Pennsylvania Department of Health
HARBORVIEW REHABILITATION AND CARE CENTER AT LANSDALE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 52 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.


HARBORVIEW REHABILITATION AND CARE CENTER AT LANSDALE - 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 August 25, 2025, it was determined that Harborview Rehabilitation and Care Center at Lansdale had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

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

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

[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]

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

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

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

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

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

Findings include:
1. Documentation review on August 25, 2025, at 8:30 a.m., revealed the facility failed to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

Exit Interview with the Administrator and Maintenance Director on August 25, 2025, at 1:00 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 09/19/2025

- Facility made arrangement agreements with the other facilities.
- Facility educated the Director of Maintenance and IDT regarding importance of the arrangement agreement with the other facilities.
-Facility will conduct monthly*3 audits and result of the audits will be discussed in monthly QAPI meeting.

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:

§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, it was determined the facility failed to conduct the required annual exercises to test the facility's emergency preparedness plan, affecting the entire facility.

Findings include:
1. Document review on August 25, 2025, at 8:30 a.m., revealed within the previous 12 months, the facility did not perform a full-scale exercise or the additional required exercise to test the emergency preparedness plan.

Exit Interview with the Administrator and Maintenance Director on August 25, 2025, at 1:00 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 09/19/2025

- Facility conducted full scale exercises and other emergency preparedness exercises.
- Facility educated the Director of Maintenance and IDT regarding importance of emergency preparedness exercises.
-Facility will conduct monthly*3 audits and result of the audits will be discussed in monthly QAPI meeting.

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

Facility ID# 140502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on August 25, 2025, it was determined that Harborview Rehabilitation And Care Center At Lansdale was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy.Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a three-story, Type III (211), protected ordinary building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

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

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

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

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

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on document review and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire facility.

Findings include:
Document review on August 25, 2025, at 8:30 a.m., revealed the building exceeded the maximum allowable story height for protected ordinary construction by one story.

Exit Interview with the Administrator and Maintenance Director on August 25, 2025, at 1:00 p.m., confirmed the building story height deficiency.

Plan of Correction - To be completed: 09/19/2025

- Facility requests a time-limited waiver to contact an engineering or architectural firm to evaluate the current building construction and determine the necessary corrective action required to meet or exceed the Life Safety Code.
- Facility emailed and mailed time-limited waivers to the field office.

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 exit stairways free of storage items, affecting one of four levels.

Findings include:
1. Observation made on August 25 at 12:05 p.m., revealed roof shingles and blankets stored in front of the stairs, Main Level East Stair Tower near the Lobby.

Exit Interview with the Administrator and Maintenance Director on August 25, 2025, at 1:00 p.m., confirmed the stair tower deficiency.

Plan of Correction - To be completed: 09/19/2025

- Facility immediately removed roof shingles and blankets placed in front of the stairs, main level.
- Facility educated the Director of Maintenance, Director of Environmental Services and Maintenance Technician about maintaining stairways, smokeproof enclosures and exit doors free of storage items.
- Facility will do audits of the egress doors about maintaining stairways, smokeproof enclosures and exit doors free of storage items weekly * 4 then monthly *2 and the results of the audits will be reviewed and discussed in QAPI meetings.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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 hazardous area enclosures, affecting one of four levels.

Findings include:
1. Observation made on August 25, 2025, at 11:45 a.m., revealed a hazardous area door failed to self-close and positively latch when tested, Basement Central Supply Room.

Exit Interview with the Administrator and Maintenance Director on August 25, 2025, at 1:00 p.m., confirmed the door failed to self-close and latch.

Plan of Correction - To be completed: 09/19/2025

- Facility fixed the self-closing latch for Central Supply Room.
- Facility educated the Director of Maintenance and Maintenance Technician regarding proper maintenance self-closing latch on the doors.
- Facility will do audits of the self-closing latch weekly * 4 then monthly *2 and the results of the audits will be reviewed and discussed in QAPI meetings.

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 - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire facility.

Findings include:
1. Document review on August 25, 2025, at 8:30 a.m., revealed the following missing sprinkler reports:
a. 5-year Internal Pipe/Valve inspection report;
b. 3-year Full-Flow Trip Test;
c. Electric Fire Pump monthly 10-minute test documentation.

Exit Interview with the Administrator and Maintenance Director on August 25, 2025, at 1:00 p.m., confirmed the lack of documentation.

2. Document review on August 25, 2025, at 8:30 a.m., revealed deficiencies on the annual sprinkler reports. Evidence of corrective action was unavailable at the time of the survey:
a. Dry sprinkler system #3, report dated July 22, 2025, listed a Hydro Test needs to be completed as soon as possible;
b. Dry sprinkler system #2, report dated July 22, 2025, listed a Hydro Test needs to be completed as soon as possible;
c. Wet sprinkler system #1, report dated July 22, 2025, listed a Hydro Test needs to be completed as soon as possible, the pipe leading to the fire pump in the stair tower was leaking and needs to be repaired, and the fire pump leaks severely when operated and needs to be repaired and investigated.

Exit Interview with the Administrator and Maintenance Director on August 25, 2025, at 1:00 p.m., confirmed the sprinkler report deficiencies.

3. Document review on August 25, 2025, at 8:30 a.m., revealed the following deficiencies on the Annual Fire Pump Inspection Report dated July 7, 2025. Evidence of corrective action was unavailable at the time of the survey.
a. The piping feeding the fire pump has major leaks and was found actively leaking at the time of inspection (07/26/22 &; 07/07/23 &; 07/05/24). The fire pump needs to be repaired as soon as possible;
b. The fire pump packing glands leak heavily and cannot be adjusted. The fire pump is currently secured with a ratchet strap and needs to be serviced as soon as possible (07/16/21-07/07/23-07/5/24);
c. The fire pump did not meet the rated capacity at time of inspection and needs to be serviced as soon as possible (7/2024);
d. Proper operation of the fire pump was not verified during inspection as the flow test was not performed per customer request.

Exit Interview with the Administrator and Maintenance Director on August 25, 2025, at 1:00 p.m., confirmed the fire pump deficiencies.

Plan of Correction - To be completed: 09/19/2025

- Facility in-serviced staff regarding fire watch and started 24*7 fire watch until the new fire pump starts working.
- Facility is in process of completion for installation with new fire pump project and is currently working on getting occupancy letter with Dept of Health.
As per vendor the new fire pump project is scheduled for completion by the end of September 2025 and facility will contact Dept of Health on getting occupancy survey.
- Facility will apply for time limited waiver for item a.5-year Internal Pipe/Valve inspection report, item b. 3-year Full-Flow Trip Test and item c. Electric Fire Pump monthly 10-minute test.
- Facility scheduled Hydrotest with the vendor for a. Dry sprinkler system #3, b. Dry sprinkler system #2, c. Wet sprinkler system #1.
-Facility will schedule inspections for Item 1 a,b,c.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

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

Based on document review and interview, it was determined the facility failed to ensure fire extinguisher inspectors were certified, affecting one of three reports.

Findings include:
1. Document review on August 25, 2025, at 8:30 a.m., revealed the facility could not provide certification documentation for the inspector that performed the facility's annual portable fire extinguisher inspection dated March 11, 2025.

Exit Interview with the Administrator and Maintenance Director on August 25, 2025, at 1:00 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 09/19/2025

- Facility got certification for the inspector that performed the facility's annual portable fire extinguisher inspection from The Tustin Group.
- Facility educated Director of maintenance regarding importance of certification for the inspector that performed the facility's annual portable fire extinguisher inspection.
-Facility will conduct monthly*3 audits and result of the audits will be discussed in monthly QAPI meeting.

NFPA 101 STANDARD HVAC - Any Heating Device:

HVAC - Any Heating Device
Any heating device, other than a central heating plant, is designed and installed so combustible materials cannot be ignited by device, and has a safety feature to stop fuel and shut down equipment if there is excessive temperature or ignition failure. If fuel fired, the device also:
* is chimney or vent connected.
* takes air for combustion from outside.
* provides for a combustion system separate from occupied area atmosphere.
19.5.2.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0522

Based on observation and interview, it was determined the facility failed to ensure heating devices were protected from combustible materials, affecting one of four levels.

Findings include:
1. Observations made on August 25, 2025, at 11:40 a.m., revealed cardboard boxes and plastic containers stored near a ceiling mounted heater, Basement Central Supply Room.

Exit Interview with the Administrator and Maintenance Director on August 25, 2025, at 1:00 p.m., confirmed the combustible materials near a heating source.

Plan of Correction - To be completed: 09/19/2025

- Facility immediately removed all combustible materials placed near the heater in Central Supply Room.
- Facility educated the Director of Maintenance, Maintenance Technician and Central Supply Clerk regarding proper storage of the combustible materials in the Central Supply Room.
- Facility will audit weekly*3 and monthly * 2 for proper storage of the combustible materials and results of the audits will be reviewed in monthly QAPI meeting.

NFPA 101 STANDARD Electrical Systems - Other:

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 access to electrical panels, affecting one of four levels.

Findings include:
1. Observation on August 25, 2025, at 11:20 a.m., revealed an electrical panel that was obstructed by boxes and miscellaneous items, Basement Boiler Room.

Exit Interview with the Administrator and Maintenance Director on August 25, 2025, at 1:00 p.m., confirmed the blocked electrical panel.

Plan of Correction - To be completed: 09/19/2025

- Facility immediately removed boxes and miscellaneous items placed in front of the electrical panel in the boiler room that was obstructing the electrical panel.
- Facility educated Director of maintenance and maintenance technician for maintaining the electrical panels free of any obstructions.
- Facility will do weekly*3 and monthly* 2 audits of maintaining the electrical panels free of any obstructions and results of audits will be provided in QAPI meeting.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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 observation, document review and interview, it was determined the facility failed to maintain and test the emergency generator, affecting the entire facility.

Findings include:
1. Observation and document review on August 25, 2025, at 8:30 a.m., revealed the following generator deficiencies:
a. 3-year, 4-hour Load Test;
b. Annual Fuel Quality Report;
c. The Emergency generator annunciator panel was not connected to the generator and failed to display lights/power when tested, first floor Nurses Station.

Exit Interview with the Administrator and Maintenance Director on August 25, 2025, at 1:00 p.m., confirmed the lack of documentation and annunciator panel deficiency.

Plan of Correction - To be completed: 09/19/2025

- Facility will request a time-limited waiver until 01/20/2026 for item a - the 3-year 4-hour load bank test, item b- Annual Fuel Quality Report and item c connection of the annunciator panel to the emergency generator with .
- Facility in-serviced staff regarding fire watch and started 24*7 fire watch until the new fire pump starts working.
-Facility equipped with emergency rental generator with which the remote annunciator panel is connected.
- Facility is awaiting from insurance company to give an update for the existing emergency generator. If the insurance company wants to repair the generator then facility will go with repairing the generator and if the insurance company approves the new generator then facility will contact Plan Review Department for prior approval and future correspondences.

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