Pennsylvania Department of Health
REHAB AT SHANNONDELL
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
REHAB AT SHANNONDELL
Inspection Results For:

There are  22 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.
REHAB AT SHANNONDELL - 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, it was determined that Rehab at Shannondell had deficiencies that have the potential for minimal harm, as related to the requirements of 42 CFR 483.73.




 Plan of Correction:


403.748(d)(2), 416.54(d)(2), 418.113(d)(2), 441.184(d)(2), 482.15(d)(2), 483.475(d)(2), 483.73(d)(2), 484.102(d)(2), 485.542(d)(2), 485.625(d)(2), 485.68(d)(2), 485.727(d)(2), 485.920(d)(2), 486.360(d)(2), 491.12(d)(2), 494.62(d)(2) STANDARD EP Testing Requirements:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).

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

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

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

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

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


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

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

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

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

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

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

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

Based on document review and interview, it was determined the facility failed to conduct the Emergency Plan's required annual-full scale exercise or accepted substitution and the required additional exercise or accepted substitution, affecting the entire facility.

Findings include:

Review of documentation on May 5, 2025, at 8:30 a.m., revealed the facility failed to conduct an annual full-scale exercise or accepted substitution and an additional exercise or accepted substitution within the previous 12 months.

Exit interview with the Maintenance Director on May 5, 2025, at 1:00 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 06/30/2025

The facility will conduct an annual full-scale exercise or accepted substitution and an additional exercise or accepted substitution.
This will be completed by Sunday, June 22nd, 2025.
The Director of Maintenance will in-service the maintenance staff on the importance of the annual full-scale exercise or accepted substitution and an additional exercise or accepted substitution.
The in-service will be completed by June 22nd, 2025.
The Director of Maintenance or his designee beginning July 1st, 2025, will conduct monthly audits to meet compliance with E 0039 verifying the annual full-scale exercise or accepted substitution and an additional exercise or accepted substitution is less than 1 year between the required exercises.

Initial comments:Name: MEADOWS II - Component: 02 - Tag: 0000


Facility ID #17580201
Component 02
Meadows II

Based on a Medicare/Medicaid Recertification Survey completed on May 5, 2025, it was determined that Rehab At Shannondell 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 four-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD General Requirements - 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.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: MEADOWS II - Component: 02 - Tag: 0100

Based on document review and interview, it was determined the facility failed to maintain carbon monoxide alarms in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act, affecting one of two carbon monoxide documents.

Findings include:

Document review on May 5, 2025, at 8:30 a.m., revealed the facility failed to test and clean carbon monoxide detectors in accordance with manufacturer's specifications.

Exit interview with the Maintenance Director on May 5, 2025, at 1:00 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 06/30/2025

The carbon monoxide alarms shall be tested and cleaned in accordance with the manufacturer's specifications and in accordance with the Care Facility Carbon Monoxide Alarms Standards Act – Enactment Act of June 23, 2016, P. L. 357, No. 48 C1. 35
This will be completed by Sunday, June 22nd, 2025.
The Director of Maintenance will in-service the maintenance staff on the importance of testing and cleaning the carbon monoxide alarms requirements.
The in-service will be completed by June 22nd, 2025.
The Director of Maintenance or his designee beginning July 1st, 2025, will conduct monthly audits to meet compliance with K 0100 verifying the carbon monoxide alarms were tested and cleaned.
These audits will continue until December31st, 2025, when at that time the Quality Assurance Committee will meet and decide if the audits should continue, or end based on the results.

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: MEADOWS II - Component: 02 - Tag: 0324

Based on document review and interview, it was determined the facility failed to maintain and inspect the kitchen exhaust hood suppression system, affecting one of two suppression system inspections.

Findings include:

Document review on May 5, 2025, at 8:30 a.m., revealed the facility could not provide the Semi-annual kitchen suppression testing/maintenance after the September 10, 2024, report.

Exit interview with the Maintenance Director on May 5, 2025, at 1:00 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 06/30/2025

The Semi-annual kitchen suppression testing/maintenance after September 10th, 2024, report was performed on March 12th, 2025. The documentation is available to the Department of Health Life Safety Division upon arrival.
This will be completed by Sunday, June 22nd, 2025.
The Director of Maintenance will in-service the maintenance staff on the importance of the Semi-annual kitchen suppression testing/maintenance requirements.
The in-service will be completed by June 22nd, 2025.
The Director of Maintenance or his designee beginning July 1st, 2025, will conduct monthly audits to meet compliance with K 0324 verifying the Semi-annual kitchen suppression testing/maintenance requirements have been met.
These audits will continue until December31st, 2025, when at that time the Quality Assurance Committee will meet and decide if the audits should continue, or end based on the results.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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: MEADOWS II - Component: 02 - Tag: 0345

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

Findings include:

Document review on May 5, 2025, at 8:30 a.m., revealed the facility could not provide documentation that the Fire Alarm Annual Inspection and the Smoke Detector Sensitivity testing were performed.

Exit interview with the Maintenance Director on May 5, 2025, at 1:00 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 06/30/2025

The Fire Alarm Annual Inspection and the Smoke Detector Sensitivity testing were performed on February 3rd, 2025. The documentation is available to the Department of Health Life Safety Division upon arrival.
The Director of Maintenance will in-service the maintenance staff on the importance of the Fire Alarm Annual Inspection and the Smoke Detector Sensitivity testing requirements.
The in-service will be completed by June 22nd, 2025.
The Director of Maintenance or his designee beginning July 1st, 2025, will conduct monthly audits to meet compliance with K 0345 verifying the Fire Alarm Annual Inspection and the Smoke Detector Sensitivity testing requirements are less than 1 year between inspections and testing.
These audits will continue until December 31st, 2025, when at that time the Quality Assurance Committee will meet and decide if the audits should continue, or end based on the results.

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: MEADOWS II - Component: 02 - Tag: 0353

Based on document review and interview, it was determined the facility failed to maintain and inspect the sprinkler system, affecting two of the required sprinkler reports.

Findings include:

Document review on May 5, 2025, at 8:30 a.m., revealed the facility could not provide documentation of the following inspections:

a. Annual Main Drain Test.
b. 3-year, Full Flow Trip Test.

Exit interview with the Maintenance Director on May 5, 2025, at 1:00 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 06/30/2025

Keystone Fire & Security Company shall perform the sprinkler system Annual Main Drain test and 3-year, Full flow Trip test.
This will be completed by Sunday, June 22nd, 2025.
The Director of Maintenance will in-service the maintenance staff on the importance of the sprinkler system Annual Main Drain test and 3-year, Full flow Trip testing requirements.
The in-service will be completed by June 22nd, 2025.
The Director of Maintenance or his designee beginning July 1st, 2025, will conduct monthly audits to meet compliance with K 0353 verifying the Annual Main Drain test and 3-year, Full flow Trip testing requirements have been met.
These audits will continue until December 31st, 2025, when at that time the Quality Assurance Committee will meet and decide if the audits should continue, or end based on the results.

NFPA 101 STANDARD Portable Fire Extinguishers: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.
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: MEADOWS II - Component: 02 - Tag: 0355

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

Findings include:

Document review on May 5, 2025, at 8:40 a.m., revealed the facility could not produce documentation of an annual fire extinguisher inspection.

Exit interview with the Maintenance Director on May 5, 2025, at 1:00 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 06/30/2025

The annual fire extinguishers maintenance was performed on Tuesday, May 13th, 2025, by Stop Fire Service. The documentation is available to the Department of Health Life Safety Division upon arrival.
The Director of Maintenance will in-service the maintenance staff on the importance of the annual fire extinguishers maintenance requirements.
The in-service will be completed by June 22nd, 2025.
The Director of Maintenance or his designee beginning July 1st, 2025, will conduct monthly audits to meet compliance with K 0355 verifying the annual fire extinguishers maintenance requirements is less than 1 year between maintenance inspections.
These audits will continue until December 31st, 2025, when at that time the Quality Assurance Committee will meet and decide if the audits should continue, or end based on the results.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
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: MEADOWS II - Component: 02 - Tag: 0761

Based on documentation review and interview, it was determined the facility failed to maintain fire rated door openings, affecting one of five levels.

Findings include:

Observation on May 5, 2025, at 10:50 a.m., revealed the double corridor fire rated doors failed to properly close and latch in the frame, in the basement, A-Wing Corridor, near Soiled Linen Room.

Exit interview with the Maintenance Director on May 5, 2025, at 1:00 p.m., confirmed the doors failed to close and latch.




 Plan of Correction - To be completed: 06/30/2025

The double corridor fire rated doors that failed to properly close and latch in the frame, in the basement, A-wing corridor, near the Soiled Linen room was repaired on Tuesday, May 20th, 2025. The doors properly close and latch.
The Director of Maintenance will in-service the maintenance staff on the importance of the corridor fire rated doors closing and latching.
The in-service will be completed by June 22nd, 2025.
The Director of Maintenance or his designee beginning July 1st, 2025, will conduct monthly audits to meet compliance with K 0761 verifying the corridor fire rated doors close and latch.
These audits will continue until December 31st, 2025, when at that time the Quality Assurance Committee will meet and decide if the audits should continue, or end based on the results.

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: MEADOWS II - Component: 02 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, affecting one of five levels.

Findings include:

Observation on May 5, 2025, at 11:40 a.m., revealed a broken duplex receptacle, on the third floor, B-Wing, next to room 5324.

Exit interview with the Maintenance Director on May 5, 2025, at 1:00 p.m., confirmed the broken receptacle.

Refer to NFPA 70, National Electric Code, and NFPA 99, 6.3.2.1.




 Plan of Correction - To be completed: 06/30/2025

The broken duplex receptacle on the third floor. B-wing, next to room 5324, was replaced on Tuesday May 6th, 2025.
The Director of Maintenance will in-service the maintenance staff on the importance of the emergency power corridor receptacles and cover plates meeting compliance with K 0911 of the Life Safety requirements.
The in-service will be completed by June 22nd, 2025.
The Director of Maintenance or his designee beginning July 1st, 2025, will conduct monthly audits to meet compliance with K 0911 verifying the emergency power corridor receptacles and cover plates meet NFPA 99, Chapter 6 requirements.
These audits will continue until December 31st, 2025, when at that time the Quality Assurance Committee will meet and decide if the audits should continue, or end based on the results.

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

Based on document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire facility.

Findings include:

Document review on May 5, 2024, at 8:30 a.m., revealed the facility could not produce documentation of the Annual, 90-minute load bank test.

Exit interview with the Maintenance Director on May 5, 2025, at 1:00 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 06/30/2025

The Annual 90-minute load bank testing of the emergency generator was performed on July 25th, 2024, by Curtis Power Solutions. The documentation is available to the Department of Health Life Safety Division upon arrival.
The Director of Maintenance will in-service the maintenance staff on the importance of the annual 90-minute bank testing of the emergency generator meeting compliance with K 0918 of the Life Safety requirements.
The in-service will be completed by June 22nd, 2025.
The Director of Maintenance or his designee beginning July 1st, 2025, will conduct monthly audits to meet compliance with K 0918 verifying the annual 90-minute load bank testing of the emergency generator is less than 1 year between testing.
These audits will continue until December 31st, 2025, when at that time the Quality Assurance Committee will meet and decide if the audits should continue, or end based on the results


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