Pennsylvania Department of Health
WILLOW GROVE POST ACUTE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 47 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.


WILLOW GROVE POST ACUTE - 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 20, 2025, it was determined that Willow Grove Post Acute 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), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

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

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

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

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

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

.

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

Based on document review and interview, it was determined the facility failed to ensure Emergency Preparedness Plan policies and procedures were reviewed and updated at least annually, affecting the entire facility.

Findings include:

Document review on May 20, 2025, at 8:30 a.m., revealed the Facility's Emergency Preparedness Plan had not been reviewed and updated at least annually.

Exit interview with the Administrator and Director of Maintenance on May 20, 2025, at 10:30 a.m., confirmed the lack of documentation.

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

- Facility could not retroactively correct the deficiency for the annual review of the Emergency Preparedness plan.
- Maintenance / Designee will be educated on ensure that the EP Plan is reviewed and updated annually.
- An audit of the EP plan will be completed to ensure that it is completed, updated and records are maintained.
- Result of the audit will be presented to the subsequent QAPI meeting.

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:

§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)

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

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

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

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

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

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

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

Observations:
Name: - Component: -- - Tag: 0006

Based on document review and interview, it was determined the facility failed to ensure the Emergency Preparedness Plan was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach and include strategies for addressing emergency events identified by the risk assessment.

Findings include:

Document review on May 20, 2025, at 8:30 a.m., revealed the Facility's Emergency Preparedness Plan did not include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach and include strategies for addressing emergency events identified by the risk assessment.

Exit interview with the Administrator and Director of Maintenance on May 20, 2025, at 10:30 a.m., confirmed the lack of documentation.

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

- Facility could not retroactively correct the deficiency related to the facility, and community based risk assessment for the facility Emergency Preparedness Plan.
- Maintenance / designee will be educated to ensure that a facility, and community based risk assessment is completed, and retained in the EP plan.
- Maintenance Dir/ designee will Be educated ensure that the facility based risk assessment is completed, and that records are maintained in the EP binder.
- Upon completion of the Risk assessment, information will be presented at the subsequent QAPI meeting.

403.748(b)(4), 416.54(b)(3), 418.113(b)(6)(i), 441.184(b)(4), 482.15(b)(4), 483.475(b)(4), 483.73(b)(4), 485.542(b)(4), 485.625(b)(4), 485.68(b)(2), 485.727(b)(2), 485.920(b)(3), 491.12(b)(2), 494.62(b)(3) STANDARD Policies/Procedures for Sheltering in Place:

§403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3).

(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:]

[(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility].

*[For Inpatient Hospices at §418.113(b):] Policies and procedures.
(6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following:
(i) A means to shelter in place for patients, hospice employees who remain in the hospice.

Observations:
Name: - Component: -- - Tag: 0022

Based on document review and interview, it was determined the facility failed to include a Policy and Procedure for Sheltering.

Findings include:

Document review on May 20, 2025, at 8:30 a.m., revealed the Emergency Preparedness Manual did not include documentation of a means to shelter in place for patients, staff, and volunteers who remain in the facility.

Exit interview with the Administrator and Director of Maintenance on May 20, 2025, at 10:30 a.m., confirmed the lack of documentation.

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

- Facility could not retroactively correct the deficiency related to the policy and procedure for Sheltering.
- Facility will establish, and implement a policy and procedure for Sheltering, and ensure that information is in the Facility EP plan.
- Maintenance / designee will be educated to ensure that the policy/procedure for sheltering is maintained in the EP plan
- Upon completion, Policy and procedure for sheltering will be reviewed, and presented at the subsequent QAPI meeting.

403.748(b)(7), 418.113(b)(5), 441.184(b)(7), 482.15(b)(7), 483.475(b)(7), 483.73(b)(7), 485.625(b)(7), 485.920(b)(6), 494.62(b)(6) STANDARD Arrangement with Other Facilities:

§403.748(b)(7), §418.113(b)(5), §441.184(b)(7), §460.84(b)(8), §482.15(b)(7), §483.73(b)(7), §483.475(b)(7), §485.625(b)(7), §485.920(b)(6), §494.62(b)(6).

[(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:]

*[For Hospices at §418.113(b), PRFTs at §441.184,(b) Hospitals at §482.15(b), and LTC Facilities at §483.73(b):] Policies and procedures. (7) [or (5)] The development of arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

*[For PACE at §460.84(b), ICF/IIDs at §483.475(b), CAHs at §486.625(b), CMHCs at §485.920(b) and ESRD Facilities at §494.62(b):] Policies and procedures. (7) [or (6), (8)] The development of arrangements with other [facilities] [or] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

*[For RNHCIs at §403.748(b):] Policies and procedures. (7) The development of arrangements with other RNHCIs and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of non-medical services to RNHCI patients.

Observations:
Name: - Component: -- - Tag: 0025

Based on document review and interview, it was determined the facility failed to provide arrangements with other facilities, affecting the entire component.

Findings include:

Document review on May 20, 2025, at 8:30 a.m., revealed the facility failed to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

Exit interview with the Administrator and Director of Maintenance on May 20, 2025, at 10:30 a.m., confirmed the lack of documentation.

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

- Facility could not retroactively correct the deficiency related to the citation for failing to provide arrangements with other facilities in the event of limitations or cessation of operations.
- Administrator/ designee will obtain transfer agreements with other facilities, and ensure that it is maintained, and kept accessible in the EP binder.
- Maintenance / designee have been educated on ensuring that transfer agreement with other facilities is in place in the event of limitations or cessation of operation, and to ensure that services continue to be rendered to the residents.
- Upon review of the Transfer agreements, Maintenance / designee will present information at the subsequent QAPI meeting.

403.748(b)(8), 416.54(b)(6), 418.113(b)(6)(C)(iv), 441.184(b)(8), 482.15(b)(8), 483.475(b)(8), 483.73(b)(8), 485.542(b)(7), 485.625(b)(8), 485.920(b)(7), 494.62(b)(7) STANDARD Roles Under a Waiver Declared by Secretary:

§403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7).

[(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:]

(8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

*[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Observations:
Name: - Component: -- - Tag: 0026

Based on document review and interview, it was determined the facility failed to provide policy and procedure documentation concerning the role of the nursing facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials, affecting the entire facility.

Findings include:

Document review on May 20, 2025, at 8:30 a.m., revealed the facility could not provide Emergency Preparedness Plan policy and procedure documentation concerning the Roles under a Waiver Declared by Secretary.

Exit interview with the Administrator and Director of Maintenance on May 20, 2025, at 10:30 a.m., confirmed the lack of documentation.

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

- Facility could not retroactively correct the deficiency related to policy / procedure regarding the role of the facility under section 1135 waiver declared by the Secretary.
- Administrator will ensure that Policy and procedure is developed citing the role of the facility under the waiver in accordance with section 1135.
- Education will be provided to Maintenance / designee to ensure that the policy/procedure is maintained in the EP binder.
- Review of the policy will be presented at the subsequent QAPI meeting.

403.748(c)(1), 416.54(c)(1), 418.113(c)(1), 441.184(c)(1), 482.15(c)(1), 483.475(c)(1), 483.73(c)(1), 484.102(c)(1), 485.542(c)(1), 485.625(c)(1), 485.68(c)(1), 485.727(c)(1), 485.920(c)(1), 486.360(c)(1), 491.12(c)(1), 494.62(c)(1) STANDARD Names and Contact Information:

§403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1).

[(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:]

(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [facilities].
(v) Volunteers.

*[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [hospitals and CAHs].
(v) Volunteers.

*[For RNHCIs at §403.748(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Next of kin, guardian, or custodian.
(iv) Other RNHCIs.
(v) Volunteers.

*[For ASCs at §416.45(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For Hospices at §418.113(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Hospice employees.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Other hospices.

*[For HHAs at §484.102(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For OPOs at §486.360(c):] The communication plan must include all of the following:
(2) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Volunteers.
(iv) Other OPOs.
(v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA).

Observations:
Name: - Component: -- - Tag: 0030

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness plan that included a communication plan containing all the required contact information, affecting the entire facility.

Findings include:

Document review on May 20, 2025, at 8:30 a.m., revealed the facility did not have an Emergency Preparedness Communication plan that included names and contact information for staff, resident's physicians, volunteers and transfer facilities that would receive residents in the event of an evacuation.

Exit interview with the Administrator and Director of Maintenance on May 20, 2025, at 10:30 a.m., confirmed the lack of documentation.

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

- Facility could not retroactively correct the deficiency related to the communication plan for the facility in the event of emergency.
- Administrator will ensure that a list of names and contact information for staff, providers, vendors, volunteers, Transfer facilities, and emergency personnel is developed within the facility's EP plan to ensure effective communication in the event of an emergency.
- Maintenance / designee will ensure that the facility Communication plan is maintained in the EP binder.
- The communication plan will be presented at the subsequent QAPI meeting.

403.748(c)(2), 416.54(c)(2), 418.113(c)(2), 441.184(c)(2), 482.15(c)(2), 483.475(c)(2), 483.73(c)(2), 484.102(c)(2), 485.542(c)(2), 485.625(c)(2), 485.68(c)(2), 485.727(c)(2), 485.920(c)(2), 486.360(c)(2), 491.12(c)(2), 494.62(c)(2) STANDARD Emergency Officials Contact Information:

§403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2).

[(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:

(2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.

*[For LTC Facilities at §483.73(c):] (2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) The State Licensing and Certification Agency.
(iii) The Office of the State Long-Term Care Ombudsman.
(iv) Other sources of assistance.

*[For ICF/IIDs at §483.475(c):] (2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.
(iii) The State Licensing and Certification Agency.
(iv) The State Protection and Advocacy Agency.

Observations:
Name: - Component: -- - Tag: 0031

Based on document review and interview, it was determined the facility failed to ensure the Emergency Preparedness Plan included all Emergency Officials Contact information, including Federal, State, tribal, regional, and local emergency preparedness staff affecting the entire component.

Findings include:

Document review on May 20, 2025, at 8:30 a.m., revealed the Facility's Emergency Preparedness Plan did not include federal, state, and regional contact information in the Emergency Officials Contact Information.

Exit interview with the Administrator and Director of Maintenance on May 20, 2025, at 10:30 a.m., confirmed the lack of documentation.

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

- Facility could not retroactively correct the deficiency related to the contact information for Emergency officials.
- Administrator will ensure that contact information for the Federal, State, regional and local emergency agencies in accord with the regulation is developed.
- Maintenance / designee will ensure that the contact information for the emergency agencies is maintained in the facility emergency preparedness binder and accessible.
- Contact Information for the emergency agencies will be reviewed at the subsequent QAPI meeting.

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

Facility ID# 069002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 20, 2025, it was determined that Willow Grove Post Acute 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 two-story, Type II (111), protected noncombustible building, with a basement and partial attic space, 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: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on document review, observation and interview, it was determined the facility failed to test/clean carbon monoxide alarms and replace batteries annually in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act, affecting the entire facility.

Findings include:

Document review on May 20, 2025, at 8:30 a.m., revealed the facility failed to adhere to the Care Facility Carbon Monoxide Alarms Standards Act in the following ways:

a. Test/clean carbon monoxide alarms in accordance with manufacturer's specifications;
b. Replace the batteries of carbon monoxide alarms annually.

Exit interview with the Administrator and Director of Maintenance on May 20, 2025, at 10:30 a.m., confirmed the facility did not adhere to the Care Facility Carbon Monoxide Alarms Standards Act.

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

- Co2 detectors have been cleaned and tested to ensure proper functioning; documentation will be retained for compliance.
-Batteries to the CO detectors were replaced as well.
- Maintenance / designee will audit cleanliness, and a functioning test of CO2 detectors monthly x3 to ensure functionality, and documentation will be retained.
- Maintenance / designee will be educated on the maintaining CO2 alarms in accordance with the 2016 Care Facility Carbon Monoxide Alarm Standard Act.
- Results of the audit will be presented at the QAPI meeting.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain means of egress free from all obstructions, affecting one of three levels in the facility.

Findings include:

Observation on May 20, 2025, at 10:04 a.m., revealed, on the first floor, the exit door near resident room 131 required excessive force to open.

Exit interview with the Administrator and Director of Maintenance on May 20, 2025, at 10:30 a.m., confirmed the required excessive force to open the door.

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

- Exit door near room 131 has been repaired to ensure proper functioning when opening.
- Maintenance/ designee will conduct and audit of exit doors on the first floor to ensure that they are functioning/opening properly. Maintenance will maintain an audit weekly x4, then monthly x2 of the exit doors on first floor for proper functioning.
- Maintenance / designee will be educated on the regulation for NFPA 101 Means of Egress to maintain unobstructed exits.
- Results of the audit will be presented at the subsequent QAPI meeting.

NFPA 101 STANDARD Fire Alarm System - Initiation:

Fire Alarm System - Initiation
Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200' travel distance is not exceeded.
18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0342

Based on observation and interview, it was determined the facility failed to properly install manual pull stations, affecting one of three levels in the facility.

Findings include:

Observation on May 20, 2025, at 9:57 a.m., revealed, on the first floorm, at the rear Ambulance Doors, the manual pull station was not installed within 5 ft. of the exit doors.

Exit interview with the Administrator and Director of Maintenance on May 20, 2025, at 10:30 a.m., confirmed the improper pull station location.

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

- Fire alarm Vendor has been contacted to move the pull station at the rear ambulance doors within 5 ft of the exit door. Facility will ensure correction and completion the pull station.
- Maintenance Director / designee will be educated on the regulation to ensure that the alarm boxes are visible, accessible, and does not exceed 200' travel distance.
- Maintenance Director / designee will complete an audit of pull stations at exits to ensure that they all meet the travel distance per regulation.
- Results of the audit will be presented at the QAPI meeting.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to maintain and inspect fire alarm systems, affecting the entire facility.

Findings include:

Document review on May 20, 2025, at 8:30 a.m., revealed the facility could not provide documentation of the following tests and inspections:

a. Semi-annual visual inspection within 6 months of 5/19/2025;
b. 2 year smoke detector sensitivity testing.

Exit interview with the Administrator and Director of Maintenance on May 20, 2025, at 10:30 a.m., confirmed the lack of documentation.

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

- Facility has reached out to Fire Alarm Vendor that completed the testing and maintenance of the fire alarm systems in order to obtain the records for the Semi-Annual inspection, and the 2 Yr smoke sensitivity test. Facility could not retroactively correct the deficiency citing providing documentation for the test and inspection.
- Maintenance / designee will complete an audit to ensure that documentation for semi annual visual inspection , and 2 year smoke sensitivity is current for 2025, and that records are maintained.
- Maintenance / designee will be educated on maintaining fire alarm systems, and ensuring that the testing and maintenance is retained for compliance.

NFPA 101 STANDARD Portable Fire Extinguishers:

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: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on document review, observation, and interview, it was determined the facility failed to maintain and inspect portable fire extinguishers, affecting the entire facility.

Findings include:

1. Document review on May 20, 2025, at 8:30 a.m., revealed the facility could not provide the certification for the technician who conducted the annual fire extinguisher maintenance.

Exit interview with the Administrator and Director of Maintenance on May 20, 2025, at 10:30 a.m., confirmed the lack of documentation.

2. Observation on May 20, 2025, at 9:47 a.m., revealed, on the second floor, the fire extinguisher next to resident room 206 was blocked by a bed tray.

Exit interview with the Administrator and Director of Maintenance on May 20, 2025, at 10:30 a.m., confirmed the blocked fire extinguisher.

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

- The bed tray blocking the fire extinguisher next to room 206 was removed immediately.
- Facility will obtain and retain a copy of the Certification for the Technician who conducted the fire extinguisher maintenance, and retain a copy for compliance.
- Maintenance Director / designee will complete an initial audit to ensure that fire extinguishers throughout the facility are not blocked, and signage will be placed to aid maintain compliance.
- Maintenance Director / designee will complete an audit weekly x4, then monthly x2 to ensure that fire extinguishers are not blocked.
- Results of the audit will be presented to the QAPI committee at the subsequent meeting.

NFPA 101 STANDARD Utilities - Gas and Electric:

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting one of three levels in the facility.

Findings include:

Observation on May 20, 2025, at 9:45 a.m., revealed storage within three feet of the electrical panels on the second floor across from resident room 216. Per NFPA70 110.26(A)(1), a 3 ft. depth clearance is required in front of electrical equipment with a nominal voltage to ground of 0 to 150 volts.

Exit interview with the Administrator and Director of Maintenance on May 20, 2025, at 10:30 a.m., confirmed the blocked electrical panels.

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

- Bedside table blocking the electrical panel across room 216 was removed immediately.
- Signage will be placed at the electrical panel to ensure that it is not blocked.
- Maintenance/ designee will be educated on maintaining access to electrical panels, and that there are no items stored within 3ft in front of the panel.
- An initial audit will be completed, then a weekly audit x4, and monthly x2 to ensure that items are not stored within 3ft in front of an electrical panel.
- Results of the audit will be presented at the subsequent QAPI meeting.

NFPA 101 STANDARD HVAC:

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: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on observation and interview, it was determined the facility failed to maintain HVAC equipment, affecting one of three levels in the facility.

Findings include:

Observation on May 20, 2025, at 9:31 a.m., revealed on the second floor, in the Physical Therapy Room, there were two portable HVAC units discharging above the ACT ceiling.

Exit interview with the Administrator and Director of Maintenance on May 20, 2025, at 10:30 a.m., confirmed the improper discharge of the portable HVAC units.

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

- Portable HVAC units were temporarily installed for air conditioning in the rehab gym.
- Portable HVAC units have been vented directly through an exhaust vent in the ceiling.
-HVAC technician has been contacted to rectify air conditioning unit for the rehab gym for a permanent solution.
-Air conditioning unit to the rehab gym will be fixed prior to 7/18/2025.
- Maintenance / designee will be educated to ensure that portable HVAC units are vented appropriately in the facility.
- Initial audit will be completed through the facility to ensure appropriate venting for all HVAC units.
- Result of the audit will be presented to the QAPI committee.

NFPA 101 STANDARD Fire Drills:

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

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to conduct required fire drills, affecting two of twelve required drills.

Findings include:

Document review on May 20, 2025, at 8:30 a.m., revealed the facility could not provide documentation of fire drills for the 3rd and 4th quarters of 2024, all shifts.

Exit interview with the Administrator and Director of Maintenance on May 20, 2025, at 10:30 a.m., confirmed the lack of documentation.

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

- Facility could not retroactively correct the deficiency for the required fire drills for 3rd and 4th Quarter 2024.
- Maintenance /designee will be educated to ensure that fire drills are conducted in accordance with the regulation NFPA 101- Fire Drills.
- Maintenance/ designee will conduct an initial audit for all required fire drills for 2025, and maintain records on file.
- Maintenance / designee will complete a monthly audit x3 to ensure that all required fire drills, all shifts, are conducted in order to maintain compliance.
- Results of the audits will be presented at the subsequent QAPI meeting.

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