 12 months:

a) 8:30 a.m., monthly inspections since February 2025;
b) 8:45 a.m., weekly inspections in 2025.

Interview with the Facility Maintenance Director, on May 21, 2025, at 8:45 a.m., confirmed the required weekly and monthly generator testing documentation was not available at the time of the survey.






 Plan of Correction - To be completed: 06/24/2025

The facility has past records for monthly and weekly generator inspections.
The Maintenance Director will utilize a premade for weekly and monthly generator inspections and follow a scheduled predetermined by the Nursing Home Administrator.
The Maintenance Director was educated on weekly and monthly generator testing and guidelines related to K0918.
The Nursing Home Administrator will complete random audits of weekly and monthly generator inspections to validate completion.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

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

Facility ID# 051202
Component 02
West Building

Based on a Medicare/Medicaid Recertification Survey completed on May 21, 2025, it was determined that Kadima Rehabilitation and Nursing at Latrobe, 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 V (000), unprotected wood frame building, without a basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Exit Signage: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.
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: BUILDING 02 - Component: 02 - Tag: 0293

Based on document review and interview, it was determined the facility failed to perform the monthly exit sign inspections for 12 of 12 months.

Findings Include:

1. Document review on May 21, 2025, at 9:00 a.m., revealed the facility lacked documentation for monthly exit sign inspections for the last 12 months.

Interview with the Facility Maintenance Director on May 21, 2025, at 9:00 a.m., confirmed the facility lacked documentation for exit sign inspections over the last 12 months at the time of the survey.






 Plan of Correction - To be completed: 06/24/2025

The Maintenance Director completed an in-house inspection on facility exit signs.
The Nursing Home Administrator will develop a monthly schedule on exit sign inspections to ensure compliance.
The Maintenance Director was educated by the Nursing Home Administrator on the requirement for monthly exit sign inspections and guidelines related to K0293.
The Nursing Home Administrator will complete a random audit on exit signage inspection to validate completion.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

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 documentation review and interview, it was determined the facility failed to maintain the fire alarm system in two instances, affecting the entire facility

Findings Include:

1. Review of documentation on May 21, 2025, at 9:15 a.m., revealed the following fire alarm system testing and maintenance deficiencies:

a) The facility lacked documentation for the semi-annual visual fire alarm inspection;
b) The facility lacked documentation for the biennial smoke detector sensitivity testing.

Interview with the Facility Maintenance Director on May 21, 2025, at 9:15 a.m., confirmed the fire alarm system deficiencies






 Plan of Correction - To be completed: 06/24/2025

The semi-annual visual fire alarm inspection completed on 04/14/2025. The biennial smoke detector sensitivity testing was completed on 04/14/2025.
The facility vendor for fire alarm system and testing and maintenance is prescheduled to ensure the facility remains in compliance. The Maintenance Director will maintain a hard copy of fire alarm system testing and maintenance to be readily accessible.
The Maintenance Director was educated by the Nursing Home Administrator on the requirement of fire alarm system testing and maintenance and guidelines related to K0345.
The Nursing Home Administrator will complete random audits of the facility's fire alarm system testing and maintenance documentation to validate completion.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting the entire facility.

Findings include:

1. Review of documentation on May 21, 2025, at 9:35 a.m., revealed the facility lacked documentation verifying that any sprinkler inspections were performed since June 2024.

Interview with the Facility Maintenance Director on May 21, 2025, at 9:35 a.m., confirmed the facility lacked documentation for sprinkler inspections.





 Plan of Correction - To be completed: 06/24/2025

The facility has records for past sprinkler inspections.
The facility vendor for the sprinkler and testing and maintenance is prescheduled to ensure the facility remains in compliance. The Maintenance Director will maintain a hard copy of the sprinkler system testing and maintenance to be readily accessible.
The Maintenance Director was educated by the Nursing Home Administrator on the requirement of the sprinkler system testing and maintenance and guidelines related to K0353.
The Nursing Home Administrator will complete random audits of the facility's sprinkler system testing and maintenance documentation validate completion.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

NFPA 101 STANDARD Fire Drills: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 Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform 1 of 12 required fire drills, affecting the entire facility.

Findings include:

1. Review of documentation on May 21, 2025, at 8:45 a.m., revealed the facility lacked documentation for the second shift fire drill in the third quarter.

Interview with the Facility Maintenance Director on May 21, 2025, at 8:45 a.m., confirmed the facility lacked documentation for the drill between July and September in 2024.





 Plan of Correction - To be completed: 06/24/2025

A second shift fire drill was completed on 06/05/2025.
The Nursing Home Administrator will develop a monthly fire drill schedule to ensure completion of drills on all three shifts, every quarter.
The Maintenance Director was educated by the Nursing Home Administrator on completion of drills on all three shifts, every quarter and guidelines related to K0712.
The Nursing Home Administrator will compete random audits on monthly fire drill to validate completion.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Categories
*Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES.
*General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES.
*Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours.
3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0915

Based on observation and interview, it was determined the facility was not able to locate the remote emergency stop switch for one of one emergency generators, affecting the entire facility.

Findings include:

1. Observation on May 21, 2025, at 10:50 a.m., revealed the facility could not verify the location of the remote manual stop station located outside of the generator enclosure.

Interview with the Facility Maintenance Director on May 21, 2025, at 11:30 a.m., confirmed the location of the remote manual stop station was unknown.




 Plan of Correction - To be completed: 06/24/2025

The remote manual stop station for the generator is labeled and located in the facility electrical room.
The Maintenance Director was educated by the Nursing Home Administrator on the location of the remote manual stop station for the generator and the guidelines related to K0915.
The Nursing Home Administrator will complete random audits to ensure the remote manual stop station for the generator remains labeled.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to perform emergency generator maintenance and testing in two instances, affecting the entire facility.

Findings include:

1. Review of documentation on May 21, 2025, at 8:45 a.m., revealed the facility lacked documentation verifying the following items were performed in the last 12 months:

a) 8:30 a.m., monthly inspections since February 2025;
b) 8:45 a.m., weekly inspections in 2025.

Interview with the Facility Maintenance Director, on May 21, 2025, at 8:45 a.m., confirmed the required weekly and monthly generator testing documentation was not available at the time of the survey.



 Plan of Correction - To be completed: 06/24/2025

The facility has past records for monthly and weekly generator inspections.
The Maintenance Director will utilize a premade for weekly and monthly generator inspections and follow a scheduled predetermined by the Nursing Home Administrator.
The Maintenance Director was educated on weekly and monthly generator testing and guidelines related to K0918.
The Nursing Home Administrator will complete random audits of weekly and monthly generator inspections to validate completion.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.



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