Observations:
Name: LONG-TERM SKILLED UNIT (VILLAGE D) - Component: 01 - Tag: 0521
Based on observation and interview, it was determined the facility failed to maintain the heating, ventilating and air conditioning (HVAC) system, on one of three stories within the facility.
1.Observation on December 29, 2025, at 10:40 a.m., revealed in the following locations, there were HVAC return transfer grills vented above the suspended ceiling into the interstitial space, creating a plenum.
a) Third floor- Dining room south, two non-ducted returns;
b) Third floor- Medical Suite outside of bathroom, one non-ducted return;
c) Third floor- Outside room D 3104 - Activities, one non-ducted return.
Exit Interview with the Administrator and Maintenance Director on December 29, 2025, at 1:30 p.m., confirmed the HVAC system was not fully ducted.
| | Plan of Correction - To be completed: 02/27/2026
The Hill at Whitemarsh has requested an Informal Dispute Resolution (IDR) regarding this citation and maintains that the HVAC system is compliant with applicable Life Safety Code requirements.
The Hill at Whitemarsh has reviewed the HVAC system identified during the survey, including the areas noted with return air transfers grilles venting into the interstitial ceiling space. The review was conducted in collaboration with facility maintenance and the engineering company to confirm that the system is designed and functioning in accordance with applicable NFPA 101 requirements.
Based on this evaluation, The Hill at Whitemarsh is has determined that the HVAC system is operating appropriately. The Hill at Whitemarsh will continue its current practices of routine monitoring and oversight to ensure regulatory compliance.
To support continued compliance, The Hill at Whitemarsh will:
1. Maintain oversight of HVAC system configuration and any future modifications by qualified personnel
2. Review any future HVAC-related work to ensure alignment with Life Safety code requirements
3. Reinforce education with maintenance staff regarding HVAC system requirements, including return air and plenum considerations, as needed
4. Ensuring The Hill at Whitemarsh staff are up-to-date with current and updated regulatory guidance.
This was submitted on 04/02/2026. Survey conducted on 12/29/2025. The Hill at Whitemarsh received letter on 03/25/2026 with a submission compliance date by 04/04/2026.
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