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

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

There are  50 surveys for this facility. Please select a date to view the survey results.

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KADIMA REHABILITATION & NURSING AT NEW CASTLE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Onsite Revisit to an Emergency Preparedness Survey completed on May 12, 2026, it was determined that Kadima Rehabilitation and Nursing at New Castle was not in compliance with the requirements of 42 CFR 483.73.









 Plan of Correction:


403.748(d), 416.54(d), 418.113(d), 441.184(d), 482.15(d), 483.475(d), 483.73(d), 484.102(d), 485.542(d), 485.625(d), 485.68(d), 485.727(d), 485.920(d), 486.360(d), 491.12(d), 494.62(d) STANDARD EP Training and Testing:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).

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

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

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

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

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one emergency preparedness plan.

Findings include:

Document review on May 12, 2026, at 9:00 a.m., revealed the facility failed to provide and maintain site-specific annual staff training of emergency preparedness procedures at the time of the survey.

Interview with the administrator on May 12, 2026, at 9:00 a.m., confirmed the deficiency at the time of the survey.
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Based on document review and interview during an Onsite Revisit Survey conducted on July 8, 2026, at 8:30 a.m., the facility was unable to provide documentation for the annual all-staff training of emergency preparedness procedures.
Interview with the administrator on July 8, 2026, at 8:30 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.











 Plan of Correction - To be completed: 07/22/2026

An audit of employee training records was conducted by the Human Resource Manager or designee, to identify staff members who lacked documented annual site-specific emergency preparedness training.

Identified staff members without documented training have received required training.

Documentation of completed trainings placed in each employee's education file.

Education:

The facility Human Resource Manager was educated on the requirements for staff Emergency Preparedness annual training and retraining.

System changes

The facility Emergency Preparedness Training Program was reviewed and revised to ensure annual emergency preparedness training is provided to all employees and appropriately documented. A standardized training curriculum and attendance tracker is being used. The Human Resource Manager will maintain a master tracking log to monitor training completion dates and ensure annual retraining occurs before expiration.

Monitoring

The Human Resource Manager or designee will conduct monthly audits of employee emergency preparedness training records for three months to verify compliance.

Results of audits will be reviewed by the facility Quality Assurance Committee.
403.748(d)(2), 416.54(d)(2), 418.113(d)(2), 441.184(d)(2), 482.15(d)(2), 483.475(d)(2), 483.73(d)(2), 484.102(d)(2), 485.542(d)(2), 485.625(d)(2), 485.68(d)(2), 485.727(d)(2), 485.920(d)(2), 486.360(d)(2), 491.12(d)(2), 494.62(d)(2) STANDARD EP Testing Requirements: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.
§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).

*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:

(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:

(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.

*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.

(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.


*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.

*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.

*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.

*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.

*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.

*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.

*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.
Observations:
Name: - Component: -- - Tag: 0039

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one emergency preparedness plan.

Findings include:

Document review on May 12, 2026, at 9:00 a.m., revealed the facility lacked records for the annual full-scale exercise and the tabletop exercise.

Interview with the administrator on May 12, 2026, at 9:00 a.m., confirmed the deficiency at the time of the survey.


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Based on document review and interview during an Onsite Revisit Survey conducted on July 8, 2026, at 8:30 a.m., the facility was unable to provide documentation for the annual full-scale and tabletop exercise.
Interview with the administrator on July 8, 2026, at 8:30 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.







 Plan of Correction - To be completed: 07/22/2026

The Human Resource Manager, The Maintenance Director, and the Facility Administrator reviewed the facility Emergency Preparedness Plan. No residents experienced adverse outcomes related to the deficient practice.

Education

The Human Resource Manager, The Maintenance Director and the Facility Administrator and Department Heads reviewed the requirements of 42 CFR §483.73(d)(2) regarding annual testing exercises and documentation of federal emergency preparedness testing requirements, including maintenance of supporting documentation such as participant attendance records, exercise scenarios, after-action reports, corrective action plans, and exercise evaluations

Systemic Changes

A comprehensive Emergency Preparedness Exercise Documentation Log was developed to ensure all required exercises are conducted, documented, and retained.

The facility established a tracking calendar identifying required emergency preparedness exercises, responsible personnel, due dates, and record retention requirements.

The facility completed and documented a tabletop exercise addressing an emergency event scenario. Documentation includes the exercise agenda, participant roster, meeting minutes, evaluation, and after-action report.

The facility conducted and documented a facility-based functional exercise in accordance with regulatory requirements

Monitoring:

The Facility Maintenance Director designee will audit emergency preparedness records quarterly to verify required exercises have been completed and supporting documentation is maintained.

Audit results will be reviewed by the Quality Assurance and Performance Improvement (QAPI) Committee.

Any identified deficiencies will be addressed immediately through corrective action and additional staff education as necessary.
Initial comments:Name: MAIN BUILDING 01 (SOUTH HALL BUILDING) - Component: 01 - Tag: 0000


Facility ID 100502
Component 01
Main Building

Based on an Onsite Revisit to a Medicare/Medicaid Recertification Survey completed on May 12, 2026, it was determined that Kadima Rehabilitation and Nursing at New Castle was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (000), unprotected, wood frame building, that is fully sprinklered.









 Plan of Correction:


NFPA 101 STANDARD Fire Alarm System - Installation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Fire Alarm System - Installation
A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity.
18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8




Observations:
Name: MAIN BUILDING 01 (SOUTH HALL BUILDING) - Component: 01 - Tag: 0341

Based on observation and interview, the facility failed to meet NFPA 72 fire alarm system requirements for three of under fifteen pull stations.

Findings include:

1. Observation on May 12, 2026, at 10:33 a.m., revealed the facility's fire alarm system pull stations were mounted above 50 inches from the floor by room 1 and near the lobby. The fire alarm pull stations must be mounted so that the operable part is located between 42-48 inches above the finished floor.

Interview with the maintenance technician on May 12, 2026, at 10:33 a.m., confirmed the pull stations were mounted over 50 inches throughout the facility.

2. Observation on May 12, 2026, at 10:38 a.m., revealed the emergency exit near the kitchen failed to have a pull station located within five feet of the exit egress door.

Interview with the maintenance technician on May 12, 2026, at 10:38 a.m., confirmed the exit door failed to have a pull station located within five feet of the egress door.

**************************************************************
Based on observation and interview during an Onsite Revisit Survey conducted on July 8, 2026, at 8:30 a.m., the facility failed to correct the pull station deficiencies.
Interview with the administrator on July 8, 2026, at 8:30 a.m., confirmed the facility did not correct the pull station deficiencies at the time of the survey.









 Plan of Correction - To be completed: 07/22/2026

Corrective Action for Residents Affected:
No residents were directly affected by the deficient practice.

An audit of all pull stations has been completed on 5/29/2026. No other non-compliant pull stations were observed.

Upon identification of the deficiency, the facility contacted its licensed fire alarm contractor to evaluate the cited locations. The pull stations near Room 1 and the lobby have been adjusted to comply with the required mounting height of 42 to 48 inches above the finished floor.

A compliant manual fire alarm pull station was installed within five feet of the emergency exit door

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING 01 (SOUTH HALL BUILDING) - Component: 01 - Tag: 0353

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

Findings include:

Document review on May 12, 2026, at 9:03 a.m., revealed the following sprinkler system deficiencies were documented by Mongiovi & Son at the time of the survey:

A. (9:03 a.m.) Facilities that have sprinkler heads over 50 years old are required to send a sample for testing;
B. (9:03 a.m.) Eight sprinkler heads were painted;
C. (9:03 a.m.) Six gauges were past the five year replacement date;
D. (9:03 a.m.) Five-year FDC hydro test was past due;
E. (9:03 a.m) Head wrench needed installed in the head box;
F. (9:03 a.m) Hydraulic name plate failed to be securely attached and legible;
G. (9:03 a.m) Facility failed to have inspection of the check valve to ensure components operate properly and are cleaned/repaired as needed;
H. (9:03 a.m) Facility failed to have a list of sprinklers on the property posted on the head box.

Interview with the maintenance technician on May 12, 2026, at 9:03 a.m., confirmed the facility was unable to provide corrective documentation of the deficiencies at the time of the survey.
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Based on document review and interview during an Onsite Revisit Survey conducted on July 8, 2026, at 8:30 a.m., the facility failed to provide corrective documentation for the sprinkler deficiencies at the time of the survey.
Interview with the administrator on July 8, 2026, at 8:30 a.m., confirmed the facility was unable to provide the sprinkler documentation at the time of the survey.











 Plan of Correction - To be completed: 07/22/2026

The facility acknowledges the findings related to sprinkler system maintenance and testing. The facility's maintenance department, in conjunction with the contracted fire protection vendor, will implement the following corrective actions to ensure compliance with NFPA 25 and NFPA 101 requirements.
Corrective Action

A sample of sprinkler heads exceeding 50 years of age will be identified and submitted to a qualified testing laboratory in accordance with NFPA 25 requirements. Documentation of testing results will be maintained on-site.

Systemic Measures:

The maintenance director will establish a tracking system identifying sprinkler installation dates and future testing requirements.

Corrective Action:

The eight painted sprinkler heads will be replaced by a licensed fire protection contractor. Documentation of replacement will be maintained on-site.

Systemic Measures:

The facility maintenance director or designee will audit sprinkler heads throughout the facility and ensure they are inspected to ensure no additional painted, damaged, or obstructed sprinkler heads exist.

Corrective Action:

The six expired gauges will be replaced with new listed gauges by the fire protection contractor.

Systemic Measures:

the facility maintenance director or designee will implement a preventative maintenance log to track future gauge replacement dates and required inspections.

Corrective Action:

The required five-year hydrostatic test of the FDC piping will be scheduled and completed by a qualified fire protection contractor.

Systemic Measures:

The facility maintenance director or designee will implement a compliance calendar identifying all required sprinkler system inspection, testing, and maintenance intervals.

Corrective Action:

An approved sprinkler head wrench has been placed in the sprinkler spare head cabinet.

Systemic Measures:

The sprinkler spare head cabinet inventory will be reviewed quarterly by the maintenance director or designee to verify required components remain present and accessible.

Corrective Action:

The hydraulic design information nameplate will be replaced or securely reattached and maintained in a legible condition.

Systemic Measures:

the maintenance director will include Hydraulic nameplates in the facility's annual fire protection system inspection checklist.

Corrective Action:

A qualified fire protection contractor will perform the required internal inspection of the check valve and complete any necessary cleaning, repair, or replacement. Documentation will be retained on-site.

Systemic Measures:

The facility maintenance director will add all required internal valve inspections to its preventative maintenance schedule to ensure ongoing compliance with NFPA 25.

Corrective Action:

A current inventory list identifying the quantity and type of spare sprinkler heads maintained on-site will be posted in or on the sprinkler head cabinet.

Systemic Measures:

The sprinkler head inventory will be reviewed quarterly and updated as needed by the Maintenance Director

Monitoring and Quality Assurance

The Maintenance Director will audit the sprinkler system inspection, testing, and maintenance documentation quarterly for a period of twelve (12) months to ensure ongoing compliance with NFPA 25 and NFPA 101 requirements. Any identified deficiencies will be corrected immediately. Results of audits will be reported to the facility Quality Assurance and Performance Improvement (QAPI) Committee for review and follow-up as appropriate.
NFPA 101 STANDARD Fire Drills: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.
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 (SOUTH HALL BUILDING) - Component: 01 - Tag: 0712

Based on observation and interview, the facility failed to meet fire drill requirements for two of three shifts.

Findings include:

Observation on May 12, 2026, at 9:11 a.m., revealed the second and third shift fire drills were held within the same hour all four quarters.

Interview with the maintenance technician on May 12, 2026, at 9:11 a.m., confirmed the fire drills were not held at unexpected times and varying conditions.

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Based on document review and interview during an Onsite Revisit Survey conducted on July 8, 2026, at 8:30 a.m., the facility failed to provide any fire drill documentation.
Interview with the administrator on July 8, 2026, at 8:30 a.m., confirmed the facility was unable to provide the fire drill documentation at the time of the survey.






 Plan of Correction - To be completed: 07/22/2026

The facility reviewed all fire drill documentation and confirmed that second-shift and third-shift fire drills were conducted within the same hour during each quarter.
The Maintenance Director and Administrator have revised the facility fire drill schedule to ensure future drills are conducted at varying times throughout each shift in accordance with NFPA 101 requirements.

Measures to Prevent Recurrence the facility Maintenance Director has updated its fire drill policy to require that fire drills be conducted at different times of the day and night on each shift.

A fire drill tracking log has been developed to document drill dates, times, shifts, and scenarios to ensure adequate variation between drills.

The Maintenance Director and designee have been educated regarding NFPA 101 fire drill requirements, including the requirement that drills be held at unexpected and varying times on all shifts on 5/29/2026

Monitoring

The Maintenance Director designee will review fire drill schedules and completed drill reports quarterly for a period of twelve (12) months to verify compliance with fire drill timing requirements. Any identified scheduling concerns will be corrected immediately.

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

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

Findings include:

Document review on May 12, 2026, at 9:50 a.m., revealed the facility failed to provide weekly generator battery voltage and visual inspections for one of one generator at the time of the survey.

Interview with the maintenance director on May 12, 2026, at 9:50 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.

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Based on document review and interview during an Onsite Revisit Survey conducted on July 8, 2026, at 8:30 a.m., the facility failed to provide weekly generator inspection documentation at the time of the survey.
Interview with the administrator on July 8, 2026, at 8:30 a.m., confirmed the facility was unable to provide the generator documentation at the time of the survey.









 Plan of Correction - To be completed: 07/22/2026

The generator was inspected and found to be operating properly with no deficiencies identified. Documentation of the inspection has been placed in the generator maintenance records.

Identification of Other Areas

The facility maintenance director reviewed all emergency power supply system documentation for the previous twelve months to determine whether additional required inspections, testing, and maintenance activities were completed and properly documented. Any missing documentation identified during the review was addressed and corrective action taken as appropriate.

Measures to Prevent Recurrence

The facility maintenance director revised its generator inspection and documentation process to ensure weekly battery voltage measurements and visual inspections are completed and recorded in accordance with NFPA 99 and NFPA 110 requirements.

The Maintenance Director and designated maintenance personnel were re-educated on emergency generator inspection requirements, including documentation of battery voltage readings, electrolyte levels (when applicable), battery charger status, and overall generator condition.

A weekly generator inspection log has been implemented and incorporated into the facility's preventative maintenance program. The log will require completion and supervisory review to ensure compliance.

Monitoring

The Maintenance Director or designee will audit generator inspection logs weekly for three months and monthly thereafter for an additional nine months to verify that required battery voltage measurements and visual inspections are completed and documented.

Results of the audits will be reported to the facility's Quality Assurance and Performance Improvement (QAPI) Committee quarterly for review and follow-up as necessary.
Initial comments:Name: BUILDING 02 (WEST WING BUILDING) - Component: 02 - Tag: 0000


Facility ID 100502
Component 02
West Wing Building

Based on an Onsite Revisit to a Medicare/Medicaid Recertification Survey completed on May 14, 2026, it was determined that Kadima Rehabilitation and Nursing at New Castle was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.









 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
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: BUILDING 02 (WEST WING BUILDING) - Component: 02 - Tag: 0100

Document review on May 12, 2026, at 9:05 a.m., revealed the facility failed to provide a set of accurate, portable floor plans. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site, to be used during the Life Safety Code Survey.

The Life Safety Code Floor Plan shall include the following:

a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls (1-2 hour walls);
c. Horizontal exits;
d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls.

Observation during the survey revealed several corridor doors as well as the dining room door had fire-rated glass without a fire-rated label on the door. The facility was unable to provide drawings to idicate if a fire wall existed.

Interview with the maintenance supervisor on May 12, 2026, at 9:05 a.m., confirmed the Life Safety Code Floor Plan provided during the survey failed to accurately contain the listed items.

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Based on document review and interview during an Onsite Revisit Survey conducted on July 8, 2026, at 8:30 a.m., the facility failed to provide accurate, portable Life Safety floor plans at the time of the survey.
Interview with the administrator on July 8, 2026, at 8:30 a.m., confirmed the facility was unable to provide Life Safety floor plans at the time of the survey.









 Plan of Correction - To be completed: 07/22/2026

The facility Director of Maintenance has reviewed all existing floor plans and will obtain and/or update a complete set of accurate floor plans reflecting the current building layout, resident care areas, exits, smoke compartments, fire barriers, utility shutoffs, and other pertinent life safety features.
Portable copies of the floor plans will be placed in a designated location readily accessible to emergency responders and facility staff.

Identification of Other Areas

The facility Director of Maintenance conducted a review of all building areas and recent renovations or modifications to ensure the floor plans accurately reflect current conditions throughout the facility. Any discrepancies identified during the review were corrected prior to finalization of the updated floor plans.

Measures to Prevent Recurrence

The facility Administrator has implemented a policy requiring the floor plans to be reviewed annually and whenever construction, renovation, or alterations occur that affect the building layout or life safety features.

The Maintenance Director and Administrator have been educated on 5/29/2026 regarding the requirement to maintain accurate, portable floor plans on-site and to ensure updates are completed following any building modifications.

The floor plans will be maintained in a designated emergency preparedness binder and will remain readily available for use by emergency responders, surveyors, and facility personnel.

Monitoring

The Maintenance Director will verify the availability and accuracy of the portable floor plans quarterly for a period of twelve (12) months. Reviews will include confirmation that the plans remain current, legible, and readily accessible.

Results of the quarterly reviews will be reported to the facility's Quality Assurance and Performance Improvement (QAPI) Committee for oversight and follow-up as necessary.
NFPA 101 STANDARD Multiple Occupancies - Construction Type:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: BUILDING 02 (WEST WING BUILDING) - Component: 02 - Tag: 0133

Based on observation and interview, the facility failed to meet multiple occupancy requirements for one of two building separations.

Findings include:

Observation on May 12, 2026, at 9:00 a.m., revealed the basement two-hour fire door was propped open by a water container, preventing it from closing.

Interview with the maintenance technician on May 12, 2026, at 9:00 a.m., confirmed the door was propped open.

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Based on observation and interview during an Onsite Revisit Survey conducted on July 8, 2026, at 8:30 a.m., the facility failed to ensure the two-hour fire door closed and latched at the time of the survey.
Interview with the administrator on July 8, 2026, at 8:30 a.m., confirmed the facility was unable to ensure the fire door closed and latched at the time of the survey.






 Plan of Correction - To be completed: 07/22/2026

Corrective Action
The water container was removed immediately upon identification, and the two-hour fire-rated door was tested to ensure it closed and latched properly without impediment. The door was found to be functioning as designed.

Identification of Other Areas

The Maintenance Director conducted an inspection of all fire-rated doors throughout the facility to identify any additional doors that were propped open, obstructed, or otherwise prevented from functioning properly. Any identified issues were corrected immediately.

Measures to Prevent Recurrence

The facility has re-educated maintenance staff, department managers, and other applicable personnel regarding the requirement that fire-rated doors remain unobstructed and may not be propped open unless equipped with an approved automatic releasing device connected to the fire alarm system.

The facility's Life Safety and Environmental Rounds policy has been revised to include routine observation of fire-rated doors to verify that doors remain unobstructed and capable of closing and latching properly.

Signage reminding staff not to prop open fire-rated doors will be installed in appropriate locations as needed.

Monitoring

The Maintenance Director or designee will conduct weekly inspections of fire-rated doors for three months and monthly inspections thereafter for an additional nine months to verify compliance. Any identified deficiencies will be corrected immediately.

Inspection results will be documented and reported to the facility's Quality Assurance and Performance Improvement (QAPI) Committee quarterly for review and follow-up as necessary
NFPA 101 STANDARD Egress Doors:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
Observations:
Name: BUILDING 02 (WEST WING BUILDING) - Component: 02 - Tag: 0222

Based on observation and interview, the facility failed to meet egress door requirements for one of over five exits.

Findings include:

Observation on May 12, 2026, at 10:40 a.m., revealed the kitchen exit had bread carts blocking the exit door from fully opening, delaying egress in the event of an emergency.

Interview with the maintenance technician on May 12, 2026, at 10:40 a.m., confirmed the exit door was obstructed at the time of the survey.

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Based on observation and interview during an Onsite Revisit Survey conducted on July 8, 2026, at 8:30 a.m., the facility failed to ensure the kitchen exit door could fully open at the time of the survey.
Interview with the administrator on July 8, 2026, at 8:30 a.m., confirmed the facility was unable to fully open the kitchen exit door at the time of the survey.









 Plan of Correction - To be completed: 07/22/2026

The bread carts were removed by the dietary manager immediately from the area in front of the kitchen exit door. The exit door was inspected and verified to open fully and provide unobstructed egress in accordance with NFPA 101 requirements.

Identification of Other Areas

The Maintenance Director and Dietary Manager conducted an inspection of all exit doors, exit access corridors, and means of egress throughout the facility to identify any additional obstructions that could impede emergency evacuation. Any identified obstructions were removed immediately.

Measures to Prevent Recurrence

The facility Administrator has re-educated dietary staff, maintenance staff, and department managers regarding the requirement to keep all exit doors, exit access pathways, and means of egress clear and unobstructed at all times.

The Dietary Department has designated approved storage locations for bread carts and other equipment to ensure that items are not placed in front of exit doors or within required egress pathways.

The facility's Environmental and Life Safety rounds process has been updated to include monitoring of exit doors and surrounding areas for potential obstructions.

Monitoring

The Maintenance Director or designee will conduct weekly inspections of all exit doors and egress pathways for a period of three months and monthly inspections thereafter for an additional nine months to verify compliance.

Any identified deficiencies will be corrected immediately and documented. Results of the inspections will be reported to the facility's Quality Assurance and Performance Improvement (QAPI) Committee quarterly for review and follow-up as necessary.
NFPA 101 STANDARD Discharge from Exits:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7
Observations:
Name: BUILDING 02 (WEST WING BUILDING) - Component: 02 - Tag: 0271

Based on observation and interview, the facility failed to meet exit discharge requirements for two of over five discharges.

Findings include:

Observation on May 12, 2026, at between 11:00 a.m. and 11:33 a.m., revealed the following deficiencies for exit discharges:

A. (11:00 a.m.) The exit discharge from the kitchen area had broken up concrete and wood obstructing the hard-packed travel surface;
B. (11:33 a.m.) The exit discharge from the west resident corridor had a drop-off from the cement ramp to the stone surface that created an uneven all-weather, hard-packed surface.

Interview with the maintenance technician on May 12, 2026, at 11:33 a.m., confirmed the exit discharge deficiencies.

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Based on observation and interview during an Onsite Revisit Survey conducted on July 8, 2026, at 8:30 a.m., the facility failed to ensure the exit discharge surface deficiencies were corrected at the time of the survey.

Interview with the administrator on July 8, 2026, at 8:30 a.m., confirmed the facility did not correct the discharge surface deficiencies at the time of the survey.








 Plan of Correction - To be completed: 07/22/2026

Corrective Action
The cited deficiencies were corrected immediately following identification.

A. The broken concrete and wood debris obstructing the kitchen exit discharge were removed, and the exit discharge pathway was restored to provide a clear, unobstructed all-weather, hard-packed travel surface.

B. The uneven transition at the west resident corridor exit discharge was repaired, eliminating the drop-off and restoring a safe, even all-weather, hard-packed travel surface suitable for emergency egress.

Both exit discharge locations were inspected following repairs and verified to provide unobstructed and safe passage to the public way by the facility administrator and director of maintenance.

Identification of Other Areas

The Maintenance Director conducted a review of all facility exit discharge pathways, ramps, sidewalks, and designated egress routes to identify any additional conditions that could impede emergency evacuation or create uneven walking surfaces. Any concerns identified during the review were addressed appropriately.

Measures to Prevent Recurrence

The facility has reinforced procedures requiring routine inspection of all exit discharge areas, sidewalks, ramps, and exterior egress pathways to ensure they remain unobstructed, properly maintained, and compliant with NFPA 101 requirements.

Maintenance staff have been educated regarding the importance of maintaining exit discharge pathways free of obstructions and surface defects that could impede evacuation during an emergency.

Exit discharge pathways will be included as part of the facility's routine environmental and life safety rounds.

Monitoring

The Maintenance Director or designee will conduct and document monthly inspections of all exit discharge pathways, ramps, sidewalks, and exterior egress routes for a period of twelve (12) months to verify continued compliance.

Any identified deficiencies will be corrected immediately. Inspection findings will be reported quarterly to the facility's Quality Assurance and Performance Improvement (QAPI) Committee for review.


NFPA 101 STANDARD Exit Signage:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Name: BUILDING 02 (WEST WING BUILDING) - Component: 02 - Tag: 0293

Based on observation and interview, the facility failed to meet exit signage requirements for one of over fifteen exit signs.

Findings include:

Observation on May 12, 2026, at 10:43 a.m., revealed the exit light bulb was not illuminated at the ambulance exit door.

Interview with the maintenance technician on May 12, 2026, at 10:43 a.m., confirmed the exit light bulb was not illuminated at the time of the survey.

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Based on observation and interview during an Onsite Revisit Survey conducted on July 8, 2026, at 8:30 a.m., the facility failed to correct the exit light bulb deficiency at the time of the survey.

Interview with the administrator on July 8, 2026, at 8:30 a.m., confirmed the facility did not correct the exit light bulb deficiency at the time of the survey.











 Plan of Correction - To be completed: 07/22/2026

The failed bulb in the exit sign at the ambulance exit door was replaced immediately upon identification. The exit sign was tested and verified to be properly illuminated and functioning in accordance with NFPA 101 requirements.

Identification of Other Areas

The Maintenance Director or designee conducted an inspection of all exit signs throughout the facility to verify proper illumination and operation. Any additional deficiencies identified during the inspection were corrected immediately.

Measures to Prevent Recurrence

The facility has reinforced procedures requiring routine inspection of all exit signs to ensure continuous illumination and proper operation.

Maintenance personnel were educated regarding NFPA 101 requirements for illuminated exit signage and the importance of promptly correcting any deficiencies identified during routine inspections.

Exit signs will be included in the facility's preventative maintenance and life safety inspection program.

Monitoring

The Maintenance Director or designee will conduct and document monthly inspections of all exit signs throughout the facility for a period of twelve (12) months to verify continued compliance.

Any identified deficiencies will be corrected immediately.

Inspection results will be reported quarterly to the facility's Quality Assurance and Performance Improvement (QAPI) Committee for review
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: BUILDING 02 (WEST WING BUILDING) - Component: 02 - Tag: 0353

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

Findings include:

Document review on May 12, 2026, at 9:03 a.m., revealed the following sprinkler system deficiencies were documented by Mongiovi & Son at the time of the survey:

A. (9:03 a.m.) Facilities that have sprinkler heads over 50 years old are required to send a sample for testing;
B. (9:03 a.m.) Eight sprinkler heads were painted;
C. (9:03 a.m.) Six gauges were past the five-year replacement date;
D. (9:03 a.m.) Five year FDC hydro test was past due;
E. (9:03 a.m) Head wrench needed installed in the head box
F. (9:03 a.m) Hydraulic name plate failed to be securely attached and legible;
G. (9:03 a.m) Facility failed to have inspection of the check valve to ensure components operated properly and were cleaned/repaired as needed;
H. (9:03 a.m) Facility failed to have a list of sprinklers on the property posted on the head box.

Interview with the maintenance technician on May 12, 2026, at 9:03 a.m., confirmed the facility was unable to provide corrective documentation for the deficiencies at the time of the survey.

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Based on document review and interview during an Onsite Revisit Survey conducted on July 8, 2026, at 8:30 a.m., the facility failed to provide corrective documentation for the sprinkler deficiencies at the time of the survey.
Interview with the administrator on July 8, 2026, at 8:30 a.m., confirmed the facility was unable to provide the sprinkler documentation at the time of the survey.







 Plan of Correction - To be completed: 07/22/2026

The facility acknowledges the findings related to sprinkler system maintenance and testing. The facility's maintenance department, in conjunction with the contracted fire protection vendor, will implement the following corrective actions to ensure compliance with NFPA 25 and NFPA 101 requirements.
Corrective Action

A sample of sprinkler heads exceeding 50 years of age will be identified and submitted to a qualified testing laboratory in accordance with NFPA 25 requirements. Documentation of testing results will be maintained on-site.

Systemic Measures:

The maintenance director will establish a tracking system identifying sprinkler installation dates and future testing requirements.

Corrective Action:

The eight painted sprinkler heads will be replaced by a licensed fire protection contractor. Documentation of replacement will be maintained on-site.

Systemic Measures:

The facility maintenance director or designee will audit sprinkler heads throughout the facility and ensure they are inspected to ensure no additional painted, damaged, or obstructed sprinkler heads exist.

Corrective Action:

The six expired gauges will be replaced with new listed gauges by the fire protection contractor.

Systemic Measures:

the facility maintenance director or designee will implement a preventative maintenance log to track future gauge replacement dates and required inspections.

Corrective Action:

The required five-year hydrostatic test of the FDC piping will be scheduled and completed by a qualified fire protection contractor. Test documentation will be maintained on-site. Vendor will be onsite 6/2/2026.

Systemic Measures:

The facility maintenance director or designee will implement a compliance calendar identifying all required sprinkler system inspection, testing, and maintenance intervals.

Corrective Action:

An approved sprinkler head wrench has been placed in the sprinkler spare head cabinet.

Systemic Measures:

The sprinkler spare head cabinet inventory will be reviewed quarterly by the maintenance director or designee to verify required components remain present and accessible.

Corrective Action:

The hydraulic design information nameplate will be replaced or securely reattached and maintained in a legible condition.

Systemic Measures:

the maintenance director will include Hydraulic nameplates in the facility's annual fire protection system inspection checklist.

Corrective Action:

A qualified fire protection contractor will perform the required internal inspection of the check valve and complete any necessary cleaning, repair, or replacement. Documentation will be retained on-site.

Systemic Measures:

The facility maintenance director will add all required internal valve inspections to its preventative maintenance schedule to ensure ongoing compliance with NFPA 25.

Corrective Action:

A current inventory list identifying the quantity and type of spare sprinkler heads maintained on-site will be posted in or on the sprinkler head cabinet.

Systemic Measures:

The sprinkler head inventory will be reviewed quarterly and updated as needed by the Maintenance Director

Monitoring and Quality Assurance

The Maintenance Director will audit the sprinkler system inspection, testing, and maintenance documentation quarterly for a period of twelve (12) months to ensure ongoing compliance with NFPA 25 and NFPA 101 requirements. Any identified deficiencies will be corrected immediately. Results of audits will be reported to the facility Quality Assurance and Performance Improvement (QAPI) Committee for review
NFPA 101 STANDARD Portable Fire Extinguishers:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
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: BUILDING 02 (WEST WING BUILDING) - Component: 02 - Tag: 0355

Based on observation and interview, the facility failed to meet portable fire extinguisher requirements for one of over twenty portable fire extinguishers.

Findings include:

Observation on May 12, 2026, at 9:55 a.m., revealed the portable fire extinguisher by room one was missing a monthly inspection.

Interview with the maintenance technician on May 12, 2026, at 9:55 a.m., confirmed the fire extinguisher was missing a monthly inspection.

***************************************************************

Based on observation and interview during an Onsite Revisit Survey conducted on July 8, 2026, at 8:30 a.m., the facility failed to ensure the portable fire extinguisher deficiency was corrected at the time of the survey.

Interview with the administrator on July 8, 2026, at 8:30 a.m., confirmed the facility did not correct the deficiency at the time of the survey.








 Plan of Correction - To be completed: 07/22/2026

Corrective Action
The monthly inspection of the portable fire extinguisher located by Room 1 was completed and documented upon identification of the deficiency. The extinguisher was inspected and found to be properly charged, accessible, free from damage, and in serviceable condition.

Identification of Other Areas

The Maintenance Director reviewed all portable fire extinguisher inspection records throughout the facility to verify that monthly inspections had been completed and documented as required. Any discrepancies identified during the review were corrected immediately.

Measures to Prevent Recurrence

The facility has reinforced procedures for conducting and documenting monthly portable fire extinguisher inspections in accordance with NFPA requirements.

The Maintenance Director and designated maintenance personnel were re-educated on the importance of timely completion and documentation of monthly extinguisher inspections. A tracking system and monthly checklist have been implemented to ensure inspections are completed and documented consistently.

Monitoring

The Maintenance Director or designee will conduct a monthly audit of portable fire extinguisher inspection records for a period of twelve (12) months to verify compliance.

Any identified deficiencies will be corrected immediately and documented. Audit results will be reported quarterly to the facility's Quality Assurance and Performance Improvement (QAPI) Committee
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: BUILDING 02 (WEST WING BUILDING) - Component: 02 - Tag: 0374

Based on observation and interview, the facility failed to meet subdivision of building space requirements in one of four smoke compartments.

Findings include:

Observation on May 12, 2026, at 10:56 a.m., revealed the south smoke barrier door near the kitchen had a large gap between the door allowing the transfer of smoke in the event of an emergency.

Interview with the maintenance technician on May 12, 2026, at 10:56 a.m., confirmed the gap deficiency at the time of the survey.

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Based on observation and interview during an Onsite Revisit Survey conducted on July 8, 2026, at 8:30 a.m., the facility failed to ensure the smoke door deficiency was corrected at the time of the survey.

Interview with the administrator on July 8, 2026, at 8:30 a.m., confirmed the facility did not correct the smoke door deficiency at the time of the survey.







 Plan of Correction - To be completed: 07/22/2026

Corrective Action
The south smoke barrier door near the kitchen was immediately evaluated by the Maintenance Director and adjusted to eliminate the excessive gap. The door was tested to ensure it closed properly and maintained the integrity of the smoke barrier in accordance with NFPA 101 requirements.

Identification of Other Areas

The Maintenance Director conducted an inspection of all smoke barrier doors throughout the facility to identify any additional gaps, damage, or conditions that could compromise smoke barrier protection. Any deficiencies identified during the inspection were corrected or scheduled for repair.

Measures to Prevent Recurrence

The facility has reinforced procedures requiring routine inspection of smoke barrier doors to ensure they close properly, latch appropriately, and maintain required clearances.

The Maintenance Director and designated maintenance personnel were re-educated regarding NFPA 101 requirements for smoke barrier assemblies and the importance of maintaining the integrity of smoke compartments.

Smoke barrier doors will be incorporated into the facility's preventative maintenance and life safety inspection program.

Monitoring

The Maintenance Director or designee will conduct and document monthly inspections of all smoke barrier doors for a period of twelve (12) months to verify continued compliance.

Any identified deficiencies will be corrected immediately and documented. Inspection results will be reported quarterly to the facility's Quality Assurance and Performance Improvement (QAPI) Committee for review and follow-up as necessary.
NFPA 101 STANDARD Fire Drills: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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: BUILDING 02 (WEST WING BUILDING) - Component: 02 - Tag: 0712

Based on observation and interview, the facility failed to meet fire drill requirements for two of three shifts.

Findings include:

Observation on May 12, 2026, at 9:11 a.m., revealed the second and third shift fire drills were held within the same hour all four quarters.

Interview with the maintenance technician on May 12, 2026, at 9:11 a.m., confirmed the fire drills were not held at unexpected times and varying conditions.

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Based on document review and interview during an Onsite Revisit Survey conducted on July 8, 2026, at 8:30 a.m., the facility failed to provide any fire drill documentation.
Interview with the administrator on July 8, 2026, at 8:30 a.m., confirmed the facility was unable to provide the fire drill documentation at the time of the survey.





 Plan of Correction - To be completed: 07/22/2026

The facility reviewed all fire drill documentation and confirmed that second-shift and third-shift fire drills were conducted within the same hour during each quarter.
The Maintenance Director and Administrator have revised the facility fire drill schedule to ensure future drills are conducted at varying times throughout each shift in accordance with NFPA 101 requirements.

Measures to Prevent Recurrence the facility Maintenance Director has updated its fire drill policy to require that fire drills be conducted at different times of the day and night on each shift.

A fire drill tracking log has been developed to document drill dates, times, shifts, and scenarios to ensure adequate variation between drills.

The Maintenance Director and designee have been educated regarding NFPA 101 fire drill requirements, including the requirement that drills be held at unexpected and varying times on all shifts on 5/29/2026

Monitoring

The Maintenance Director designee will review fire drill schedules and completed drill reports quarterly for a period of twelve (12) months to verify compliance with fire drill timing requirements. Any identified scheduling concerns will be corrected immediately.

Results of these audits will be reported to the facility's Quality Assurance and Performance Improvement (QAPI) Committee
NFPA 101 STANDARD Electrical Systems - Receptacles:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)
Observations:
Name: BUILDING 02 (WEST WING BUILDING) - Component: 02 - Tag: 0912

Based on document review and interview, the facility failed to meet receptacle requirements in eight of over 30 rooms.

Findings include:

Document review on May 12, 2026, at 10:10 a.m., revealed the 2026 receptacle testing was missing resident common room receptacles.

Interview with the maintenance technician on May 12, 2026, at 10:10 a.m., confirmed the receptacles in the resident common areas were not tested at the time of the survey.

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Based on document review and interview during an Onsite Revisit Survey conducted on July 8, 2026, at 8:30 a.m., the facility failed to test deficient electrical receptacles at the time of the survey.
Interview with the administrator on July 8, 2026, at 8:30 a.m., confirmed the facility was unable to provide the required receptacle testing at the time of the survey.







 Plan of Correction - To be completed: 07/22/2026

The receptacles located in the resident common room were tested upon identification of the deficiency in accordance with NFPA 99 and facility procedures.

Documentation of the completed testing was added to the facility's receptacle testing records. All tested receptacles were found to be functioning properly, or any deficiencies identified were corrected immediately.

Identification of Other Areas

The Maintenance Director reviewed the 2026 receptacle testing records for all resident care areas and non-resident care areas requiring testing to ensure all receptacles were included and properly documented. Any omitted receptacles identified during the review were tested and documented accordingly.

Measures to Prevent Recurrence

The facility has revised its receptacle testing inventory and testing procedures to ensure all required receptacles, including those located in resident common rooms and other resident-use areas, are included in future testing cycles.

The Maintenance Director and designated maintenance personnel were re-educated regarding NFPA requirements for receptacle testing and documentation. An updated receptacle inventory checklist has been implemented to verify all locations are included during annual testing.

Monitoring

The Maintenance Director or designee will audit receptacle testing documentation quarterly for a period of twelve (12) months to verify that all required receptacles are included in the testing program and properly documented.

Any identified omissions will be corrected immediately. Audit results will be reported quarterly to the facility's Quality Assurance and Performance Improvement (QAPI) 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: BUILDING 02 (WEST WING BUILDING) - Component: 02 - Tag: 0918

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

Findings include:

Document review on May 12, 2026, at 9:50 a.m., revealed facility failed to provide weekly battery voltage and visual generator inspections for one of one generator at the time of the survey.

Interview with the maintenance director on May 12, 2026, at 9:50 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.

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Based on document review and interview during an Onsite Revisit Survey conducted on July 8, 2026, at 8:30 a.m., the facility failed to provide weekly generator inspection documentation at the time of the survey.
Interview with the administrator on July 8, 2026, at 8:30 a.m., confirmed the facility was unable to provide the generator documentation at the time of the survey.








 Plan of Correction - To be completed: 07/22/2026

The Maintenance Director conducted and documented the required battery voltage measurement and visual inspection for the emergency generator. The generator was inspected and found to be operating properly with no deficiencies identified. Documentation of the inspection has been placed in the generator maintenance records.

Identification of Other Areas

The facility maintenance director reviewed all emergency power supply system documentation for the previous twelve months to determine whether additional required inspections, testing, and maintenance activities were completed and properly documented. Any missing documentation identified during the review was addressed and corrective action taken as appropriate.

Measures to Prevent Recurrence

The facility maintenance director revised its generator inspection and documentation process to ensure weekly battery voltage measurements and visual inspections are completed and recorded in accordance with NFPA 99 and NFPA 110 requirements.

The Maintenance Director and designated maintenance personnel were re-educated on emergency generator inspection requirements, including documentation of battery voltage readings, electrolyte levels (when applicable), battery charger status, and overall generator condition.

A weekly generator inspection log has been implemented and incorporated into the facility's preventative maintenance program. The log will require completion and supervisory review to ensure compliance.

Monitoring

The Maintenance Director or designee will audit generator inspection logs weekly for three months and monthly thereafter for an additional nine months to verify that required battery voltage measurements and visual inspections are completed and documented.

Results of the audits will be reported to the facility's Quality Assurance and Performance Improvement (QAPI) Committee quarterly for review and follow-up as necessary.
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: BUILDING 02 (WEST WING BUILDING) - Component: 02 - Tag: 0920

Based on observation and interview, the facility failed to meet electrical equipment requirements for one of over twenty rooms.

Findings include:

Observation on May 12, 2026, at 10:01 a.m., revealed the basement boiler room had a six-to-one outlet in use at the time of the survey.

Interview with the maintenance technician on May 12, 2026, at 10:01 a.m., confirmed the boiler room had a six-to-one outlet device.

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Based on observation and interview during an Onsite Revisit Survey conducted on July 8, 2026, at 8:30 a.m., the facility failed to ensure the six-to-one outlet was removed at the time of the survey.

Interview with the administrator on July 8, 2026, at 8:30 a.m., confirmed the facility did not correct the outlet deficiency at the time of the survey.








 Plan of Correction - To be completed: 07/22/2026

The six-to-one outlet adapter was removed upon identification of the deficiency. Equipment connected to the adapter was evaluated and connected to approved electrical outlets and/or power distribution devices as appropriate. The area was inspected to ensure compliance with NFPA 101 requirements.

Identification of Other Areas

The Maintenance Director conducted a facility-wide inspection of resident care areas, mechanical rooms, storage areas, offices, and other support spaces to identify any additional unauthorized multi-plug adapters, extension cords, or improper electrical connections. Any deficiencies identified during the inspection were corrected immediately.

Measures to Prevent Recurrence

The facility has reinforced its electrical safety policy prohibiting the use of unauthorized multi-plug adapters and improper extension cord usage.

The Maintenance Director and department managers were re-educated regarding NFPA 101 electrical safety requirements, including approved methods for supplying power to electrical equipment.

Routine environmental and life safety rounds will include inspection for unauthorized electrical devices and improper electrical connections.

Monitoring

The Maintenance Director or designee will conduct and document monthly inspections of electrical equipment, outlets, power strips, and extension cord usage throughout the facility for a period of twelve (12) months to verify continued compliance.

Any identified deficiencies will be corrected immediately and documented. Inspection results will be reported quarterly to the facility's Quality Assurance and Performance Improvement (QAPI) Committee

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