Pennsylvania Department of Health
 JERSEY SHORE SKILLED NURSING AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
JERSEY SHORE SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  39 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
JERSEY SHORE SKILLED NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on May 5, 2025, at Jersey Shore Skilled Nursing and Rehabilitation Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


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


Facility ID# 121302
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 5, 2025, it was determined that Jersey Shore Skilled Nursing and Rehabilitation Center, 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 483.70(a).

This is a three story, Type II (111), protected, noncombustible structure that is fully sprinklered.




 Plan of Correction:


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: MAIN BUILDING 01 - Component: 01 - Tag: 0225

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

Findings include:

1. Observation on May 5, 2025, at 9:54 a.m., 1st floor, central communicating stair tower, had a plastic folding table being stored under the stairs.

Exit interview with the facility administrator and facilities representative on May 5, 2025, at 11:30 a.m., confirmed the stairwell tower enclosures deficiency.




 Plan of Correction - To be completed: 06/24/2025

1. and 2. The container was immediately removed from the stair tower and the door codes to the stair tower were changed so that unauthorized individuals would not be able to access the stair tower to store any containers.
3. Maintenance department will be educated on the standards of keeping the facilities stairway enclosures free of clutter.
4. Maintenance or facility designee will audit facilities stairway enclosures weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
NFPA 101 STANDARD Vertical Openings - Enclosure:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to protect vertical enclosures, affecting three of three floors.

Findings include:

1. Observation on May 5, 2025, at 9:45 a.m., revealed the following vertical enclosures lacked the required one-hour fire resistance rating:

a. Central (communicating) stair tower.
b. North wing heating, cooling, and ventilation (HVAC) shaft.

Exit interview with the facility administrator and facilities representative on May 5, 2025, at 11:30 a.m., confirmed the vertical enclosure deficiencies.




 Plan of Correction - To be completed: 06/24/2025

Facility requests PA DSI to complete an FSES.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain three hazardous area enclosures, affecting two of three floors.

Findings include:

1. Observation on May 5, 2025, between 10:00 a.m., and 10:33 a.m., revealed the following:

a. At 10:00 a.m., 1st floor Laundry Storage door, failed to fully close and latch into frame when tested.
b. At 10:12 a.m., 1st floor Soiled Utility door, had (2) unsealed penetrations of the door above the door hardware, at nurses' station.
c. At 10:33 a.m., 3rd floor Soiled Utility door, was being held open by unapproved means, at nurses' station. (styrofoam taped into the door frame).

Exit interview with the facility administrator and facilities representative on May 5, 2025, at 11:30 a.m., confirmed the hazardous area enclosure deficiencies.




 Plan of Correction - To be completed: 06/24/2025

1. and2. Maintenance Director will fix 1st floor laundry storage door to ensure it closes/latches, maintenance director will seal penetrations of door on 1st floor soiled utility door, and maintenance director will remove styrofoam taped on 3rd floor soiled utility room to allow door to close.
3. Maintenance department will be educated on the standards of ensuring the facility's enclosures do not have penetration, closes/latches, and no items holding doors open.
4. Maintenance or facility designee will audit the facilities doors weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.

NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on observation and interview, it was determined the facility failed to maintain cooking facilities, affecting three of three floors.

Findings include:

1. Observation on May 5, 2025, at 9:29 a.m., revealed the facility could not provide documentation for the following:

a.) Kitchen suppression test/maintenance since 4/11/2024.
b.) Kitchen exhaust hood/duct cleaning within the last 12 months.

Exit interview with the facility administrator and facilities representative on May 5, 2025, at 11:30 a.m., confirmed the lack of documentations.





 Plan of Correction - To be completed: 06/24/2025

1.and 2. The Maintenance Director completed the monthly check of the chemical fire suppression system and the vendor, Fry's Fire Protection, LLC to cleaned the kitchen exhaust hood/duct on May 20, 2025.

3. The maintenance department will be educated on the standards to ensure we are checking the chemical fire suppression system monthly and ensure the vendor is completing cleaning of kitchen hood/duct.

4. Maintenance or facility designee will audit facilities chemical fire suppression system/cleanings of kitchen hood/duct to ensure it is checked off weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA committee.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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 Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on review of documentation and interview, it was determined the facility failed to maintain the fire alarm system, affecting three of three floors.

Findings include:

1.. Observation on May 5, 2025, at 10:55 a.m., FACP, revealed a supervisory trouble alarm signal for the 1st floor tamper.

Exit interview with the facility administrator and facilities representative on May 5, 2025, at 11:30 a.m., confirmed the trouble signal at the time of the survey.







 Plan of Correction - To be completed: 06/24/2025

1 and 2. The Maintenance Director contracted Penn Fire Protection, Inc. and signed a contract to revisit the facility on 7/18/25 to complete semi-annual fire alarm system testing and to fix the faulty supervisory signal on the sprinkler system.

3. The maintenance department will be educated on the standards of the facilities fire alarm system inspection.

4. Maintenance or facility designee will audit facilities fire alarm system inspection located in the life safety book weekly x2 for 2 months then quarterly throughout the year to confirm fire alarm reports are still available for review and results of the audit will be reported to the QA 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 01 - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to maintain the sprinkler system in three instances, affecting three of three floors.

Findings include:

1. Observation on May 5, 2025, at 9:25 a.m., revealed the facility lacked documentation, verifying the sprinkler system had the following 5-year services:

a. internal valve inspection.
b. internal pipe inspection.
c. obstruction inspection

Exit interview with the facility administrator and facilities representative on May 5, 2025, at 11:30 a.m., confirmed the facility lacked documentation for these 5-year test.

2. Observation on May 5, 2025, at 9:27 a.m., revealed the facility failed to provide documentation, that the system had been inspected during the 4th quarter of 2024.

Exit interview with the facility administrator and facilities representative on May 5, 2025, at 11:30 a.m., confirmed the facility lacked documentation for this quarterly inspection.

3. Observation on May 5, 2025, at 10:08 a.m., 1st floor, revealed an unsealed penetration of a corridor ceiling tile, outside the kitchen door.

Exit interview with the facility administrator and facilities representative on May 5, 2025, at 11:30 a.m., confirmed the ceiling tile unsealed penetration.







 Plan of Correction - To be completed: 06/24/2025

1.and 2. The Maintenance Director contracted Penn Fire Protection, Inc. and signed a contract to complete the facility's sprinkler system inspection on 7/18/25.
3. The maintenance department will be educated on the standards of the facilities sprinkler system and timely inspection, testing, and maintenance.
4. Maintenance or facility designee will audit facilities sprinkler system inspection located in the life safety book weekly x2 for 2 months then quarterly throughout the year to confirm sprinkler inspections are still available for review and results of the audit will be reported to the QA 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: MAIN BUILDING 01 - Component: 01 - Tag: 0355

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

Findings Include:

1. Observation made on May 5, 2025, between 9:28 a.m., and 10:21 a.m., revealed the lack of the following inspections for 21 of 21 portable fire extinguishers.

a. Annual inspection within the last 12 months.
b. Monthly Inspections since 3/2025.

Exit interview with the facility administrator and facilities representative on May 5, 2025, at 11:30 a.m., confirmed the lack of inspections.







 Plan of Correction - To be completed: 06/24/2025

1.and 2. The Maintenance Director had Fry's Fire Protection, LLC on 5/20/25 complete a monthly/annual portable fire extinguisher inspection.
3. The maintenance department will be educated on the standards of the facilities monthly/annual portable fire extinguisher inspection.
4. Maintenance or facility designee will audit facilities monthly/annual portable fire extinguisher inspection weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA 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 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: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to provide smoke barrier walls for each floor or fire section of the building, affecting three of three floors.
Findings include:

1. Observation on May 5, 2025, at 9:40 a.m., revealed the facility lacked smoke barrier walls on all three floors of the building. The existing walls are not continuous from outside wall to outside wall due to large gaps above ceilings in room areas.

Exit interview with the facility administrator and facilities representative on May 5, 2025, at 11:30 a.m., confirmed the smoke barrier wall deficiencies.





 Plan of Correction - To be completed: 06/24/2025

Facility will be asking for FSES
NFPA 101 STANDARD HVAC: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.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




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

Based on documentation review and interview, the facility failed to maintain Heating, Ventilating, and Air Conditioning (HVAC) system ductwork through fire-rated walls, on one of three floors.

Findings include:

1. Observation on May 5, 2025, at 9:00 a.m., revealed that six fire/smoke dampers on 3rd floor D-Wing, have not been exercised in the past 4 years, last documented on 10/22/2020.

Exit interview with the facility administrator and facilities representative on May 5, 2025, at 11:30 a.m., confirmed the fire/smoke dampers have not been exercised in the last 4 years.





 Plan of Correction - To be completed: 06/24/2025

1 and 2. The Maintenance Director contracted Penn Fire Protection, Inc. and signed a contract to revisit the facility to inspect one of the six fire dampers, damper on 3rd floor D-Wing and will repair any failed fire dampers, inspection set for 7/18/25.
3. The maintenance department will be educated on the standards of the facilities fire damper inspection.
4. Maintenance or facility designee will audit facilities fire damper inspection located in the life safety book on an annual basis to confirm fire damper reports are still available for review and results of the audit will be reported to the QA Committee.


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 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform the required quarterly fire drills for staff.

Findings include:

1. Observation on May 5, 2025, at 8:45 a.m., revealed the facility lacked documentation for fire drills being performed in the 1st quarter of 2025, for 2nd and 3rd shift.

Exit interview with the facility administrator and facilities representative on May 5, 2025, at 11:30 a.m., confirmed the lack of documentation.




 Plan of Correction - To be completed: 06/24/2025

1 and 2. The Maintenance Director will complete monthly fire drills, one per shift, per quarter.
3. The maintenance department will be educated on the standards of the facilities monthly fire drill policy ensuring they are being conducted one per shift, per quarter.
4. Maintenance or facility designee will audit facilities fire drills to ensure it is checked off weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.

NFPA 101 STANDARD Electrical Systems - Other:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

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

Findings include:

1. Observation on May 5, 2025, between 10:05 a.m., and 10:39 a.m., revealed the following outlet receptacles lacking a cover plate.

a. At 10:05 a.m., 1st floor, Employee break room, next to the vending machines.
b. At 10:39 a.m., 2nd floor, Ice Machine room.

Exit interview with the facility administrator and facilities representative on May 5, 2025, at 11:30 a.m., confirmed the receptacles lacked a cover plate.




 Plan of Correction - To be completed: 06/24/2025

1.and 2. The Maintenance Director placed an outlet receptacle cover plate in the 1st floor employee break room next to the vending machine and 2nd floor ice machine room.
3. The maintenance department will be educated on the standards of electrical systems and having outlet receptacle cover plates.
4. Maintenance or facility designee will audit 10 receptacles throughout the facility weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.

NFPA 101 STANDARD Electrical Systems - 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.
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914

Based on document review and interview, the facility failed to maintain electrical receptacles, affecting the entire facility.

Findings include:

1. Observation on May 5, 2025, at 9:38 a.m., revealed the facility lacked documentation for the annual electrical receptacle inspection data, last documented 1/25/2024.

Exit interview with the facility administrator and facilities representative on May 5, 2025, at 11:30 a.m., confirmed the lack of documentation.





 Plan of Correction - To be completed: 06/24/2025

1.and 2. The Maintenance Director completed annual electrical receptacle inspection.
3. The maintenance department will be educated on the standards of the facilities annual electrical receptacle inspection.
4. Maintenance or facility designee will audit facilities electrical receptacle inspection located in the life safety book weekly x2 for 2 months then quarterly throughout the year to confirm electrical receptacle inspections are still available for review and results of the audit will be reported to the QA Committee.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Electrical Systems - 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 - Component: 01 - Tag: 0918

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

Findings include:

1. Observation on May 5, 2025, at 9:31 a.m., revealed the facility failed to provide documentation for the following generator inspection/ testing data.

a. Weekly visual inspection, last documented 3/14/2025.
b. Monthly 30-minute run under load, last documented 2/26/2025.
c. 3-year, 4-hour load test data within the last 36 months.

Exit interview with the facility administrator and facilities representative on May 5, 2025, at 11:30 a.m., confirmed the lack of documentation.






 Plan of Correction - To be completed: 06/24/2025

1 and 2. The Maintenance Director will perform the monthly 30 minute run under load and will contact Penn Fire Protection, Inc. to complete the 3-year, 4-hour load bank inspection and testing of the facilities generator, inspection set for 7/18/25.
3. The maintenance department will be educated on the standards of completing weekly, monthly and annual inspections and testing of the generator.
4. Maintenance or facility designee will audit the facility's generator weekly for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.


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: MAIN BUILDING 01 - Component: 01 - Tag: 0919

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

Findings include:

1. Observation on May 5, 2025, at 9:59 a.m., 1st floor, Electrical room, revealed the storage of items within 36 inches of electrical components.

Exit interview with the facility administrator and facilities representative on May 5, 2025, at 11:30 a.m., confirmed the electrical system deficiency.




 Plan of Correction - To be completed: 06/24/2025

1 and 2. The Maintenance Director will move storage of items within 36 inches of electrical components.
3. The maintenance department will be educated on the standards of storing items within 36 inches of electrical components.
4. Maintenance or facility designee will audit facilities electrical room weekly for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.


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