Pennsylvania Department of Health
 NORTHAMPTON COUNTY HOME- GRACEDALE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
NORTHAMPTON COUNTY HOME- GRACEDALE
Inspection Results For:

There are  70 surveys for this facility. Please select a date to view the survey results.

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NORTHAMPTON COUNTY HOME- GRACEDALE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on April 28, 2025, at Northampton County Home-Gracedale, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: NORTHWEST WING - Component: 01 - Tag: 0000


Facility ID# 072802
Component 01
Northwest Wing

Based on a Medicare/Medicaid Recertification Survey completed on April 28, 2025, it was determined that Northampton County Home-Gracedale, was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two story, Type III (200), unprotected, ordinary building, with a basement, basement-level crawl space, and unused attic, 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: NORTHWEST WING - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements on three of three floors.

Findings include:

1. Observation on April 28, 2025, at 11:00 a.m., revealed the facility exceeded the maximum allowable story height for the type of construction.

Exit interview with the Facility Administrator and the Facilities Manager on April 28, 2025, between 2:30 p.m., and 2:45 p.m., confirmed the building exceeded the maximum allowable story height by one story.




 Plan of Correction - To be completed: 05/27/2025

The Nursing Facility requests the department to complete a current FSES.
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: NORTHWEST WING - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain one exit stair tower enclosure, affecting two of three floors.

Findings include:

1. Observation on April 28, 2025, at 10:44 a.m., revealed the distance between the first floor, front stair tower enclosure doors exceeded one-eighth-inch.

Exit interview with the Facility Administrator and the Facilities Manager on April 28, 2025, between 2:30 p.m., and 2:45 p.m., confirmed the stair tower enclosure deficiency.



 Plan of Correction - To be completed: 05/27/2025

The corrections set forth in this document do not constitute admission or agreement by the provider of the truth of facts alleged or the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and executed solely because it is required by provisions of Federal and State law.

APPROVED ASTRAGAL INSTALLED ON DOORS 41 AND 42 TO PROVIDE PROPER GAP. STAFF EDUCATED TO IDENTIFY DOOR ISSUES.

Maintenance Director or designee will audit doors weekly for 1 week, then monthly, then according to policy. Results will be reported to QAPI Steering Committee.
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: NORTHWEST WING - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in four locations, affecting two of three floors.

Findings include:

1. Observation on April 28, 2025, between 11:11 a.m., and 11:42 a.m., revealed the following:

a. 11:11 a.m., "loaded" sprinkler head assemblies, within the first floor, Resident Room NW 211.
b. 11:29 a.m., ceiling tiles missing within the basement-level, OT/PT area.
c. 11:40 a.m., a ceiling tile lacking within the basement-level Activities.
d. 11:42 a.m., painted sprinkler head assemblies (2), located within the basement-level Activities.

Exit interview with the Facility Administrator and the Facilities Manager on April 28, 2025, between 2:30 p.m., and 2:45 p.m., confirmed the automatic sprinkler system deficiencies.



 Plan of Correction - To be completed: 05/27/2025

The corrections set forth in this document do not constitute admission or agreement by the provider of the truth of facts alleged or the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and executed solely because it is required by provisions of Federal and State law.

SPRINKLER ASSEMBLIES CLEANED AND CLEAR OF DEBRIS
CEILING TILES REPLACED IN THERAPY AREA
CEILING TILE REPLACED IN ACTIVITIES AREA
SPRINKLER ASSEMBLIES CLEANED - PAINT REMOVED.
STAFF EDUCATED ON IDENTIFYING THESE ISSUES.

Sprinkler heads and ceiling tiles will be audited weekly for 4 weeks, then monthly for 1 month, then according to policy by Maintenance Director or designee. Results will be reported to QAPI Steering Committee.

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: NORTHWEST WING - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain one corridor opening, affecting one of three floors.

Findings include:

1. Observation on April 28, 2025, at 10:32 a.m., revealed the first floor, Front Lounge doors required adjustment to fully latch.

Exit interview with the Facility Administrator and the Facilities Manager on April 28, 2025, between 2:30 p.m., and 2:45 p.m., confirmed the corridor opening deficiency.




 Plan of Correction - To be completed: 05/27/2025

The corrections set forth in this document do not constitute admission or agreement by the provider of the truth of facts alleged or the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and executed solely because it is required by provisions of Federal and State law.

SOLARIUM LOUNGE DOORS 38 AND 39 ADJUSTED TO FULLY LATCH. Other doors were checked. STAFF EDUCATED ON IDENTIFYING THESE ISSUES.

Maintenance Director or designee will monitor door latching weekly for 1 week, then monthly, then following policy and procedure. Results will be reported to QAPI committee.
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: NORTHWEST WING - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier separation walls in two instances, affecting one of two floors.

Findings include:

1. Observation on April 28, 2025, at 11:30 a.m., revealed second floor smoke barrier separation walls did not extend through the attic spaces.

Exit interview with the Facility Administrator and the Facilities Manager on April 28, 2025, between 2:30 p.m., and 2:45 p.m., confirmed the smoke barrier separation wall deficiencies.



 Plan of Correction - To be completed: 05/27/2025

The NF requests the department to conduct a current FSES.
NFPA 101 STANDARD Gas and Vacuum Piped 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.
Gas and Vacuum Piped Systems - Other
List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum 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 5 (NFPA 99)
Observations:
Name: NORTHWEST WING - Component: 01 - Tag: 0902

Based on observation and interview, it was determined the facility failed to maintain medical gas piping in two locations, affecting two of three floors.

Findings include:

1. Observation on April 28, 2025, between 11:02 a.m., and 11:28 a.m., revealed dissimilar metals in contact with medical gas piping in the following locations:

a. 11:02 a.m., first floor, "middle" smoke barrier separation doors.
b. 11:28 a.m., basement level, Life Enrichment Area.

Exit interview with the Facility Administrator and the Facilities Manager on April 28, 2025, between 2:30 p.m., and 2:45 p.m., confirmed the medical gas piping deficiencies.



 Plan of Correction - To be completed: 05/27/2025

The corrections set forth in this document do not constitute admission or agreement by the provider of the truth of facts alleged or the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and executed solely because it is required by provisions of Federal and State law.

MC CABLE LOCATED IN NW 1 MIDDLE HALL CEILING SECURED
MC CABLE LOCATED IN LIFE ENRICHMENT AREA SECURED.
STAFF EDUCATED ON IDENTIFYING THESE ISSUES. Other medical gas piping was checked.

Maintenance Director or designee will audit piping weekly for 4 weeks, then monthly, then according to Policies and Procedures. Results will be reported to QAPI steering Committee.

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: NORTHWEST WING - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain the emergency generator which serves the facility.

Findings include:

1. Observation on April 28, 2025, between 10:45 a.m., and 11:45 a.m., revealed the facility lacked the following generator documentation:

a. 3-year, 4-hour load bank testing data
b. Annual fuel quality testing data.

Exit interview with the Facility Administrator and the Facilities Manager on April 28, 2025, at 2:45 p.m., confirmed the lack of documentation.




 Plan of Correction - To be completed: 05/27/2025

The corrections set forth in this document do not constitute admission or agreement by the provider of the truth of facts alleged or the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and executed solely because it is required by provisions of Federal and State law.

3 YEAR, 4 HOUR LOAD TEST COMPLETE ON LIFE SAFETY GENERATORS
ANNUAL FUEL ANALYSIS COMPLETE ON LIFE SAFETY GENERATORS.
REQUIRED TESTS ARE ADDED TO SCOPE OF WORK WITH PREVENTATIVE MAINTENANCE CONTRACTOR. Maintenance Director will review reports received from contractors to ensure all required work was complete each visit.

NFPA 101 STANDARD Electrical Equipment - 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 Equipment - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, 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 10 (NFPA 99)
Observations:
Name: NORTHWEST WING - Component: 01 - Tag: 0919

Based on observation and interview, it was determined the facility failed to maintain electrical systems in one location, affecting one of three floors.

Findings include:

1. Observation on April 28, 2025, at 10:38 a.m., revealed a junction box, located within the Front Storage Room, lacked a cover plate.

Exit interview with the Facility Administrator and the Facilities Manager on April 28, 2025, between 2:30 p.m., and 2:45 p.m., confirmed the electrical systems deficiency.



 Plan of Correction - To be completed: 05/27/2025

The corrections set forth in this document do not constitute admission or agreement by the provider of the truth of facts alleged or the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and executed solely because it is required by provisions of Federal and State law.

SECURED COVER ON LOW VOLTAGE JUNCTION BOX IN NW STORAGE ROOM CEILING. STAFF EDUCATED ON IDENTIFYING FUTURE ISSUES.

Covers will be audited weekly for 4 weeks, then monthly, then according to policy by Maintenance Director or designee. Results will be reported to QAPI steering committee.
Initial comments:Name: MAIN BUILDING - Component: 02 - Tag: 0000


Facility ID# 072802
Component 02
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 28, 2025, it was determined that Northampton County Home-Gracedale, was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two story, Type II (222), fire resistive building, with a basement, basement-level crawl space, penthouse, and unused attic, 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: MAIN BUILDING - Component: 02 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain means of egress requirements in one location, affecting one of three floors.

Findings include:

1. Observation on April 28, 2025, at 12:25 p.m., revealed multiple storage items were located within the basement-level exit access corridor system.

Exit interview with the Facility Administrator and the Facilities Manager on April 28, 2025, between 2:30 p.m., and 2:45 p.m., confirmed the means of egress deficiency.



 Plan of Correction - To be completed: 05/27/2025

The corrections set forth in this document do not constitute admission or agreement by the provider of the truth of facts alleged or the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and executed solely because it is required by provisions of Federal and State law.

ITEMS LOCATED IN BASEMENT CORRIDOR ARE REMOVED. STAFF EDUCATED ON PROPER STORAGE LOCAT
Maintenance Director or designee will audit corridor weekly for 4 weeks, then monthly, then according to policy and procedure. Results will be reported to QAPI steering Committee.
NFPA 101 STANDARD Vertical Openings - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING - Component: 02 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain vertical openings in two locations, affecting two of three floors.

Findings include:

1. Observation on April 28, 2025, between 12:30 p.m., and 2:14 p.m., revealed vertical penetrations were located in the following areas:

a. 12:30 p.m., a pipe penetration of the floor slab assembly, located within the basement-level, Housekeeping Closet (above the suspended ceiling assembly).
b. 2:14 p.m., a pipe penetration of the floor slab assembly, located at the first floor, Arcade, common wall area (above the suspended ceiling assembly).

Exit interview with the Facility Administrator and the Facilities Manager on April 28, 2025, between 2:30 p.m., and 2:45 p.m., confirmed the vertical opening deficiencies.





 Plan of Correction - To be completed: 05/27/2025

The corrections set forth in this document do not constitute admission or agreement by the provider of the truth of facts alleged or the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and executed solely because it is required by provisions of Federal and State law.

PIPE PENETRATION ABOVE HOUSEKEEPING CLOSET SEALED.
PIPE PENETRATION ABOVE ARCADE AREA SEALED.
STAFF EDUCATED TO IDENTIFY THESE DEFICIENCIES.

Maintenance Director or designee will audit areas of possible penetration weekly for 4 weeks, then monthly, then according to policy and procedure. Results will be reported to QAPI steering Committee.

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: MAIN BUILDING - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in three locations, affecting two of three floors.

Findings include:

1. Observation on April 28, 2025, between 12:22 p.m., and 2:20 p.m., revelaed the following:

a. 12:22 p.m., "loaded" sprinkler head assemblies, located within the basement-level, Electrical Distribution Room.
b. 12:44 p.m., an automatic sprinkler head assembly within the basement-level Cooler (Refuse Room) lacked an escutcheon plate.
c. 2:20 p.m., wiring atop branch sprinkler piping, located at the Arcade "common wall" area.

Exit interview with the Facility Administrator and the Facilities Manager on April 28, 2025, between 2:30 p.m., and 2:45 p.m., confirmed the automatic sprinkler system deficiencies.



 Plan of Correction - To be completed: 05/27/2025

The corrections set forth in this document do not constitute admission or agreement by the provider of the truth of facts alleged or the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and executed solely because it is required by provisions of Federal and State law.

SPRINKLER HEAD ASSEMBLY IN ELECTRICAL ROOM CLEANED AND FREE OF DEBRIS.
REFUSE ROOM SPRINKLER ESCUTCHEON REPLACED. WIRING IN ARCADE AREA SECURED.
STAFF EDUCATED ON IDENTIFYING DEFICIENCIES.

Maintenance Director or designee will audit sprinkler heads and sprinkler piping weekly for 4 weeks, then monthly, then according to policy and procedure. Results will be reported to QAPI Steering Committee.

NFPA 101 STANDARD Smoking Regulations: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.
Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING - Component: 02 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain smoking regulations in one location, affecting one of three floors.

Findings include:

1. Observation on April 28, 2025, at 1:50 p.m., revealed cigarette butts were located within a trash receptacle, located at the dietary smoking area.

Exit interview with the Facility Administrator and the Facilities Manager on April 28, 2025, between 2:30 p.m., and 2:45 p.m., confirmed the smoking regulations deficiency.



 Plan of Correction - To be completed: 05/27/2025

The corrections set forth in this document do not constitute admission or agreement by the provider of the truth of facts alleged or the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and executed solely because it is required by provisions of Federal and State law.

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

Based on document review and interview, it was determined the facility failed to maintain the emergency generator which serves the facility.

Findings include:

1. Observation on April 28, 2025, between 10:45 a.m., and 11:45 a.m., revealed the facility lacked the following generator documentation:

a. 3-year, 4-hour load bank testing data
b. Annual fuel quality testing data.

Exit interview with the Facility Administrator and the Facilities Manager on April 28, 2025, at 2:45 p.m., confirmed the lack of documentation.



 Plan of Correction - To be completed: 05/27/2025

The corrections set forth in this document do not constitute admission or agreement by the provider of the truth of facts alleged or the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and executed solely because it is required by provisions of Federal and State law.

3 YEAR ,4 HOUR LOAD TEST COMPLETE ON LIFE SAFETY GENERATORS
ANNUAL FUEL ANALYSIS COMPLETE ON LIFE SAFETY GENERATORS.
REQUIRED TESTS ARE ADDED TO SCOPE OF WORK WITH PREVENTATIVE MAINTENANCE CONTRACTOR.
Maintenance Director or designee will monitor contractor reports to ensure all required work is completed during 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: MAIN BUILDING - Component: 02 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain cylinder storage in one location, affecting one of three floors.

Findings include:

1. Observation on April 28, 2025, at 1:01 p.m., revealed a free-standing oxygen cylinder, located within the SW1 Linen Room.

Exit interview with the Facility Administrator and the Facilities Manager on April 28, 2025, between 2:30 p.m., and 2:45 p.m., confirmed the cylinder storage deficiency.



 Plan of Correction - To be completed: 05/27/2025

The corrections set forth in this document do not constitute admission or agreement by the provider of the truth of facts alleged or the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and executed solely because it is required by provisions of Federal and State law.

SW1 LINEN ROOM OXYGEN CYLINDER SECURED AND STORED IN PROPER LOCATION. STAFF REEDUCATED ON PROPER HANDLING OF OXYGEN CYLINDERS.

Maintenance Director or designee will audit oxygen storage weekly for 4 weeks, then monthly, then according to policy and procedure. Results will be reported to QAPI Steering COmmittee.
Initial comments:Name: TOWER BUILDING - Component: 03 - Tag: 0000


Facility ID# 072802
Component 03
Building 03
Tower Building

Based on a Medicare/Medicaid Recertification Survey completed April 28, 2025, it was determined that Northampton County Home-Gracedale, was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a ten story, Type II (222), fire resistive building, with miscellaneous rooftop mechanical spaces, and a basement, that is fully sprinklered.



 Plan of Correction:


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: TOWER BUILDING - Component: 03 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in one location, affecting one of eleven floors.

Findings include:

1. Observation on April 28, 2025, at 2:02 p.m., Basement Level, revealed the Electrical Power Room door failed to positive latch into frame when tested, near the east stair tower.

Exit interview with the Facility Administrator and the Facilities Manager on April 28, 2025, at 2:45 p.m., confirmed the hazardous enclosure deficiency.




 Plan of Correction - To be completed: 05/27/2025

The corrections set forth in this document do not constitute admission or agreement by the provider of the truth of facts alleged or the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and executed solely because it is required by provisions of Federal and State law.

ELECTRICAL POWER ROOM DOOR ADJUSTED TO LATCH PROPERLY. STAFF EDUCATED ON IDENTIFYING THIS DEFICIENCY.

Door latching will be audited weekly for 4 weeks, then monthly, then according to policy and procedure. Results will be reported to QAPI Steering Committee.
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: TOWER BUILDING - Component: 03 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system in two locations, on two of eleven floors.

Findings include:

1. Observation on April 28, 2025, between 12:44 p.m., and 1:28 p.m., revealed the following:

a. At 12:44 p.m., 9th floor, Housekeeping room, had a warped ceiling tile causing it to not be sealed into the ceiling assembly.
b. At 1:28 p.m., 4th floor, AV solarium was missing an escutcheon.

Exit interview with the Facility Administrator and the Facilities Manager on April 28, 2025, at 2:45 p.m., confirmed sprinkler system deficiencies.




 Plan of Correction - To be completed: 05/27/2025

The corrections set forth in this document do not constitute admission or agreement by the provider of the truth of facts alleged or the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and executed solely because it is required by provisions of Federal and State law.

9TH FLOOR HOUSEKEEPING CLOSET CEILING TILE REPLACED.
4TH FLOOR EAST SOLARIUM SPRINKLER ESCUTCHEON REPLACED.
OTHER CEILINES AND SPRINKLERS WERE CHECKED.
STAFF EDUCATED ON IDENTIFYING THESE DEFICIENCIES.

Maintenance Director or designee will audit sprinklers and ceiling tiles weekly for 4 weeks, then monthly, then according to policy and procedure. Results will be reported to QAPI Steering Committee..

NFPA 101 STANDARD Portable Fire Extinguishers: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.
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: TOWER BUILDING - Component: 03 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain accessible access to fire extinguishers on four of eleven floors.

Findings include:

1.Observation on April 28, 2025, between 12:51 p.m., and 1:29 p.m., revealed the following:

a. At 12:51 p.m., 9th floor, B wing fire extinguisher was blocked by a lift.
b. At 1:15 p.m., 6th floor, C wing fire extinguisher was blocked by walkers.
c. At 1: 18 p.m., 5th floor, C wing fire extinguisher was blocked by wheelchairs.
d. At 1:29 p.m., 4th floor, B wing fire extinguisher was blocked by wheelchairs.

Exit interview with the Facility Administrator and the Facilities Manager on April 28, 2025, at 2:45 p.m., confirmed the extinguishers were blocked.




 Plan of Correction - To be completed: 05/27/2025

The corrections set forth in this document do not constitute admission or agreement by the provider of the truth of facts alleged or the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and executed solely because it is required by provisions of Federal and State law.

9TH FLOOR B SECTION FIRE EXTINGUISHER OBSTRUCTIONS CLEARED.
6TH FLOOR C SECTION FIRE EXTINGUISHER OBSTRUCTIONS CLEARED.
5TH FLOOR C SECTION FIRE EXTINGUISHER OBSTRUCTIONS CLEARED.
4TH FLOOR B SECTION FIRE EXTINGUISHER OBSTRUCTIONS CLEARED.
Other fire extinguishers checked to ensure no blockage.
STAFF REEDUCATED ON FIRE SAFETY REGULATIONS AND PROPER STORAGE OF ITEMS.

Maintenance Director or designee will audit weekly for 4 weeks, then monthly, then according to policy and procedure. Results will be reported to QAPI Steering Committee.


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: TOWER BUILDING - Component: 03 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain three corridor openings, affecting three of eleven floors.

Findings include:

1.Observation on April 28, 2025, between 12:45 p.m., and 1:42 p.m., revealed the following:

a. At 12:45 p.m., 9th floor, Housekeeping door failed to latch into positive latch into frame.
b. At 12:55 p.m., 8th floor, Resident Room 8A2 door failed to latch into positive latch into frame.
c. At 1:42 p.m., 3rd floor, Resident Room 3A2 door was not smoke tight when latched into frame.

Exit interview with the Facility Administrator and the Facilities Manager on April 28, 2025, at 2:45 p.m., confirmed the corridor opening deficiencies.




 Plan of Correction - To be completed: 05/27/2025

The corrections set forth in this document do not constitute admission or agreement by the provider of the truth of facts alleged or the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and executed solely because it is required by provisions of Federal and State law.

A9TH FLOOR HOUSEKEEPING DOOR ADJUSTED TO LATCH PROPERLY.
8TH FLOOR ROOM A2 DOOR ADJUSTED TO LATCH PROPERLY
3RD FLOOR ROOM A2 DOOR ADJUSTED TO LATCH PROPERLY.
Other door latches were checked.
STAFF EDUCATED ON IDENTIFYING DEFICIENCIES.

Maintenance Director or designee will audit weekly for 4 weeks, then monthly, then according to policy and procedure. Results will be reported to QAPI Steering Committee.
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: TOWER BUILDING - Component: 03 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain the emergency generator which serves the facility.

Findings include:

1. Observation on April 28, 2025, between 10:45 a.m., and 11:45 a.m., revealed the facility lacked the following generator documentation:

a. 3-year, 4-hour load bank testing data
b. Annual fuel quality testing data.

Exit interview with the Facility Administrator and the Facilities Manager on April 28, 2025, at 2:45 p.m., confirmed the lack of documentation.





 Plan of Correction - To be completed: 05/27/2025

The corrections set forth in this document do not constitute admission or agreement by the provider of the truth of facts alleged or the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and executed solely because it is required by provisions of Federal and State law.

3 YEAR ,4 HOUR LOAD TEST COMPLETE ON LIFE SAFETY GENERATORS
ANNUAL FUEL ANALYSIS COMPLETE ON LIFE SAFETY GENERATORS.
REQUIRED TESTS ARE ADDED TO SCOPE OF WORK WITH PREVENTATIVE MAINTENANCE CONTRACTOR.

Maintenance Director or designee will check contractor reports to ensure they contain all required services.

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: TOWER BUILDING - Component: 03 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain cylinder storage in one location, affecting one of eleven floors.

Findings include:

1. Observation on April 28, 2025, at 1:58 p.m., revealed a free-standing (E) oxygen cylinder, located within the Administration area, behind reception.

Exit interview with the Facility Administrator and the Facilities Manager on April 28, 2025, at 2:45 p.m., confirmed the cylinder storage deficiency.



 Plan of Correction - To be completed: 05/27/2025

The corrections set forth in this document do not constitute admission or agreement by the provider of the truth of facts alleged or the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and executed solely because it is required by provisions of Federal and State law.

OXYGEN CYLINDER SECURED AND STORED PROPERLY.
Other oxygen cylinders were checked for proper storage.
STAFF REEDUCATED ON PROPER OXYGEN CYLINDER STORAGE.

Maintenance Director or designee will audit oxygen storage weekly for 4 weeks, then monthly, then according to policy and procedure. Results will be reported to QAPI Steering Committee.


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