Pennsylvania Department of Health
PHOENIX CENTER FOR REHABILITATION AND NURSING, THE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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PHOENIX CENTER FOR REHABILITATION AND NURSING, THE - 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 4, 2026, it was determined that The Phoenix Center for Rehabilitation and Nursing was not in compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:

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.

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

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

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

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

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

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

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Observations:
Name: - Component: -- - Tag: 0004 Based on document review and interview, it was determined the facility failed to provide documentation verifying the emergency preparedness plan had been reviewed within the previous twelve months, which affects the entire component. Findings include: 1. Review of documentation on August 4, 2026, at 9:50 AM, revealed the facility failed to provide documentation verifying the emergency preparedness plan had been reviewed, since 12/24/21. Interview with the Director of Environmental Services on August 4, 2026, at 9:50 AM, confirmed the lack of documentation verifying the emergency preparedness plan had been reviewed, since 12/24/21.

Plan of Correction - To be completed: 09/17/2026

1 Documentation obtained for emergency preparedness plan all members of the committee have signed off on the annual review face page.
2 Emergency Preparedness (EP) Committee has been educated to conduct an annual review.
3 Audits of Emergency preparedness plan review and documentation will be conducted annually
4 The findings of these quality monitoring's to be reported to the Quality assurance/performance improvement committee monthly x6months

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000
Facility ID #160702

Component 01

Main Building

Based on a Medicare/Medicaid Recertification Survey completed on August 4, 2026, it was determined that The Phoenix Center for Rehabilitation and Nursing 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 three-story, Type II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

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

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

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

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

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

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

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0161 Based on observation and interview, it was determined the facility failed to maintain building construction requirements, on three of three floors within the component. Findings include: 1. Observation on August 4, 2026, at 12:30 PM, revealed the building is a three-story, unprotected noncombustible structure, without a basement, which is fully sprinklered. This type of construction is not permitted to be greater than two stories in height. Interview with the Director of Environmental Services on August 4, 2026, at 12:30 PM, confirmed the facility exceeds the maximum allowable story height for this type of construction.

Plan of Correction - To be completed: 09/17/2026

The facility is requesting a time limited waiver and an FSES conducted by DSI
The findings of these quality monitoring's to be reported to the Quality assurance/performance improvement committee monthly x6months

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 - Component: 01 - Tag: 0225 Based on observation and interview, it was determined the facility failed to maintain the rating of stairtower doors, and to maintain stairtower enclosures to be readily available for full and instant use, affecting two of five smoke compartments within the component. Findings include: 1. Observation on August 4, 2025, at 10:20 AM, revealed the 3rd floor Zone 5 Front Stairtower Closet door had an unprotected penetration where latching hardware was missing. This closet contained flooring and a ladder. Interview with the Director of Environmental Services on August 4, 2026, at 10:20 AM, confirmed the compromised fire resistance of the stairtower enclosure. 2. Observation on August 4, 2026, at 11:40 AM, revealed mattresses, paints and primers stored beneath the lowest riser within the Rear Stairtower, by the generator. Interview with the Director of Environmental Services on August 4, 2026, at 11:40 AM, confirmed the stairtower was used for storage.

Plan of Correction - To be completed: 09/17/2026

1- Maintenance installation of new doorknob with latching for stairtower closet door, paint, primers and mattresses removed.
2- Audits of all stairtower closets to ensure positive latching and no storage beneath any stairtowers.
3-Maintenance will conduct continuous audits 1x weekly x4 weeks and 2x monthly x1 month and then quarterly on 2 stairtower closets to ensure positive latching and under 2 stairtowers areas to ensure they are free of storage.
4-The findings of these quality monitoring's to be reported to the Quality assurance/performance improvement committee monthly x6months

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0291 Based on document review and interview, it was determined the facility failed to provide documentation verifying battery back up emergency lighting fixtures had been tested for 90 continuous minutes within the previous twelve months, within seven of seven smoke zones within the component. Findings include: 1. Review of documentation on August 4, 2026, at 9:32 AM, revealed the facility failed to provide documentation verifying battery back-up emergency lighting fixtures had been tested for 90 continuous minutes, within the previous twelve months. Interview with the Director of Environmental Services on August 4, 2026, at 9:32 AM, confirmed the lack of documentation verifying battery back-up emergency lighting fixtures had been tested for 90 continuous minutes, within the previous twelve months.

Plan of Correction - To be completed: 09/17/2026

1- Facility purchased battery backup fixture and maintenance will perform installation and confirm to be in working order.
2- Maintenance was educated to ensure documentation is obtained verifying battery backup emergency lighting fixtures had been checked within the previous twelve months.
3- Audits will be conducted semiannually by both Administrator and Maintenance director to ensure that documentation verifying battery backup emergency lighting fixtures had been checked within the previous twelve months.
4- The findings of these quality monitoring's to be reported to the Quality assurance/performance improvement committee monthly x6months

NFPA 101 STANDARD Exit Signage:

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: MAIN BUILDING - Component: 01 - Tag: 0293 Based on document review and interview, it was determined the facility failed to provide documentation verifying exit signage had been visually inspected, on a monthly basis, during the previous twelve months, in seven of seven smoke zones within the component. Findings include: 1. Review of documentation on August 4, 2026, at 9:31 AM, revealed the facility failed to provide documentation verifying exit signage had been visually inspected, prior to 7/6/26. Interview with the Director of Environmental Services on August 4, 2026, at 9:31 AM, confirmed the lack of documentation verifying exit signage had been visually inspected, on a monthly basis, during the previous twelve months.

Plan of Correction - To be completed: 09/17/2026

1- Documentation obtained verifying exit signage had been visually inspected, on a monthly basis, during the previous twelve months.
2- Maintenance educated to ensure exit signage had been visually inspected, on a monthly basis, during the previous twelve months.
3- Semiannual audits will be conducted to ensure documentation is obtained verifying that exit signage had been visually inspected, on a monthly basis, during the previous twelve months.
4- The findings of these quality monitoring's to be reported to the Quality assurance/performance improvement committee monthly x6months

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 - Component: 01 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintain hazardous area doors to positively latch, affecting one of seven smoke compartments within the component. Findings include: 1. Observation on August 4, 2026, at 10:31 AM, revealed the door, to the 3rd floor, Zone 5, Biohazard Room, failed to positively latch within the door frame, due to cardboard taped over the strike plate. Interview with the Director of Environmental Services on August 4, 2026, at 10:31 AM, confirmed the compromised smoke resistance of the hazardous area enclosure.

Plan of Correction - To be completed: 09/17/2026

1- Maintenance immediately corrected the positive latch on the door
2- Maintenance conducted audit of all Biohazard room positive latches

3- Maintenance was Educated on ensuring all Biohazard rooms positively latch

4--Maintenance/Designee will conduct continuous audits on 3 Biohazard room door latches Quarterly x3 Quarters.

5-The findings of these quality monitoring's to be reported to the Quality assurance/performance improvement committee monthly x6months

NFPA 101 STANDARD Cooking Facilities:

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.

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 - Component: 01 - Tag: 0324 Based on document review and interview, it was determined the facility failed to provide documentation verifying the Kitchen automatic fire suppression system had been inspected semi-annually during the previous twelve months, affecting one of seven smoke compartments within the component. Findings include: 1. Review of documentation on August 4, 2026, at 9:30 AM, revealed the facility failed to provide documentation verifying the Kitchen automatic fire suppression system had been inspected, semi-annually, during the previous twelve months. Interview with the Director of Environmental Services on August 4, 2026, at 9:30 AM, confirmed the lack of documentation verifying the Kitchen automatic fire suppression system had been inspected, semi-annually, during the previous twelve months.

Plan of Correction - To be completed: 09/17/2026

1-Maintenance obtained inspection of kitchen suppression system
2- Maintenance was Educated on ensuring kitchen suppression system is inspected every 6 months

3-Maintenance will conduct audit of Kitchen suppression system 1x every 6 months the audit will confirm the kitchen suppression system reports have been filed in the life safety book

4-The findings of these quality monitoring's to be reported to the Quality assurance/performance improvement committee monthly x6months

NFPA 101 STANDARD Fire Alarm System - Notification:

Fire Alarm - Notification
2012 EXISTING
Positive alarm sequence in accordance with 9.6.3.4 are permitted in buildings protected throughout by a sprinkler system. Occupant notification is provided automatically in accordance with 9.6.3 by audible and visual signals.
In critical care areas, visual alarms are sufficient. The fire alarm system transmits the alarm automatically to notify emergency forces in the event of a fire.
19.3.4.3, 19.3.4.3.1, 19.3.4.3.2, 9.6.4, 9.7.1.1(1)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0343 Based on observation and interview, it was determined the facility failed to maintain the automatic fire alarm system in a fully reliable operating manner, which serves the entire component. Findings include: 1. Observation on August 4, 2026, at 10:35 AM, revealed the automatic fire alarm system was silenced and showing trouble at the panel. Interview with a facility staff member indicated the fire alarm system "kept ringing after the last fire drill" and had been silenced to cease the notification devices. Interview with the Director of Environmental Services on August 4, 2026, at 10:35 AM, confirmed the automatic fire alarm system was silenced and showing trouble.

Plan of Correction - To be completed: 09/17/2026

1- Service scheduled with Fire Company to resolve silence mode and trouble message.
2- Maintenance educated to always notify fire company in the event that fire alarm maintenance is needed.
3- Fire alarm system panel will be audited
on daily on an ongoing basis
4- The findings of these quality monitoring's to be reported to the Quality assurance/performance improvement committee monthly x6months

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0353 Based on document review, observation and interview, it was determined the facility failed to provide documentation verifying representative sampling of older sprinkler heads had occurred, and to maintain sprinkler heads to be installed per manufacturer specifications, in seven of seven smoke zones within the component. Findings include: 1. Review of documentation on August 4, 2026, at 9:26 AM, revealed the facility lacked documentation verifying a representative sample of quick response sprinkler heads had been taken for testing, within the previous 20 years. Quick response sidewall and pendant sprinkler heads were dated 1999. Additionally, dry heads located within the cooler and freezer were dated 1995 and no documentation was provided to verify these had been tested, within the previous 15 years. Interview with the Director of Environmental Services on August 4, 2026, at 9:26 AM, confirmed the lack of documentation verifying representative sampling of older sprinkler heads had occurred, within the previous 15 and 20 years. 2. Observation on August 4, 2026, at 11:20 AM, revealed the sidewall sprinkler head, protecting 1st floor, Zone 1, Resident Room 106, was missing an escutcheon. Interview with the Director of Environmental Services on August 4, 2026, at 11:20 AM, confirmed the missing escutcheon.

Plan of Correction - To be completed: 09/17/2026

1- Service scheduled for 08/24/2026 with sprinkler system company for representative sampling of older sprinkler heads and to replace missing escutcheon.
2- Audit of escutcheon throughout facility conducted.
2- Maintenance was Educated on ensuring documentation that sample of quick response sprinkler heads had been taken for testing, within the previous 20 years. and escutcheon are in place.
3- Audit will be conducted for 12 months to ensure sample of quick response sprinkler heads had been taken for testing, within the previous 20 years.

4-audit of the life safety book will be conducted annually to confirm that the documentation verifying representative sampling of older sprinkler heads had occurred within the previous 15-20 years has been filed in the life safety book. Audit of 3 escutcheon will be conducted monthly x6 months.

5-The findings of these quality monitoring's to be reported to the Quality assurance/performance improvement committee monthly x6months

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 - Component: 01 - Tag: 0355 Based on document review and interview, it was determined the facility failed to provide documentation verifying portable fire extinguishers were visually inspected on a monthly basis during the previous twelve months, affecting two of seven smoke compartments within the component. Findings include: 1. Review of documentation on August 4, 2026, between 10:59 AM and 11:30 AM, revealed the facility lacked documentation verifying the following portable fire extinguishers had been inspected, between the dates below: a) 10:59 AM, 2nd floor, Zone 3, Pantry extinguisher - February 2026 to August 2026; b) 11:07 AM, 2nd floor, Zone 3, extinguisher next to Resident Room 201 - March 2026 to August 2026; c) 11:08 AM, 2nd floor, Zone 3, Lounge extinguisher - September 3, 2025 to August 2026; d) 11:30 AM, 1st floor, Zone 1, two extinguishers within the Fire Alarm Room - February 2026 to August 2026. Interview with the Director of Environmental Services on August 4, 2026, at 11:30 AM, confirmed the lack of documentation verifying portable fire extinguisher had been visually inspected, on a monthly basis, during the previous twelve months.

Plan of Correction - To be completed: 09/17/2026

1-Audit of the listed portable fire extinguishers conducted.
2- Audit conducted on all portable fire extinguishers to ensure inspection was completed.

3- Maintenance was Educated on ensuring monthly inspection of portable fire extinguishers.

4- Audits of 3 portable fire extinguishers will be conducted on a monthly basis until compliance is achieved, and then to be conducted on a quarterly basis.

5-The findings of these qualities to be reported to the quality assurance /performance committee monthly x6 months.

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0363 Based on observation and interview, it was determined the facility failed to maintain corridor doors to positively latch, affecting two of seven smoke compartments within the component. Findings include: 1. Observation on August 4, 2026, at 10:22 AM, revealed the 3rd floor, Zone 5, door to the Linen, failed to positively latch within the door frame. Interview with the Director of Environmental Services on August 4, 2026, at 10:22 AM, confirmed the corridor door did not latch within the door frame. 2. Observation on August 4, 2026, at 11:35 AM, revealed the 1st floor, Zone 1, door to the Staff Dining Room, lacked positive latching hardware. Interview with the Director of Environmental Services on August 4, 2026, at 11:35 AM, confirmed the corridor door did not latch within the door frame.

Plan of Correction - To be completed: 09/17/2026

1-Maintenance/ Designee ensured positive latches were in working order by removing all obstacles. staff dining room door latching mechanism has been repaired and is positively latching.
2-Maintenance/ Designee conducted an audit on all corridor doors to ensure there were no obstacles and they are in working order.

3-Maintenance and all floor staff were educated to not block the latching mechanism of doors and to report broken doors to maintenance department through Tels.

4-Maintenance will conduct continuous audits on 2 linen room corridor doors and 1 staff dining room door monthly on a continuing basis.
5- The findings of these quality monitoring's to be reported to the quality assurance/performance improvement committee monthly x6 months.

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NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0372 Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of smoke barrier walls, affecting two of seven smoke compartments within the component. Findings include: 1. Observation on August 4, 2026, at 10:30 AM, revealed an unprotected penetration of the 3rd floor smoke barrier wall, located above the double doors, above the suspended ceiling, around a gray wire, by the Biohazard Room. Interview with the Director of Environmental Services on August 4, 2026, at 10:30 AM, confirmed the compromised smoke resistance of the smoke barrier wall.

Plan of Correction - To be completed: 09/17/2026

1 Fire rated caulk to be submitted on
All fire smoke barriers to be audited to ensure protected penetration of smoke barrier walls the repair was made using an approved through penetration fire stop system. Facility will maintain the rating of the smoke barrier walls.
2 Maintenance was educated to ensure protected penetration of smoke barrier walls using an approved through penetration fire stop system.
3 fire smoke barriers to be audited to ensure protected penetration of smoke barrier walls on an above ceiling work permit basis.
4 The findings of these quality monitoring's to be reported to the Quality assurance/performance improvement committee monthly x6months

NFPA 101 STANDARD Utilities - Gas and Electric:

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

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0511 Based on document review, observation, and interview, it was determined the facility failed to provide documentation verifying electrical receptacles had been tested and inspected, and to maintain the physical integrity of electrical receptacles, in seven of seven smoke zones within the component. Findings include: 1. Review of documentation on August 4, 2026, at 9:45 AM, revealed the facility failed to provide documentation verifying electrical receptacles, in patient care areas, had been inspected, within the previous twelve months. Interview with the Director of Environmental Services on August 4, 2026, at 9:45 AM, confirmed the lack of documentation verifying electrical receptacles, in patient care areas, had been inspected, within the previous twelve months. 2. Observation on August 4, 2026, at 10:33 AM, revealed a physically broken outlet, with no cover plate, located at the 3rd floor, Zone 4, Nurses' Station, at the center workstation. Interview with the Director of Environmental Services on August 4, 2026, at 10:33 AM, confirmed the compromised physical integrity of the electrical receptacle.

Plan of Correction - To be completed: 09/17/2026

1 Audit to be conducted immediately any Physically broken outlets with no cover plates to be repaired by Maintenance immediately
2 All Nursing station electrical receptacles and cover plates will be audited to confirm the physical integrity of the electrical receptacle.
3 Maintenance will be educated on ensuring that electrical receptacles are confirmed to be in a status of physical integrity and documented annually
4 2 Nursing station electrical receptacles will be audited 1x weekly for 4 weeks and then 2x a month for 4 weeks and documentation of inspection will be Audited annually. annual testing and inspection of receptacles in patient care areas will be conducted on 8/29.
5 The findings of these quality monitoring's to be reported to the Quality assurance/performance improvement committee monthly x6months

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0761 Based on document review and interview, it was determined the facility failed to provide documentation verifying fire doors had been inspected within the previous twelve months, in seven of seven smoke zones within the component. Findings include: 1. Review of documentation on August 4, 2026, at 9:40 AM, revealed the facility failed to provide documentation verifying fire doors, within the facility, had been inspected, within the previous twelve months. Interview with the Director of Environmental Services on August 4, 2026, at 9:40 AM, confirmed the lack of documentation verifying fire doors, within the facility, had been inspected, within the previous twelve months.

Plan of Correction - To be completed: 09/17/2026

1 Documentation obtained confirming that fire doors had been inspected within the previous twelve months
2 Maintenance was educated to ensure documentation is obtained verifying fire doors had been inspected within the previous twelve months
3 Audit of fire door documentation verifying fire doors, within the facility, had been inspected, within the previous twelve months will be done annually
4 The findings of these quality monitoring's to be reported to the Quality assurance/performance improvement committee monthly x6months

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 - Component: 01 - Tag: 0918 Based on document review and interview, it was determined the facility failed to provide documentation verifying weekly, monthly, annual and tri-annual inspections and testing of the emergency generator had occurred, within the previous three years, affecting the entire component. Findings include: 1. Review of documentation on August 4, 2026, between 8:55 AM and 9:26 AM, revealed the facility failed to provide documentation verifying the following inspections and testing had occurred: a) 8:55 AM, weekly visual inspection of the emergency generator, between the following dates: 1) 11/15/25 - 12/13/25; 2) 12/20/25 - 1/3/26; 3) 1/10/26 - 1/24/26; 5) 1/31/26 - 2/28/26; 6) 3/21/26 - 4/4/26; 7) 4/11/26 - 8/4/26; b) 9:20 AM, monthly exercises of the emergency generator, under load, during the previous twelve months; c) 9:21 AM, testing of the diesel fuel servicing the emergency generator, during the previous twelve months; d) 9:22 AM, 90-minute load bank exercise of the diesel generator, during the previous twelve months; e) 9:26 AM, 4-hour exercise, under load, during the previous 36 months. Interview with the Director of Environmental Services on August 4, 2026, at 9:26 AM, confirmed the lack of documentation verifying weekly, monthly, annual and tri-annual inspections and testing of the emergency generator had occurred, within the previous three years

Plan of Correction - To be completed: 09/17/2026

1 Documentation of weekly visual inspection of the emergency generator obtained, Facility generator is automatic and does not contain manual switchover confirmed by Generator servicing company, 4 - hour exercise under load during the previous 36 months conducted, a 2-hour load bank has been performed testing of the diesel fuel servicing the emergency generator tentatively scheduled for 8/25/2026
2 Maintenance was Educated on ensuring documentation of weekly generator visual inspection and testing of the diesel fuel servicing the emergency generator is conducted every 12 months
3 Maintenance/designee will conduct audit to ensure documentation of weekly generator inspection, 4 - hour exercise under load during the previous 36 months, testing of the diesel fuel servicing the emergency generator is obtained to be conducted monthly. Audit confirming the annual testing and inspection to be conducted monthly. Monthly build load runs will be conducted and recorded in the generator book.
4 The findings of these quality monitoring's to be reported to the quality assurance/performance improvement committee monthly x6 months.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

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: MAIN BUILDING - Component: 01 - Tag: 0920 Based on observation and interview, it was determined the facility failed to monitor the use of extension cords, affecting one of five smoke compartments within the component. Findings include: 1. Observation on August 4, 2026, at 10:25 AM, revealed an extension cord, plugged into an outlet in the 3rd floor, Zone 5, Lounge, running across the threshold of the door to the Storage/IT Closet, powering a fan within the closet. Interview with the Director of Environmental Services on August 4, 2026, at 10:25 AM, confirmed the extension cord ran across the threshold of a door.

Plan of Correction - To be completed: 09/17/2026

1 All Extension cords have been unplugged
2 Maintenance educated to monitor the use of extension cord
3 Maintenance/ Designee to conduct monthly audits to remove all extension cords.
4 The findings of these quality monitoring's to be reported to the quality assurance/performance improvement committee monthly x6 months.

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