Pennsylvania Department of Health
 FAIR ACRES GERIATRIC CENTER
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
FAIR ACRES GERIATRIC CENTER
Inspection Results For:

There are  53 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.
FAIR ACRES GERIATRIC CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000
Based on an Emergency Preparedness Survey conducted on March 9, 2026 and completed on March 10, 2026, at Fair Acres Geriatric Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.


 Plan of Correction:


Initial comments:Name: BLDG 5 (NE WING ONLY=COMP 50 CROZER CHESTER GERI) - Component: 02 - Tag: 0000
Facility ID# 061002

Component 02

Building 05

Based on a Medicare/Medicaid Recertification Survey conducted on March 9, 2026 and completed on March 10, 2026, it was determined that Fair Acres Geriatric Center - Building 05 was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type III (200) unprotected ordinary building, with a basement, that is fully sprinklered.


 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type: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.
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: BLDG 5 (NE WING ONLY=COMP 50 CROZER CHESTER GERI) - Component: 02 - Tag: 0133 Based on observation and interview, it was determined the facility failed to maintain the fire resistance of fire barriers, affecting one of two levels. Findings include: 1. Observation on March 10, 2026, at 10:05 a.m., revealed an open penetration above double doors on the left side, Breezeway that leads to Building 6. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 am, confirmed the penetration.
 Plan of Correction - To be completed: 03/26/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

Penetration filled with Hilti Fire Stop System W-L-3385

Area will be monitored monthly for 1 quarter to ensure there are no penetrations.


Completed: 3/26/26

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: BLDG 5 (NE WING ONLY=COMP 50 CROZER CHESTER GERI) - Component: 02 - Tag: 0353 Based on document review and interview, it was determined the facility failed to maintain and inspect the sprinkler system, affecting the entire facility. Findings include: Document review on March 9, 2026, at 8 am, revealed the facility could not provide documentation of the following:Internal pipe and valve inspection within the past five years;Sprinkler gauge replacement within the past five years.Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 am, confirmed the lack of documentation.
 Plan of Correction - To be completed: 04/14/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

Sprinkler company called to secure date of 5 Year Sprinkler Inspection completion.

Work is scheduled to be completed by April 14, 2026

Maintenance designee will monitor yearly to ensure 5 year sprinkler inspection is completed timely.





NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
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: BLDG 5 (NE WING ONLY=COMP 50 CROZER CHESTER GERI) - Component: 02 - Tag: 0372 Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting one of two levels. Findings include: 1. Observation on March 10, 2026, at 10:20 a.m., revealed an unsealed penetration above double smoke doors, 5 North West near the Tub Room. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 am, confirmed the open penetration.
 Plan of Correction - To be completed: 03/26/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

Penetration filled with Hilti Fire Stop System W-L-3385

Area will be monitored monthly for 1 quarter to ensure penetrations are not present in the area.
Completed: 3/26/26


Initial comments:Name: BLDG. 6 - Component: 03 - Tag: 0000
Facility ID# 061002

Component 03

Building 06

Based on a Medicare/Medicaid Survey conducted on March 9, 2026 and completed on March 10, 2026, it was determined that Fair Acres Geriatric Center - Building 06 was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 three-story, Type II (222) fire resistive building, with a basement, that is fully sprinklered.


 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: BLDG. 6 - Component: 03 - Tag: 0211 Based on observation and interview, it was determined the facility failed to maintain doors in the means of egress free of obstructions to full use, affecting one of three levels. Findings Include: 1. Observation on March 10, 2026, at 10:30 am, revealed the emergency exit door was stuck and difficult to open due to frame distortion, ground floor, by supervisors' office. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 a.m., confirmed the emergency egress obstruction.
 Plan of Correction - To be completed: 04/14/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

Door and frame will be repaired to ensure proper opening during an emergency

Maintenance designee will monitor door sweeps identified monthly for 1 Quarter.
NFPA 101 STANDARD Egress 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.
Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
Observations:
Name: BLDG. 6 - Component: 03 - Tag: 0222 Based on observation and interview, it was determined the facility failed to maintain egress doors with special locking arrangements, affecting one of three levels. Findings include: 1. Observation on March 10, 2026, at 9:20 a.m., revealed the egress door #103, failed to release when tested. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 a.m., confirmed the door failed to release at 30 seconds when tested.
 Plan of Correction - To be completed: 03/26/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

Door lock was replaced by M3T Corp. on 3/23/26 and tested to meet code.

Door will be monitored weekly for 1 Quarter to ensure door releases properly.
3/26/2026

NFPA 101 STANDARD Exit Signage: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.
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: BLDG. 6 - Component: 03 - Tag: 0293 Based upon observation and interview, it was determined the facility failed to ensure that exitsigns were maintained within two of three levels of the component. Findings include: 1.Observation made on March 10, 2026, between 9:00 a.m., and 11:30 a.m., revealed: a) An exit sign was dislodged from ceiling on the first floor by the soiled utility. b) An exit sign inside Stair Tower One, ground floor, was not illuminated. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 a.m., confirmed the dislodged exit sign.
 Plan of Correction - To be completed: 03/26/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

Exit Sign by first floor soiled utility room was repaired.

Exit sign light was replaced.

Exit signs in the above areas will monitor monthly for 1 Quarter to ensure the are working properly

Completed: 3/26/2026


NFPA 101 STANDARD Smoke Detection: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.
Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2
Observations:
Name: BLDG. 6 - Component: 03 - Tag: 0347 Based upon observation and interview, it was determined the facility failed to maintain smoke detectors on one of at least twenty-five smoke detectors within this component. Findings include: 1.Observation made on March 10, 2026, at 9:15 a.m., revealed a broken smoke detector on ceiling outside of soiled utility room, first floor. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 am,confirmed the damaged smoke detector.
 Plan of Correction - To be completed: 03/26/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

Smoke Detector was repaired, will monitor monthly for one quarter to ensure it is not broken.
Completed: 3/26/26

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: BLDG. 6 - Component: 03 - Tag: 0363 Based on observation and interview it was determined the facility failed to ensure that corridor doors were maintained to resist the passage of smoke and positively latch on one of three levels. Findings include: 1.Observation on March 10, 2026, at 9:50 a.m., revealed first floor resident room 116, failed to latch smoke tight in frame. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 a.m., confirmed the door failed to latch.
 Plan of Correction - To be completed: 03/26/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

Door was adjusted to latch smoke tight in frame.

Maintenance designee will monitor door monthly for one quarter.

Completed: 3/26/26


NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
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: BLDG. 6 - Component: 03 - Tag: 0372 Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls, affecting one of three levels. Findings include: 1. Observation on March 10, 2026, at 10:00 a.m., revealed an unsealed penetration around data wires, 1st floor above smoke doors by Nourishment. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 a.m., confirmed the penetration.
 Plan of Correction - To be completed: 03/26/2026

Plan of Correction:























Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

Penetration filled with Hilti Fire Stop System W-L-3385, monitored for 1 Quarter.

Maintenance Designee will monitor area monthly for one quarter to ensure no penetrations.

Completed: 3/26/26

3/26/2026

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: BLDG. 6 - Component: 03 - Tag: 0918 Based on document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire component. Findings include: Document review on March 9, 2026, at 8:00 am, revealed the facility could not produce documentation for the following tests and inspections:Monthly generator testing, under load, for: February, 2025; April, 2025; June, 2025; September, 2025; October, 2025; November, 2025; December, 2025;Monthly testing of ATS for: February, 2025; April, 2025; June, 2025; September, 2025; October, 2025; November, 2025; December, 2025.Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 am, confirmed the lack of documentation.
 Plan of Correction - To be completed: 04/02/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

Contract Generator Company was immediately called to request prior paperwork to show all previous required generator testing and inspection were completed timely. Paperwork was obtained and will be placed in book for review.

Maintenance designee will monitor monthly for one year to ensure all proper paperwork pertaining to required generator testing and inspection is received at time of service.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
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: BLDG. 6 - Component: 03 - Tag: 0923 Based on observation and interview, it was determined the facility failed to ensure oxygen cylinders stored within rooms, were distanced from combustible materials / ignition sources in one of three levels within this component. Findings include: 1.Observation made on March 10, 2026, at 9:55 a.m., revealed within ground floor Med room/oxygen storage, oxygen cylinders were stored less than five feet from electrical receptacles and battery charging stations. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 a.m., confirmed that the cylinders were stored less than five feet from combustible / ignition sources.
 Plan of Correction - To be completed: 03/26/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

Oxygen Storage will be relocated to an area away from combustibles.

New area will be monitored by maintenance designee monthly for 1 Quarter to ensure area is away from combustibles.

Completed: 3/26/26


Initial comments:Name: BLDG. 7 - Component: 04 - Tag: 0000
Facility ID# 061002

Component 04

Building 7

Based on a Medicare/Medicaid Recertification Survey conducted on March 9, 2026 and completed on March 10, 2026, it was determined that Fair Acres Geriatric Center -Building 07 was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy.  Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type III (200) unprotected ordinary building, with a basement, that is fully sprinklered.


 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: BLDG. 7 - Component: 04 - Tag: 0211 Based on observation and interview, it was determined the facility failed to maintain the means of egress free of impediments to full and instant use, affecting one of two levels. Findings include: 1. Observation on March 10, 2026, at 11:35 a.m., revealed, 1st floor emergency exit by the day room, the exit door was obstructed by a chair in the vestibule area. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 a.m., confirmed the obstructed egress door.
 Plan of Correction - To be completed: 03/26/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

Chair was removed from exit

Maintenance Designee will monitor area weekly for 1 Quarter.


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: BLDG. 7 - Component: 04 - Tag: 0363 Based on observation and interview, it was determined the facility failed to ensure that corridor doors were maintained to resist the passage of smoke, affecting one of two levels. Findings include: 1. Observation on March 10, 2026, at 11:15 a.m., revealed SW wing Nurse supply room corridor door failed to close and latch when tested. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 a.m., confirmed the door failed to close and latch when tested.
 Plan of Correction - To be completed: 03/26/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

Door was repaired to latch in the frame.

Maintenance Designee will monitor door weekly for 1 Quarter to ensure door latches properly.



3/26/2026

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: BLDG. 7 - Component: 04 - Tag: 0911 Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting one of two levels. 1. Observation on March 10, 2026, at 10:45 a.m., revealed inside corridor to 7SW, where a barber pole was removed, capped exposed wiring remained hanging outside of wall. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 a.m., confirmed the exposed electrical wire. 2. Observation on March 10, 2026, at 10:45 a.m., revealed a junction box missing its cover plate and exposing the inner wiring, Basement Level above the Kitchen Sprinkler System. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 a.m., confirmed the open junction box.
 Plan of Correction - To be completed: 03/26/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

1. Exposed wiring was repaired into the junction box.



2. Cover plate was replaced to cover exposed wire.

Maintenance designee will be monitor both areas monthly for 1 Quarter.



3/26/2026

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: BLDG. 7 - Component: 04 - Tag: 0918 Based on document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire component. Findings include: Document review on March 9, 2026, at 8:00 am, revealed the facility could not produce documentation for the following tests and inspections:Monthly generator testing, under load, for: February, 2025; April, 2025; September, 2025; October, 2025;Monthly testing of ATS for: February, 2025; April, 2025; September, 2025; October, 2025.Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 am, confirmed the lack of documentation.
 Plan of Correction - To be completed: 04/02/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

Contract Generator Company was called to request prior paperwork to show all previous required generator testing and inspection were completed timely. Paperwork was obtained and will be placed in book for review.

Maintenance designee will monitor monthly for one year to ensure all proper paperwork pertaining to required generator testing and inspection is received at time of service.

Initial comments:Name: BLDG. 8 - Component: 05 - Tag: 0000
Facility ID# 061002

Component 05

Building 8

Based on a Medicare/Medicaid Recertification Survey conducted on March 9, 2026 and complete on March 10, 2026, it was determined that Fair Acres Geriatric Center - Building 8 was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 fifteen-story, Type II (000), unprotected noncombustible building, with a basement, that is fully sprinklered.


 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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 Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: BLDG. 8 - Component: 05 - Tag: 0161 Based on observation, document review and interview, it was determined the facility failed to maintain the fire resistance rating of the building construction, affecting the entire building component. Findings include: 1. Observation and document review on March 9, 2026, between 9:00 a.m., and 2:00 p.m., revealed this building has been classified as a fifteen story, Type II (000), unprotected noncombustible construction, with a basement, which is fully sprinklered. The story height exceeds the maximum allowance for this construction type by thirteen stories. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 a.m.,confirmed the story height exceeded the maximum allowance for this construction type.
 Plan of Correction - To be completed: 03/26/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

FSES: Facility requested the division of Life Safety inspection to do building evaluation to complete an updated FSES. Current FSES will be maintained to provide a safe environment for the residents. All existing fire protection systems will be monitored and kept in place.

3/26/2026.

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: BLDG. 8 - Component: 05 - Tag: 0225 Based on observation and interview, it was determined the facility failed to maintain stair towers, affecting one of fifteen stories. Findings include: 1. Observation on March 9, 2026, at 10:40 a.m., revealed the door failed to close and latch when tested, Ground Level Stair Tower Door #2 near the Doctor's Clinic. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 am, confirmed the door failed to latch.
 Plan of Correction - To be completed: 03/26/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

Door Closer was replaced so door will latch in its frame.

Maintenance designee will monitor door weekly for 1 Quarter.

3/26/2026

NFPA 101 STANDARD Emergency Lighting:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: BLDG. 8 - Component: 05 - Tag: 0291 Based on document review and interview, it was determined the facility failed to maintain and inspect emergency lighting, affecting the entire component. Findings include: Document review on March 9, 2026, at 8:00 am, revealed the facility could not produce documentation for the following tests and inspections:Monthly thirty-second testing for: September, 2025; October, 2025; November, 2025; December, 2025; January, 2026; February, 2026;Annual ninety-minute testing failed on December 19, 2025. Documentation showing this was corrected was not available.Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 am, confirmed the lack of documentation.
 Plan of Correction - To be completed: 04/02/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

Emergency lighting was checked and tested by Maintenance department. Any repairs needed were completed.

Maintenance designee will monitor monthly for one year to ensure all proper paperwork pertaining to required emergency light testing and inspection is completed.

NFPA 101 STANDARD Vertical Openings - Enclosure: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.
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: BLDG. 8 - Component: 05 - Tag: 0311 Based on observation, document review and interview, it was determined the facility failed to maintain the fire resistance of vertical openings, affecting the entire building component. Findings include: 1. Observation and document review on March 9, 2026, between 9:00 a.m. and 2:00 p.m., revealed the facility failed to provide vertical shafts between floors with construction having a fire resistance rating of at least two hours. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 a.m., confirmedthe building shafts were not constructed with the proper fire resistive rating.
 Plan of Correction - To be completed: 03/26/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.
FSES: Facility requested the division of Life Safety inspection to do building evaluation to complete an updated FSES. Current FSES will be maintained to provide a safe environment for the residents. All existing fire protection systems will be monitored and kept in place.

3/26/2026.

NFPA 101 STANDARD Hazardous Areas - 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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: BLDG. 8 - Component: 05 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintain hazardous areas in sprinklered locations, affecting one of fifteen stories. Findings Include: 1. Observation on March 9, 2026, at 10:25 a.m., revealed the door failed to latch closed when tested, Ground Floor Trash Room. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 am, confirmed the door failed to latch.
 Plan of Correction - To be completed: 03/26/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

Door was repaired to latch in its frame.

Maintenance Director will monitor door weekly to ensure proper latching for 1 Quarter.



3/26/2026

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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: BLDG. 8 - Component: 05 - Tag: 0353 Based on document review, observation, and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting two of 16 levels. Findings include: 1. Observations on March 9, 2026, revealed the following sprinkler system deficiencies: a. 10:15 am, ground floor pot room, sprinklers recessed into ceiling under the sofit. b. 10:20 am, ground floor physical therapy closet, missing escutcheon. c. 10:40 am, main floor lounge, missing escutcheon. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 am, confirmed the sprinkler deficiencies.
 Plan of Correction - To be completed: 03/26/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.



Contractor was called to secure date to complete the recessed sprinkler under sofit and identified missing escutcheons .

A. New sprinkler pendent were installed under sofit.

Maintenance designee will monitor bi-weekly for one quarter to ensure sprinkler is not recessed.

B. Escutcheon was replaced.
Maintenance designee will monitor bi-weekly for one quarter to ensure escutcheon is in place.

C. Escutcheon was replaced.

Maintenance designee will monitor bi-weekly for one quarter to ensure escutcheon is in place.



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: BLDG. 8 - Component: 05 - Tag: 0363 Based on observation and interview, it was determined the facility failed to maintain corridor doors to close and resist the transfer of smoke, on one of sixteen levels within the building. Findings include: 1.Observation on March 9, 2026, between 9:00a.m., and 2:00 p.m., revealed: a) Third floor resident room 313, failed to latch smoke tight in frame. b) Ninth floor (no residents/construction buffer floor), eight resident room doors were without door latching handle hardware. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 a.m., confirmed the doors failed to latch.
 Plan of Correction - To be completed: 03/26/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

A. Door was repaired to latch in its frame.

Maintenance designee will monitor door weekly for 1 Quarter.

Completed: 3/26/26


B. Door hardware for the 8 identified doors were replaced.

Maintenance designee will monitor doors weekly for 1 Quarter.









3/26/2026

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
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: BLDG. 8 - Component: 05 - Tag: 0372 Based on observation and interview, it was determined the facility failed to ensure smoke barriers maintained a fire resistance rating, affecting the entire building component. Findings include: 1. Observation on March 9, 2026, between 9:00 a.m. and 2:00 p.m., revealed the facility failed to provide smoke barriers constructed with at least a one-half hour fire resistance rating on all floors within the building. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 a.m., confirmedsmoke barrier partitions were incomplete.
 Plan of Correction - To be completed: 03/26/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.
FSES: Facility requested the division of Life Safety inspection to do building evaluation to complete an updated FSES. Current FSES will be maintained to provide a safe environment for the residents. All existing fire protection systems will be monitored and kept in place.

3/26/2026.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: BLDG. 8 - Component: 05 - Tag: 0374 Based on observation and interview, it was determined the facility failed to ensure doors in smoke barrier walls were maintained to resist the passage of smoke, affecting three of sixteen levels. Findings include: 1. Observation on March 9, 2026, between 9:00 a.m., and 2:00 p.m. revealed, on floors ten, eleven, and twelve, the automatically closed double smoke doors, three door sets per floor, had gaps which would allow the passage of smoke. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 am,confirmed the door gaps at bottom and side were excessive
 Plan of Correction - To be completed: 03/26/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

Door sweeps were installed on sets of doors identified to eliminate gaps and prevent the passage of smoke.

Maintenance designee will monitor door sweeps identified monthly for 1 Quarter.

Completed: 3/26/26















NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu: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.
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
Observations:
Name: BLDG. 8 - Component: 05 - Tag: 0541 Based on observation and interview, it was determined the facility failed to maintain the fire protection rating for trash and linen chutes, affecting three of fifteen levels. Findings include: 1. Observations on March 9, 2026, revealed trash and linen chute deficiencies in the following locations: a. 11:30 am, 1st floor linen chute door propped with a laundry bin. b. 11:35 am, 1st floor trash chute door failed to latch. c. 11:50 am, 2nd floor linen chute door propped with a laundry bin. d. 11:55 am, 2nd floor trash chute door failed to latch. e. 12:00 pm, 6th floor linen chute door propped with a laundry bin. f. 12:05 pm, 6th floor trash chute door failed to latch. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 a.m., confirmed the chute door deficiencies.
 Plan of Correction - To be completed: 03/26/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

A. Laundry bin will be moved away from the identified linen chute door to ensure bin does not prop chute door open.

Maintenance designee will monitor doors biweekly for one quarter to ensure bins are not propping doors open.

B. Door was repaired to ensure it latches properly.

Maintenance designee will monitor doors biweekly for one quarter to ensure bins are not propping doors open.

C. Laundry bin will be moved away from the identified linen chute door to ensure bin does not prop chute door open.

Maintenance designee will monitor doors biweekly for one quarter to ensure bins are not propping doors open.

D. Door was repaired to ensure it latches properly.

Maintenance designee will monitor doors biweekly for one quarter to ensure doors latches properly.

E. Door was repaired to ensure it latches properly.

Maintenance designee will monitor doors biweekly for one quarter to ensure doors latches properly.

F. Door was repaired to ensure it latches properly.

Maintenance designee will monitor doors biweekly for one quarter to ensure doors latches properly.







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: BLDG. 8 - Component: 05 - Tag: 0911 Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting two of fifteen stories. Findings include: 1. Observations on March 9, 2026, revealed the following electrical deficiencies: a. 11:20 a.m., open wires not ending in a junction box, Second Floor above double smoke doors near resident lounge. b. 11:30 a.m., junction box missing its cover plate, Second Floor above double doors near Visitors Toilet. c. 12:00 p.m., junction box missing its cover plate, Third Floor above double doors near room 309. Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 am, confirmed the electrical deficiencies. Refer to NFPA 70, National Electric Code, and NFPA 99, 6.3.2.1.
 Plan of Correction - To be completed: 03/27/2026

Plan of Correction:

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

A. Wires were resecured into junction box.

Maintenance designee will monitor junction box monthly junction for 1 Quarter to ensure wires are secured.



B. Cover was replaced on junction box.

Maintenance designee will monitor junction box monthly junction for 1 Quarter to ensure face plate is on junction box.

C. Cover was replaced on junction box.

Maintenance designee will monitor junction box monthly junction for 1 Quarter to ensure face plate is on junction box.



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: BLDG. 8 - Component: 05 - Tag: 0918 Based on document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire component. Findings include: Document review on March 9, 2026, at 8:00 am, revealed the facility could not produce documentation for the following tests and inspections:Monthly generator testing, under load, for: February, 2025; April, 2025; June, 2025; September, 2025; October, 2025; November, 2025; December, 2025;Monthly testing of ATS for: February, 2025; April, 2025; June, 2025; September, 2025; October, 2025; November, 2025; December, 2025.Exit interview with the Administrator and the Maintenance Director on March 10, 2026, at 11:30 am, confirmed the lack of documentation.
 Plan of Correction - To be completed: 04/02/2026

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute any admission for purposes of general liability, professional malpractice, or any other court proceedings or findings.

Contract Generator Company was immediately called to request prior paperwork to show all previous required generator testing and inspection were completed timely. Paperwork was obtained and will be placed in book for review.

Maintenance designee will monitor monthly for one year to ensure all proper paperwork pertaining to required generator testing and inspection is received at time of service.


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