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

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Severity Designations

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

There are  40 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 HARMONY - 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 13, 2025, it was determined that Kadima Rehabilitation and Nursing at Harmony had deficiencies 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 documentation review and interview, the facility failed to maintain the emergency preparedness program, affecting the entire facility.

Findings include:

Document review and interview on May 13, 2025, at 9:00 a.m., revealed the facility lacked documentation showing an all hazard-approach plan that includes a hazard assessment.

Interview with the facility administrator and the maintenance director on May 13, 2025, at 9:00 a.m., confirmed the lack of documentation at the time of survey.




 Plan of Correction - To be completed: 07/14/2025

The facility will conduct and maintain a hazard assessment

The Nursing Home Administrator and Maintenance Director will be educated by the Regional Operations Director on hazard assessments

The Hazard assessment will be audited and reviewed by the interdisciplinary team monthly to evaluate if any changes are needed in the assessment.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.
403.748(b)(1), 418.113(b)(6)(iii), 441.184(b)(1), 482.15(b)(1), 483.475(b)(1), 483.73(b)(1), 485.542(b)(1), 485.625(b)(1) STANDARD Subsistence Needs for Staff and Patients: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(b)(1), §418.113(b)(6)(iii), §441.184(b)(1), §460.84(b)(1), §482.15(b)(1), §483.73(b)(1), §483.475(b)(1), §485.542(b)(1), §485.625(b)(1)

[(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:

(1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following:
(i) Food, water, medical and pharmaceutical supplies
(ii) Alternate sources of energy to maintain the following:
(A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(B) Emergency lighting.
(C) Fire detection, extinguishing, and alarm systems.
(D) Sewage and waste disposal.

*[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures.
(6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following:
(iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following:
(A) Food, water, medical, and pharmaceutical supplies.
(B) Alternate sources of energy to maintain the following:
(1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(2) Emergency lighting.
(3) Fire detection, extinguishing, and alarm systems.
(C) Sewage and waste disposal.
Observations:
Name: - Component: -- - Tag: 0015

Based on document review and interview, the facility failed to maintain the emergency preparedness program, affecting the entire facility.

Findings include:

Document review and interview on May 13, 2025, at 9:06 a.m., revealed the facility lacked documentation for a plan to track the location of on-duty staff in the event of an emergency.

Interview with the facility administrator and the maintenance director on May 13, 2025, at 9:06 a.m., confirmed the lack of documentation at the time of survey.



 Plan of Correction - To be completed: 07/14/2025

The facility will remove the language discussing locating staff during an emergency from the evacuation policy and will create an individual policy outlining the process and procedure for identifying and tracking the location of staff during an emergency.

All policies pertaining to emergency preparedness will be audited monthly by the interdisciplinary team to ensure every aspect of and emergency level event has a policy outlining the process and procedure to follow during that event.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.
403.748(b)(3), 416.54(b)(2), 418.113(b)(6)(ii), 441.184(b)(3), 482.15(b)(3), 483.475(b)(3), 483.73(b)(3), 485.542(b)(3), 485.625(b)(3), 485.68(b)(1), 485.727(b)(1), 485.920(b)(2), 491.12(b)(1), 494.62(b)(2) STANDARD Policies for Evac. and Primary/Alt. Comm.: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(b)(3), §416.54(b)(2), §418.113(b)(6)(ii), §441.184(b)(3), §460.84(b)(3), §482.15(b)(3), §483.73(b)(3), §483.475(b)(3), §485.68(b)(1), §485.542(b)(3), §485.625(b)(3), §485.727(b)(1), §485.920(b)(2), §491.12(b)(1), §494.62(b)(2)

[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]

[(3) or (1), (2), (6)] Safe evacuation from the [facility], which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.

*[For RNHCIs at §403.748(b)(3) and ASCs at §416.54(b)(2) and REHs at §485.542(b)(3):]
Safe evacuation from the [RNHCI or ASC or REHs] which includes the following:
(i) Consideration of care needs of evacuees.
(ii) Staff responsibilities.
(iii) Transportation.
(iv) Identification of evacuation location(s).
(v) Primary and alternate means of communication with external sources of assistance.

* [For CORFs at §485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at §485.727(b)(1), and ESRD Facilities at §494.62(b)(2):]
Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients.

* [For RHCs/FQHCs at §491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients.
Observations:
Name: - Component: -- - Tag: 0020

Based on document review and interview, the facility failed to maintain the emergency preparedness program, affecting the entire facility.

Findings include:

Document review and interview on May 13, 2025, at 9:22 a.m., revealed the facility lacked a transportation policy in the event of an evacuation. During an interview, the facility indicated company vans could be utilized.

Interview with the facility administrator and the maintenance director on May 13, 2025, at 9:22 a.m., confirmed the lack of documentation at the time of survey.




 Plan of Correction - To be completed: 07/14/2025

The facility will remove the language discussing emergency transportation during an emergency from the evacuation policy and will create an individual policy outlining the process and procedure for transportation during an emergency situation.

All policies pertaining to emergency preparedness will be audited monthly by the interdisciplinary team to ensure every aspect of and emergency level event has a policy outlining the process and procedure to follow during that event.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.
403.748(b)(5), 416.54(b)(4), 418.113(b)(3), 441.184(b)(5), 482.15(b)(5), 483.475(b)(5), 483.73(b)(5), 484.102(b)(4), 485.542(b)(5), 485.625(b)(5), 485.68(b)(3), 485.727(b)(3), 485.920(b)(4), 486.360(b)(2), 491.12(b)(3), 494.62(b)(4) STANDARD Policies/Procedures for Medical Documentation: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(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4).


[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]

[(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

*[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following:
(i) Preserves patient information.
(ii) Protects confidentiality of patient information.
(iii) Secures and maintains the availability of records.

*[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.
Observations:
Name: - Component: -- - Tag: 0023

Based on document review and interview, the facility failed to maintain the emergency preparedness program, affecting the entire facility.

Findings include:

Document review and interview on May 13, 2025, at 9:08 a.m., revealed the facility lacked documentation regarding how the facility plans to preserve resident information, confidentiality, and secure medical records.

Interview with the facility administrator and the maintenance director on May 13, 2025, at 9:08 a.m., confirmed the lack of documentation at the time of survey.



 Plan of Correction - To be completed: 07/14/2025

The facility will adopt and implement a policy to secure medical records for confidentiality during the event of the emergency.

All policies pertaining to emergency preparedness will be audited monthly by the interdisciplinary team to ensure every aspect of and emergency level event has a policy outlining the process and procedure to follow during that event.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.
403.748(c)(3), 416.54(c)(3), 418.113(c)(3), 441.184(c)(3), 482.15(c)(3), 483.475(c)(3), 483.73(c)(3), 484.102(c)(3), 485.542(c)(3), 485.625(c)(3), 485.68(c)(3), 485.727(c)(3), 485.920(c)(3), 486.360(c)(3), 491.12(c)(3), 494.62(c)(3) STANDARD Primary/Alternate Means for Communication: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(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3).

[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:

(3) Primary and alternate means for communicating with the following:
(i) [Facility] staff.
(ii) Federal, State, tribal, regional, and local emergency management agencies.

*[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies.
Observations:
Name: - Component: -- - Tag: 0032

Based on document review and interview, the facility failed to maintain the emergency preparedness program, affecting the entire facility.

Findings include:

Document review and interview on May 13, 2025, at 9:10 a.m., revealed the facility lacked documentation showing the plans for alternative means of communication in the event of an emergency.

Interview with the facility administrator and the maintenance director on May 13, 2025, at 9:10 a.m., confirmed the lack of documentation at the time of survey.



 Plan of Correction - To be completed: 07/14/2025

The facility will remove the language discussing alternative means of communication if the phone system were to fail from the evacuation policy and will create an individual policy outlining the process and procedure maintaining effective communication through means outside of the facilities phone system.

All policies pertaining to emergency preparedness will be audited monthly by the interdisciplinary team to ensure every aspect of and emergency level event has a policy outlining the process and procedure to follow during that event.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.
483.475(c)(8), 483.73(c)(8) STANDARD LTC and ICF/IID Sharing Plan with Patients: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.
§483.73(c)(8); §483.475(c)(8)

*[For LTC Facilities at §483.73(c):]
[(c) The LTC facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually. The communication plan must include all of the following:]

*[For ICF/IIDs at §483.475(c):]
[(c) The ICF/IID must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years. The communication plan must include all of the following:]

(8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.
Observations:
Name: - Component: -- - Tag: 0035

Based on document review and interview, the facility failed to maintain the emergency preparedness program, affecting the entire facility.

Findings include:

Document review and interview on May 13, 2025, at 9:20 a.m., revealed the facility lacked documentation to share the emergency preparedness plan with resident families and representatives.

Interview with the facility administrator and the maintenance director on May 13, 2025, at 9:20 a.m., confirmed the lack of documentation at the time of survey.



 Plan of Correction - To be completed: 07/14/2025

The facility will add a fact sheet covering main topics of the emergency preparedness plan in the admissions packet.
The facility will educate residents families and representatives on the Emergency preparedness plan during routine car plan meetings for all residents who currently reside in the facility.
403.748(d), 416.54(d), 418.113(d), 441.184(d), 482.15(d), 483.475(d), 483.73(d), 484.102(d), 485.542(d), 485.625(d), 485.68(d), 485.727(d), 485.920(d), 486.360(d), 491.12(d), 494.62(d) STANDARD EP Training and Testing: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(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.

*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).

*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.
Observations:
Name: - Component: -- - Tag: 0036

Based on document review and interview, the facility failed to maintain the emergency preparedness program, affecting the entire facility.

Findings include:

Document review and interview on May 13, 2025, at 9:03 a.m., revealed the facility lacked documentation for on-hire emergency preparedness trainings, annual tabletop exercises, and all-employee annual preparednesss trainings.

Interview with the facility administrator and the maintenance director on May 13, 2025, at 9:03 a.m., confirmed the lack of documentation at the time of survey.



 Plan of Correction - To be completed: 07/14/2025

The facility will conduct education on all current dietary staff members on emergency preparedness.

The facility will also ensure all newly hired dietary staff members receive this education as a part of the onboarding process.
482.15(e), 483.73(e), 485.542(e), 485.625(e) STANDARD Hospital CAH and LTC Emergency Power: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.
§482.15(e) Condition for Participation:
(e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section.

§483.73(e), §485.625(e), §485.542(e)
(e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section.

§482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1)
Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated.

482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2)
Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code.

482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2)
Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates.

*[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):]
The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.
If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes.
(1) National Fire Protection Association, 1 Batterymarch Park,
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
(i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011.
(ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011.
(iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
(iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
(v) TIA 12-5 to NFPA 99, issued August 1, 2013.
(vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
(vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011.
(viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
(ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
(x) TIA 12-3 to NFPA 101, issued October 22, 2013.
(xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
(xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009..
Observations:
Name: - Component: -- - Tag: 0041

Based on document review and interview, the facility failed to maintain the emergency preparedness program, affecting the entire facility.

Findings include:

Document review and interview on May 13, 2025, at 9:15 a.m., revealed the facility lacked plan documentation for emergency standby power to sustain power, fire detection, facility temperatures, and extinguishing systems. The facility is currently using a rented generator, as its generator is out of commission. The facility lacked a standby power policy.

Interview with the facility administrator and the maintenance director on May 13, 2025, at 9:15 a.m., confirmed the lack of documentation at the time of survey.



 Plan of Correction - To be completed: 07/14/2025

The facility will implement documentation to show how the generator will supply the facility with power in the event of an emergency.

The facility has a rented backup generator until the new generator is fully installed and operable.

All policies pertaining to emergency preparedness, as well as documentation outlying the process of the generator will be audited monthly by the interdisciplinary team to ensure every aspect of and emergency level event has a policy outlining the process and procedure to follow during that event.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.
Initial comments:Name: ENTIRE BUILDING - Component: 02 - Tag: 0000


Facility ID #051302
Component 02
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 13, 2025, it was determined that Kadima Rehabilitation and Nursing at Harmony was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type III (211), protected, ordinary building, with a partial basement and attic, that is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
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: ENTIRE BUILDING - Component: 02 - Tag: 0100

Based on observation, document review, and interview, the facility failed to report an incident affecting one of one facility.

Findings include:

Observation and document review on May 13, 2025, at 9:21 a.m., revealed the basement dryer had caught on fire on February 5, 2025. There was confirmed smoke in the building and residents were relocated safely behind fire doors until the smoke was completely ventilated. The facility failed to report the incident and provide an after-action report or detail the cause of the fire.

Interview with the maintenance director on May 13, 2025, at 9:21 a.m., confirmed the facility failed to report the incident.


Based on document review, observation, and interview, the facility failed to maintain portable floor plans that outlined designated rated partitions, affecting the entire facility. The facility also failed to receive State Plan Review approval and a granted occupancy from the Life Safety Division for a room change of use.

Findings include:

Observation and document review on May 13, 2025, between 8:18 a.m. and 8:55 a.m., revealed the following deficiencies:

A. (8:18 a.m.) 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 failed to include the following:

a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls (2-hour walls);
c. Rated rooms (storage rooms, soiled utility rooms, and 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 shall be clearly noted;
f. Shaft walls.

B. (8:55 a.m.) The main floor activities room bathroom was converted into a storage room without plans being submitted to State Plan Review or receiving a granted occupancy from the Life Safety Division.

Interview with the maintenance supervisor on May 13, 2025, at 8:55 a.m., confirmed the facility's Life Safety Code Floor Plan was unavailable at the time of the survey and the facility had an unauthorized room change of use.







 Plan of Correction - To be completed: 07/12/2025

The facility will create and maintain an accurate floor plan showing Smoke barrier walls, Fire barrier walls, rate rooms, exits and Shaft walls.

The activities room bathroom will be used as a bathroom.

The floor plan showing the referenced items needed will be audited monthly by the interdisciplinary team to ensure every aspect of floor plan is present on the form.
The activities room restroom will be audited weekly for four weeks and then monthly for three months to ensure it is being used as a restroom.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.

The facility will submit a report to the department of health detailing the dryer fire that occurred on February 5th, 2025
NFPA 101 STANDARD Building Rehabilitation: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.
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: ENTIRE BUILDING - Component: 02 - Tag: 0111

Based on observation, document review, and interview, the facility failed to meet building rehabilitation requirements for one of one facility.

Findings include:

Observation and document review on May 13, 2025, at 11:00 a.m., revealed the basement had a wooden plywood box installed under a dryer. The facility failed to provide documentation to indicate the wood was fire retardant. The box was built where the previous dryer fire was located.

Interview with the maintenance director on May 13, 2025, at 11:00 a.m., confirmed the facility was unable to provide documentation at the time of the survey.





 Plan of Correction - To be completed: 07/14/2025

The wooden box was removed from the laundry room.

The Nursing Home Administrator or designee will audit the laundry room weekly for four weeks and then monthly for three months to ensure that no potential fire hazards exist.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.
NFPA 101 STANDARD Multiple Occupancies - Construction Type: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.
Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: ENTIRE BUILDING - Component: 02 - Tag: 0133

Based on observation and interview, the facility failed to meet multiple occupancy requirements for one of one building component.
Findings include:
Observation on May 13, 2025, at 11:33 a.m., revealed the basement two-hour fire separation to personal care was propped open with a door wedge.
Interview with the maintenance director on May 13, 2025, at 11:33 a.m., confirmed the deficiency.



 Plan of Correction - To be completed: 07/12/2025

The wedge propping the doors was removed.

Housekeeping & laundry staff will be educated on keeping that door closed when not in immediate use to prevent the spread of fire/smoke in an emergency situation.

The basement two-hour fire separation to personal care will be audited daily for four weeks and then weekly for three weeks to ensure it is not propped open when not in immediate use.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.
NFPA 101 STANDARD Doors with Self-Closing Devices: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.
Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8
Observations:
Name: ENTIRE BUILDING - Component: 02 - Tag: 0223

Based on observation and interview, the facility failed to maintain doors with self-closing devices on four of over eight doors.

Findings include:

Observation on May 13, 2025, between 8:33 a.m. and 9:55 a.m., revealed the following self-closing door deficiencies:
A. (8:33 a.m.) Main level north wing electrical room failed to have a self-closing device;
B. (8:38 a.m.) Main level physical therapy room had a disconnected self-closing device on the door;
C. (9:34 a.m.) Main floor kitchen area door to the dishwashing room did not latch in the frame due to a broken egress bar;
D. (9:55 a.m.) Basement laundry area door to the central supply had the closure device removed.

Interview with the maintenance director on May 13, 2025, at 9:55 a.m., confirmed the self-closing door deficiencies.





 Plan of Correction - To be completed: 07/12/2025

The north unit electrical room will be installed with a self closing device to ensure the door is self closing.

The physical therapy rooms self closing device will be reconnected.

The kitchen door between the kitchen and dishwashing room will have a new egress bar installed on the door.

The central supply door in the basement will have a closure device installed.

The Nursing Home Administrator or designee will audit all doors in the facility to ensure they have the appropriate self-closing devices and egress bars installed on them. these audits will be done weekly for four weeks and then monthly for three months

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.


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: ENTIRE BUILDING - Component: 02 - Tag: 0225

Based on observation and interview, the facility failed to meet stairway and smokeproof enclosure requirements for one on over three stairway enclosures.
Findings include:
Observation on May 13, 2025, at 9:22 a.m., revealed the basement fire door to the stairwell had holes present from previous panic bar hardware. The current hardware is not fire-rated hardware. The door failed to latch.
Interview with the maintenance director on May 13, 2025, at 9:22 a.m., confirmed the deficiency.




 Plan of Correction - To be completed: 07/12/2025

A new door that is fire rated, and latches appropriately will be installed replacing the current door in the stairwell

The Nursing Home Administrator or designee will audit the facility weekly for four weeks and then monthly for three months to ensure all fire rated doors are intact and latch appropriately.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.
NFPA 101 STANDARD Discharge from Exits: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.
Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7
Observations:
Name: ENTIRE BUILDING - Component: 02 - Tag: 0271

Based on observation and interview, the facility failed to meet exit discharge requirements for two exit discharges affecting the entire facility.
Findings include:
1. Observation on May 13, 2025, at 8:39 a.m., revealed the south exit near the conference room had a milk crate blocking the door and a vehicle parked on the exit pathway that leads to the public way.
Interview with the maintenance director on May 13, 2025, at 8:39 a.m., confirmed the deficiency.

2. Observation on May 13, 2025, at 11:45 a.m., revealed both of the north exit doors that provide the only egress for over thirty residents failed to open when tested. The doors remained closed when the fire alarm was pulled. No exit was accessible in the north smoke compartment. Additional interview uncovered door relay deficiencies with the fire alarm system. No troubles were visible on the panel. The facility removed the mag locks to open the doors and put in a repair request to Silent Night at the time of the survey.
Interview with the maintenance director on May 13, 2025, at 11:45 a.m., confirmed the deficiencies.




 Plan of Correction - To be completed: 07/12/2025

The milk crate was immediately removed from the vestibule. The vehicle was removed by the employee who owned the vehicle.

The west doors were identified to be malfunctioning due to a shorted relay. Mongiovi and Horizion came in to due the necessary repairs that night.

The vestibules will be audited weekly for four weeks and then monthly for three months to ensure they are free of anything that should not be located within them. The parking lot will be audited weekly for four weeks and then monthly for three months to ensure no vehicles are parked on the sidewalk. All exit doors will be audited weekly for four weeks and then monthly for three months to ensure all doors open to the exterior of the facility when needed.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.
NFPA 101 STANDARD Exit Signage: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.
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: ENTIRE BUILDING - Component: 02 - Tag: 0293

Based on observation and interview, the facility failed to meet exit signage requirements for one of two dining room areas.
Findings include:
Observation on May 13, 2025, at 10:43 a.m., revealed the south dining room had no exit signage visible to direct residents out of the building in the event of an emergency.
Interview with the maintenance director on May 13, 2025, at 10:43 a.m., confirmed the deficiency.





 Plan of Correction - To be completed: 07/12/2025

The facility has installed exit signs above both of the two doors to exit the dining room

The Nursing Home Administrator or designee will do a whole house audit to ensure there is no other location that would need exit signs and currently does not have them. This audit will then occur weekly for four weeks and then monthly for three months.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.
NFPA 101 STANDARD Vertical Openings - Enclosure: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.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: ENTIRE BUILDING - Component: 02 - Tag: 0311

Based on observation and interview, the facility failed to maintain vertical openings for one of two vertical enclosures.

Findings include:

Observation on May 13, 2025, at 10:04 a.m., revealed the main level laundry chute door failed to self-close and to latch.

Interview with the maintenance director on May 13, 2022, at 10:04 a.m., confirmed the vertical opening deficiencies.




 Plan of Correction - To be completed: 07/12/2025

The laundry chute will have a self-closing device installed

The Nursing Home Administrator or designee will audit the laundry chute to ensure the self-closing device is installed and is correctly working. These audits will be conducted weekly for four weeks and then monthly for three months.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.
NFPA 101 STANDARD Cooking Facilities: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.
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: ENTIRE BUILDING - Component: 02 - Tag: 0324

Based on observation, document review, and interview, the facility failed to maintain cooking facilities in one of one kitchen area.
Findings include:
1. Observation and interview on May 13, 2025, at 9:42 a.m., revealed one of one kitchen staff member interviewed was unaware of the location and procedure for manually activating the hood suppression system. This finding is a repeat deficiency from the 2024 survey.
Interview with the maintenance director on May 13, 2025, at 9:42 a.m., confirmed the staff member was unaware of the activation of the hood system.
2. Document review on May 13, 2025, at 8:33 a.m., revealed the following kitchen maintenance deficiencies at the time of the survey:
A.(8:33 a.m.) The facility failed to provide one of two semi-annual kitchen hood suppression disputations. March 6, 2025, and September 15, 2022, were provided at the time of the survey;
B. (8:33 a.m.) The facility failed to provide two of two kitchen hood and duct cleaning reports, the last report dated May 8, 2023.
Interview with the maintenance director on May 13, 2025, at 8:33 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.







 Plan of Correction - To be completed: 07/12/2025

Hood suppression disputation education will be provided to all dietary staff members.

The facility will conduct hood and duct cleaning.

The Nursing Home Administrator or designee will audit dietary staff education for 100% completion. These audits will be conducted weekly for four weeks and then monthly for three months. The Hood and duct cleaning report will be audited during the facilities stand up meeting to review when service will need to be done after it is completed. These audits will be conducted weekly for four weeks and then monthly for three months.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Fire Alarm System - 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: ENTIRE BUILDING - Component: 02 - Tag: 0345

Based on observation, document review, and interview, the facility failed to maintain fire alarm system and maintenance requirements for one of one system.
Findings Include:
1. Document review on May 13, 2025, between 8:40 a.m. and 8:43 a.m., revealed the following kitchen maintenance deficiencies at the time of the survey:
A.(8:40 a.m.) The facility failed to provide one of two semi-annual visual inspections of the fire alarm system;
B. (8:41 a.m.) The facility failed to provide the two-year smoke detector sensitivity report, with the last report dated December 1, 2022.
C. (8:43 a.m.) The facility's annual fire alarm report, completed February 6, 2025, reported the battery was expired;
D. (8:43 a.m.) The facility's annual fire alarm report, completed February 6, 2025, reported the smoke detector near room 305 failed;
E. (8:43 a.m.) The facility's annual fire alarm report, completed February 6, 2025, failed to report a pass or fail on the horn section.
Interview with the maintenance director on May 13, 2025, at 8:43 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.

2. Observation and document review on May 13, 2025, between 11:20 a.m. and 11:25 a.m., revealed the following fire alarm system deficiencies for one of one system:

A. (11:20 a.m.) South dining room had a battery-operated smoke detector with tape with the date of 2018;
B. (11:24 a.m.) The facility was unable to provide documentation for the monthly testing of the battery-operated smoke detector;
C. (11:24 a.m.) The facility was unable to provide documentation for the battery-operated smoke detector policy;
D. (11:25 a.m.) The facility was unable to provide documentation for the six-month battery replacement.

Interview with the maintenance director on May 13, 2025, at 11:25 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.








 Plan of Correction - To be completed: 07/12/2025

The facility will conduct a visual inspection of the dire alarm system.

The facility will conduct a smoke detector sensitivity test

The battery in the fire alarm will be replaced with a new one

The smoke detector near room 305 will be evaluated and repaired.

The facility will conduct a fire alarm inspection to determine a pass or fail report on the horn section.

The facility will implement a battery operated smoke detector policy.

The facility will replace the batteries in the dinning room smoke detector and replace them every 6 months.

The Nursing Home Administrator or designee will audit all fire alarm/smoke detectors to ensure they are functioning correctly and maintenance on them is being done timely and appropriately. These audits will be conducted weekly for four weeks and then monthly for three months.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.


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: ENTIRE BUILDING - Component: 02 - Tag: 0353

Based on document review and interview, the facility failed to meet sprinkler system requirements for two of two sprinkler systems.

Findings include:

1. Document review on May 13, 2025, between 9:10 a.m. and 9:14 a.m., revealed the following sprinkler system deficiencies at the time of the survey:
A.(9:10 a.m.) The facility failed to provide documentation for the third and fourth quarter.
B.(9:11 a.m.) The facility failed to provide the three-year, full-flow trip test documentation;
C.(9:12 a.m.) The facility failed to provide the annual partial trip test documentation;
D. (9:13 a.m.) The facility failed to provide the five-year internal pipe inspection documentation;
E. (9:13 a.m.) The facility failed to provide semi-annual valve supervisory switches and waterflow alarm device documentation;
F. (9:13 a.m.) The facility's five-year gauge replacement or recalibration was last documented January 2020.

Interview with the maintenance director on May 13, 2025, at 9:13 a.m., confirmed the documentation was unavailable at the time of the survey.

2. Document review on May 13, 2025, at 9:22 a.m., revealed the following sprinkler system deficiencies that were listed on the April 22, 2025 sprinkler report:
A.(9:22 a.m.) Hydrostatic test is due for the fire department connection piping back to the check valve;
B.(9:22 a.m.) Dry pendent heads over 15 years need one percent pulled for testing.
C.(9:22 a.m.) Kitchen area sprinkler heads too close together could cause "cold soldering";
D. (9:22 a.m.) Sprinkler heads throughout the facility over 50 years old need a percentage pulled for testing;
E. (9:22 a.m.) Air compressor in the water room was shutting on and off every ten minutes, indicating a hole in the dry system;
F. (9:22 a.m.) Sprinkler heads throughout corroded and dirty.

Interview with the maintenance director on May 13, 2025, at 9:22 a.m., confirmed the deficienices were listed on the April 22, 2025, sprinkler report.

3. Observation on May 13, 2025 at 10:29 a.m., revealed the basement break room had painted sprinkler heads and gaps around the escutcheons.
Interview with the administrator and maintenance supervisor on May 13, 2025 at 10:29 a.m., confirmed the deficiencies.







 Plan of Correction - To be completed: 07/12/2025

The facility will conduct a sprinkler system inspection

The facility will conduct a full flow trip test

The facility will conduct a partial trip test

The facility will conduct an internal pipe inspection

The facility will obtain documentation on the vale supervisory switches and waterflow alarm device

The facility will conduct an inspection into the gauge replacement or recalibration

The Nursing Home Administrator or designee will audit all routine physical site testing to ensure all testing has been conducted timely. These audits will be conducted weekly for four weeks and then monthly for three months to ensure that
NFPA 101 STANDARD Portable Fire Extinguishers: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.
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: ENTIRE BUILDING - Component: 02 - Tag: 0355

Based on document review and interview, the facility failed to meet portable fire extinguisher requirements for one of one component.

Findings include:

1. Document review on May 13, 2025, at 9:50 a.m., revealed the fire extinguisher service certification expired.

Interview with the maintenance director on May 13, 2025, at 9:50 a.m., confirmed the documentation was expired at the time of the survey.

2. Observation on May 13, 2025, at 11:50 a.m., revealed two fire extinguishers in the attic were dated 2023 and lacked monthly inspections.

Interview with the maintenance director on May 13, 2025, at 11:50 a.m., confirmed the fire extinguishers were outdated and lacked monthly inspections.






 Plan of Correction - To be completed: 07/12/2025

The facility will renew the fire extinguisher service certification.

The fire extinguishers in the attic will be replaced and inspected monthly

The Nursing Home Administrator or designee will audit all facility fire extinguishers to ensure they are up to date and inspected monthly. These audits will be conducted weekly for four weeks and then monthly for three months.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: ENTIRE BUILDING - Component: 02 - Tag: 0372

Based on observation and interview, the facility failed to maintain smoke barrier construction on two of two building levels.

Findings include:

Observations on May 13, 2025, between 8:21 a.m. and 10:05 a.m., revealed the following:

A. (8:21 a.m.) Mechanical room ceiling had openings and unsealed drywall repairs that would allow the transfer of smoke;
B. (9:49 a.m.) Basement laundry corridor had missing drywall and unsealed repairs in the ceiling that would allow the transfer of smoke;
C. (9:57 a.m.) Basement laundry chute room had several holes, repairs with loose tape, and ceiling tiles replacing drywall;
D (9:57 a.m.) Basement laundry corridor had a ceiling tile taped to the ceiling, possibly covering a unsealed repair;
E. (10:05 a.m.) Main level laundry chute room had an opening above the chute door, allowing the transfer of smoke.

Interview with the maintenance director on May 13, 2025, at 10:05 a.m., confirmed the smoke barrier deficiencies, with an estimated up to ten percent of the ceiling area affected in the observation.







Based on observation and interview, the facility failed to meet smoke barrier construction requirements for one of one facility.
Findings include:
Observation on May 13, 2025, between 10:57 a.m. and 11:10 a.m., revealed the following smoke barrier construction deficiencies:
A.(10:57 a.m.) South dining room had railing supports that were hanging off the wall, creating openings in the drywall;
B.(11:10 a.m.) Basement break room had drooping ceiling tiles and gaps that allow the passage of smoke.
Interview with the maintenance director on May 13, 2025, at 11:10 a.m., confirmed the deficiencies.


 Plan of Correction - To be completed: 07/12/2025

The south hall dining room railing supports have been removed with a new rail system installed.

The basement break room ceiling has been fixed with new ceiling tiles

The mechanical room ceiling will have ceiling holes filed and drywall repaired

The basement laundry corridor drywall will be repaired, and the ceiling will be filled to correct the holes

The basement laundry chute room will have holes repaired. The tape will be removed the ceiling tiles will be replaced with drywall

The opening above the chute door will be corrected

The Nursing Home Administrator or designee will audit the basement and dinning room to ensure all drywall is in tact, no tape or ceiling tiles are used in Lou of drywall. And that the new rail system in the dinning room is intact. These audits will be conducted weekly for four weeks and then monthly for three months.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.
NFPA 101 STANDARD HVAC: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.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: ENTIRE BUILDING - Component: 02 - Tag: 0521

Based on document review and interview, the facility failed to maintain smoke and fire damper requirements for one of one facility:

Findings include:

Document review on May 13, 2025, at 11:44 a.m., revealed the report completed on July 3, 2024, revealed the following information was compiled on a proposal for the fire and smoke damper inspection:
A.(11:44 a.m.) "From the mechanical drawings found at the site, there were 3 fire/smoke dampers (FSD) total, 2 we located in the attic, The 3rd we believe is in the attic as well but could not be verified today. We found a plywood access screwed shut. This will have to be removed and made accessible for future inspection (see exclusions) if we find this damper exists";
B. (11:44 a.m.) "We found 2 FSD's today, each had power, but actuators were burnt holding damper blades open";
C.(11:44 a.m.) "Dampers move freely and can be repaired";
D. (11:44 a.m.) "Replace existing actuators with direct drive like SPEC UL-555C rated electric actuators";
E.(11:44 a.m) "By code each damper will need a UL listed duct access installed";
F.(11:44 a.m) "Upgrade existing 2x4 junction box with 4x4 junction box to provide a test switch for repairs and future testing";
G.(11:44 a.m.) "Trouble shoot wiring to try to locate power source";
H. (11:44 a.m.) "Work with Mongovi to test duct detector and fire system to test damper activation";
I. (11:44 a.m.) "If fire system does not operate fire smoke dampers FSD a separate isolation relay will have to be installed separately from this proposal";
J.(11:44 a.m.) "We found the hallways are fire rated ceiling and all diffusers and registers have ceiling rated fire dampers (CRD). We counted 29 in the hallway. These will need to be inspected. Existing have no inspection sticker and by NFPA code is required on a 4 year rotation."

Interview with the adminstrator on May 13, 2025, at 11:44 a.m., confirmed deficient documentation was provided for the fire and smoke damper inspection.




 Plan of Correction - To be completed: 07/12/2025

The plywood access screws will be removed

The actuators will be replaced, and junction box will be upgraded to 4x4

The ceiling rated fire dampers have been inspected, and new stickers have been previously put on

The Nursing Home Administrator or designee will audit the ceiling rated fire dampers and the plywood access point to ensure they are up to date and inspected, and the plywood access point is not screwed shut. These audits will be conducted weekly for four weeks and then monthly for three months.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.
NFPA 101 STANDARD Fire Drills: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.
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: ENTIRE BUILDING - Component: 02 - Tag: 0712

Based on document review and interview, the facility failed to meet fire drill requirements for one of three shifts.

Findings include:

Document review on May 13, 2025, at 9:00 a.m., revealed the facility was unable to provide documentation for the second shift, third quarter. The fire drill provided for the second shift, fourth quarter had a March date erased.

Interview with the maintenance director on May 13, 2025, at 9:21 a.m., confirmed the facility was unable to provide the documentation.



 Plan of Correction - To be completed: 07/12/2025

The facility will conduct fire drills on all shifts and will maintain through each quarter.

The Nursing Home Administrator or designee will audit all fire drills to ensure they are being conducted appropriately and timely. These audits will be conducted weekly for four weeks and then monthly for three months.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.


NFPA 101 STANDARD Smoking Regulations: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.
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: ENTIRE BUILDING - Component: 02 - Tag: 0741

Based on observation and interview, the facility failed to maintain smoking regulations for one of one building component.
Findings include:
Observation on May 13, 2025, at 8:45 a.m., revealed the facility failed to adhere to its smoking policy regarding the designated smoking area. Specifically, smoking was allowed at the exit near resident room 402, with a one-gallon metal container overflowing with smoking debris present. There was an accumulation of cigarette butts on the ground outside this exit and in the gravel near the pathway. Additionally, no ashtrays or metal containers with self-closing cover devices were present. This finding is a repeat deficiency from the 2024 survey. No smoking signs were also present on the exit door, visible on both sides of the door.
Interview with the maintenance director on May 13, 2025, at 8:45 a.m., confirmed the smoking policy was not being followed.





 Plan of Correction - To be completed: 07/12/2025

Staff will be educated on the designated smoking locations.

The cigarette butts will be removed from the referenced area

The one gallon metal container will be removed from the referenced area.

A daily audit will be completed to ensure that no staff member is smoking in a non smoking designated area
NFPA 101 STANDARD Electrical Systems - Other: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.
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: ENTIRE BUILDING - Component: 02 - Tag: 0911

Based on observation and interview, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, on two of more than five wiring connections.

Findings include:

Observation on May 13, 2025, between 9:37 a.m. and 9:52 a.m., revealed the following electrical deficiencies;
A. (9:37 a.m.) Kitchen ice machine was connected to a non-protected ground fault circuit interrupter (GFCI) receptacle on the opposite side of the wall in the dishwashing area. The appliance cord was routed through the wall to the receptacle;
B. (9:52 a.m.) Basement laundry room exhaust fan was wired with non-metallic wire and a plug connected into a receptacle.

Reference: NFPA 70-400.8 (2) & 70-300.15

Interview with the maintenance director on May 13, 2025, at 9:52 a.m., confirmed the electrical system deficiencies.








 Plan of Correction - To be completed: 07/12/2025

The dishwasher area receptacle was changed into a GFCI outlet. A new GFCI receptacle was installed on the side of the wall where the ice machine is located. The ice machine is now connected to the GFCI receptacle on the side of the wall where the ice machine is located.

The basement laundry room exhaust fan will be hard wired into the electrical system.

The Nursing Home Administrator or designee will audit the ice machine to ensure it is powered correctly and the GFCI outlet is intact. The laundry room exhaust fan will be audited to ensure it is hard wired into the electrical system. These audits will be conducted weekly for four weeks and then monthly for three months.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.
NFPA 101 STANDARD Electrical Systems - Receptacles: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 - 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: ENTIRE BUILDING - Component: 02 - Tag: 0912

Based on observation and interview, the facility failed to maintain seven of more than thirty electrical receptacles.

Findings include:

Observation on May 13, 2025, between 8:36 a.m. and 9:37 a.m., revealed the following electrical outlet deficiencies:
A. (8:36 a.m.) Main level physical therapy room, above the main entrance door, had an electrical outlet uncovered with exposed wiring;
B. (8:47 a.m.) Main level north-northwest wing med room #2 had two receptacles that were not ground fault circuit interrupter (GFCI) protected within six feet of a water basin;
C. (8:51 a.m.) Main level northwest wing soiled utility room had two receptacles that were not GFCI protected within six feet of a water basin;
D. (9:32 a.m.) Main level kitchen dishwashing area had a receptacle that was not GFCI protected within six feet of a water basin;
E. (9:35 a.m.) Main level kitchen janitorial closet, near dishwashing room, had a receptacle that was not GFCI protected within six feet of a water basin;
F. (9:37 p.m.) Main level kitchen coffee maker and soda machine were not connected to a GFCI protected receptacle.

Interview with the maintenance director on May 13, 2025, at 9:37 a.m., confirmed the electrical outlet deficiencies.






 Plan of Correction - To be completed: 07/12/2025

The main level physical therapy room will have the electrical outlet covered with wiring unexposed.

The northwest med room #2 will have both referenced receptacles will have GFCI outlets installed

The northwest wing soiled utility room will have both referenced receptacles will have GFCI outlets installed

The kitchen dishwasher areas receptacle will have a GFCI outlet installed

The janitorial closet near the dishwashing room will have the receptacle installed with GFCI outlets

the kitchens coffee maker and soda machine will be connected to a GFCI protected receptacle.

The Nursing Home Administrator or designee will audit the facility to ensure all needed GFCI outlets are installed and in tact. The outlet cover in the physical therapy room will also be audited. These audits will be conducted weekly for four weeks and then monthly for three months.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.
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: ENTIRE BUILDING - Component: 02 - Tag: 0918

Based on document review and interview, the facility failed to meet electrical system requirements for one of one generator.

Findings include:

1. Document review on May 13, 2025, between 8:52 a.m. and 8:56 a.m., revealed the facility failed to provide the following generator documentation at the time of the survey:

A.(8:52 a.m.) December 2024-May 2025 weekly visual and battery voltage reports;
B.(8:54 a.m.) December 2024-May 2025 monthly load tests;
C.(8:55 a.m.) Three-year, four-hour load test;
D. (8:56 a.m.) Last-documented 90-minute load test completed April 25, 2023;
E. (8:56 a.m.) Fuel quality testing.

Interview with the maintenance director on May 13, 2025, at 8:56 a.m., confirmed the documentation was unavailable at the time of the survey.

2. Observation on May 13, 2025, at 9:10 a.m., revealed the generator malfunctioned on July 7, 2023. Through observation and interview, the facility stated that it installed and is currently using a temporary generator. The facility failed to meet monthly and weekly requirements for the temporary generator.
Interview with the administrator and maintenance supervisor on May 13, 2025, at 9:10 a.m., confirmed the deficiencies.

3. Observation on May 13, 2025, at 10:45 a.m., revealed the generator annunciator panel failed to operate at the time of the inspection.
Interview with the administrator and maintenance supervisor on May 13, 2025, at 10:45 a.m., confirmed the annunciator panel failed to operate.





 Plan of Correction - To be completed: 07/12/2025

The facility will conduct a weekly visual and battery voltage inspection and report the data

The facility will conduct a monthly load test and report the data

The facility will conduct a three-year, four-hour load test and report the data

The facility will conduct a 90 minute load test and report the data

The facility will conduct a fuel quality test and report the data.

The facility will create a schedule to ensure these tests are done and are conducted and reported timely in the future.
NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: ENTIRE BUILDING - Component: 02 - Tag: 0923

Based on observation and interview, the facility failed to maintain gas equipment storage requirements in one of one storage area.

Findings include:

Observation on May 13, 2025, at 9:07 a.m., revealed the oxygen cylinder storage room had a used oxygen cylinder in the full cylinder rack. The cylinder separation, with location of empty and full signs, was not defined..

Interview with the maintenance director on May 13, 2025, at 9:07 a.m., confirmed the oxygen cylinder deficiencies.




 Plan of Correction - To be completed: 07/12/2025

The oxygen storage room will be audited to ensure that there are no current oxygen cylinders stored in the incorrect location

The full and empty oxygen storage racks will be further separated away from each other in the room

The Nursing Home Administrator or designee will audit the oxygen storage room to ensure all oxygen cylinders are stored in the correct location. These audits will be conducted weekly for four weeks and then monthly for three months.

The results of those audits will be forwarded monthly to the Quality assurance improvement meeting for review, recommendations and frequency of audits.


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