Pennsylvania Department of Health
ST. FRANCIS CENTER FOR REHABILITATION & HEALTHCARE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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ST. FRANCIS CENTER FOR REHABILITATION & HEALTHCARE - 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 June 9, 2026, at St. Francis Center for Rehabilitation &; Healthcare, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 (MAIN & PAVILION BUILDINGS) - Component: 01 - Tag: 0000
Facility ID #190502Building 01Main and Pavilion BuildingsBased on a Medicare/Medicaid Recertification Survey completed on June 9, 2026, it was determined that St. Francis Center for Rehabilitation &; Healthcare 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 and sub-basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies - Construction Type:

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.

Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3

Observations:
Name: MAIN BUILDING 01 (MAIN & PAVILION BUILDINGS) - Component: 01 - Tag: 0133 Based on observation and interview, it was determined the facility failed to maintain the fire resistance of fire barriers, affecting two of four levels. Findings include: 1. Observation on June 9, 2026, between 9:30 a.m., and 10:05 a.m., revealed penetrations at the following locations: a. 9:30 a.m., Above ceiling at Room 430 door, two open penetrations. b. 10:05 a.m., Above ceiling at Room 330 door, penetration surrounding MC Cable. Exit interview with the Administrator and Regional Maintenance Manager, on June 9, 2026, at 11:45 a.m., confirmed the fire wall penetrations.

Plan of Correction - To be completed: 07/29/2026

It is the practice of the facility to maintain fire resistance of fire barriers. All residents had the potential to be affected by this deficiency.
1. The penetration above Room 430 doors and 330 doors has been corrected using approved UL rated fire caulk as per the UL design for penetration through fire barriers.
2. Facility wide inspection of fire barrier walls was inspected and found to be in good condition as of 6/29/2026. Residents were free from hazards.
3. The Director of Maintenance has completed education with Maintenance staff to monitor vendors, and any fire barrier penetration must be maintained immediately using approved fire caulking methods.
4. Every quarter for a year the Maintenance Director or designee will check a fire barrier wall for penetration. This information will then be entered on a log and will be presented to the monthly QAPI meeting.

NFPA 101 STANDARD Means of Egress - General:

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: MAIN BUILDING 01 (MAIN & PAVILION BUILDINGS) - Component: 01 - Tag: 0211 Based on observation and interview, it was determined the facility failed to maintain the means of egress free of impediments to full and instant use, affecting one of five levels. Findings include: 1. Observation on June 9, 2026, at 11:15 a.m., revealed basement storage emergency exit doors were secured shut with padlocks. Exit interview with the Administrator and Regional Maintenance Manager, on June 9, 2026, at 11:45 a.m., confirmed the obstructed emergency exit door.

Plan of Correction - To be completed: 07/29/2026

It is the practice of the facility to maintain an egress path outside fire exits. All residents had the potential to be affected by this deficiency.
1. The egress path from the basement storage room has had the pad lock removed and is free from obstructions.
2. Facility wide inspection of exit egress paths has been inspected and found to be in good condition as of 6/29/2026. Residents were free from hazards.
3. The Director of Maintenance has completed education with Maintenance staff to observe conditions of exit paths.
4. Every quarter for a year the Maintenance Director or designee will check a random exit path throughout the facility to ensure exit path functions. This information will then be entered on a log and will be presented to the monthly QAPI meeting.

NFPA 101 STANDARD Egress Doors:

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

Observations:
Name: MAIN BUILDING 01 (MAIN & PAVILION BUILDINGS) - Component: 01 - Tag: 0222 Based on observation and interview, it was determined the facility failed to maintain delayed egress doors, affecting three of four levels in the facility. Findings include: Observations on June 9, 2026, between 10:05 a.m. and 11:00 a.m., revealed the following deficiencies:a. 10:05 a.m., on the third floor, delayed egress door by resident room 330 failed to open; b. 10:34 a.m., on the first floor, Chapel, the delayed egress door on the right side of the altar was missing signage stating "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS "; c. 10:39 a.m., on the first floor, delayed egress door across from Nurses' Station failed to open; d. 11:11 a.m., in the basement, Folding Room delayed egress door failed to open. Exit interview with the Administrator and Regional Maintenance Manager, on June 9, 2026, at 11:45 a.m., confirmed the above deficiencies.

Plan of Correction - To be completed: 07/29/2026

It is the practice of the facility to ensure all exit doors have proper functioning delayed egress. All residents had the potential to be affected by this deficiency.
1. The facility has repaired delayed egress doors by room 330, first floor by nurses station, and basement folding room door. Proper signage has been installed on first floor chapel door with the language "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS". These doors are now functioning as designed.
2. All doors have been inspected by a third-party door company and no additional defects are present that could delay egress. All residents are free from hazard.
3. The Director of Maintenance has completed education with Maintenance staff to confirm proper functioning of the doors and locking as well as proper signage.
4. Every quarter for a year the Maintenance Director or designee reviews egress doors to check for delayed egress function and signage. This information will then be entered on a log and will be presented to the QAPI meeting.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

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.

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 (MAIN & PAVILION BUILDINGS) - Component: 01 - Tag: 0225 Based on observation, document review, and interview, the facility failed to maintain the fire resistance rating for stairways and smoke-proof towers, affecting four of six stair towers. Findings include: 1. Observation and document review on June 9, 2026, between 9:00 a.m. and 10:30 a.m., revealed the main building, basement level, medical records and dietary dry store rooms opened directly to the chapel fire exit stair tower #3. The employee locker room also opened directly to the south stair tower. Exit interview with the Administrator and Regional Maintenance Manager, on June 9, 2026, at 11:45 a.m., confirmedthe openings to the stair tower enclosures.

Plan of Correction - To be completed: 07/29/2026

It is the practice of the facility to maintain stair tower egress discharges.

1. The facility is requesting The Department of Health to complete the FSES.
2. All stair tower doors have been inspected for proper function on 6/29/2026.
3. The Director of Maintenance has completed education with Maintenance staff to monitor and inspect latching fire doors and the procedures for FSES.
4. Every quarter for a year The Director of Maintenance or designee will monitor for compliance monthly through preventative maintenance rounds and the reporting of the rounds to the monthly QAPI committee.

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 01 (MAIN & PAVILION BUILDINGS) - Component: 01 - Tag: 0291 Based on observation and interview, it was determined the facility failed to ensure battery back-up lighting was maintained in operable condition affecting one of four levels. Findings include: 1. Observation on June 9, 2026, at 11:10 a.m., revealed a battery backup light with one of two lights that failed to illuminate when tested, Basement Corridor near Maintenance Director's Office. Exit interview with the Administrator and Regional Maintenance Manager, on June 9, 2026, at 11:45 a.m., confirmed the deficient battery back-up light.

Plan of Correction - To be completed: 07/29/2026

It is the practice of the facility to have proper backup lighting on all exit discharge paths, and all residents had the potential to be affected by this deficiency.
1. Facility has replaced the battery backup light by the basement corridor near maintenance exit door is now functioning as per the design.
2. All battery backup lighting has been tested on 6/29/2026 and is functioning as per the design. All resident areas are free from hazard, and all systems are operating as designed.
3. The Director of Maintenance has completed education and training with Maintenance staff on testing battery backup lighting for proper function.
4. Every quarter for a year the Maintenance Director or designee will complete testing of battery backup lights. This information will then be entered on a log and will be presented by the director to the monthly QAPI meeting for one year.

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 01 (MAIN & PAVILION BUILDINGS) - Component: 01 - Tag: 0353 Based on observation and interview, it was determined the facility failed to maintain sprinkler system, affecting two of four floors. Findings include: 1. Observation on June 9, 2026, between 10:10 a.m., and 10:40 a.m., revealed missing sprinkler head escutcheons at the following locations: a. 10:10 a.m., on the third floor, Trash Room. b. 10:40 a.m., on the first floor, Admissions Office Room #132. Exit interview with the Administrator and Regional Maintenance Manager, on June 9, 2026, at 11:45 a.m., confirmed the missing escutcheons.

Plan of Correction - To be completed: 07/29/2026

It is the practice of the facility to ensure sprinkler heads are maintained in accordance with requirements. All residents had the potential to be affected by this deficiency.
1. The sprinkler head escutcheon in third floor trash room and first floor admission office has been replaced.
2. All sprinkler heads around the building have been inspected, are installed, and clean as per the manufacturers design. All residents were safe, and no hazards were present.
3. The Director of Maintenance has completed education with Maintenance staff to confirm proper maintenance of sprinkler heads.
4. Every quarter for a year the Maintenance Director or designee reviews sprinkler heads for cleanliness and hardware. This information will then be entered on a log and will be presented to the QAPI meeting.

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 (MAIN & PAVILION BUILDINGS) - Component: 01 - Tag: 0355 Based on observation and interview, it was determined the facility failed to maintain fire extinguishers, affecting two of four levels in the facility. Findings include: Observations on June 9, 2026, between 10:15 a.m. and 11:02 a.m., revealed the following:a. 10:15 a.m., on the third floor, flush mounted fire extinguishers throughout the third floor lacked indicating signage; b. 10:56 a.m., in the basement, fire extinguisher in the Elevator Machine Room was not mounted to the wall; c: 11:02 a.m., in the basement, the K-rated fire extinguisher in the Kitchen was blocked by a trash can. Exit interview with the Administrator and Regional Maintenance Manager, on June 9, 2026, at 11:45 a.m., confirmed the above deficiencies.

Plan of Correction - To be completed: 07/29/2026

It is the practice of the facility to ensure Fire Extinguishers are properly accessible. All residents had the potential to be affected by this deficiency.
1. The fire extinguisher in the basement elevator room has been mounted on the wall. The signage by all fire extinguishers on the 3rd floor have been hung and the K rated fire extinguisher has had the trash can removed from blocking access.
2. All Fire Extinguishers in the facility have been reinspected and are ready for use and the staff inspect the extinguisher areas to prevent this from happening in the future.
3. The Director of Maintenance has completed education with Maintenance staff regarding monitoring Fire Extinguishers by Maintenance Staff.
4. Every quarter for a year the Maintenance Director or designee will check Fire Extinguishers throughout the facility to ensure they are ready for use with proper signage. This information will then be entered on a log and will be presented to the monthly

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 01 (MAIN & PAVILION BUILDINGS) - Component: 01 - Tag: 0372 Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls, affecting one of five levels. Findings include: 1. Observation on June 9, 2026, at 10:45 a.m., revealed an unsealed penetration around data wires, on the third floor, above smoke doors by room 319. Exit interview with the Administrator and Regional Maintenance Manager, on June 9, 2026, at 11:45 a.m., confirmed the penetration.

Plan of Correction - To be completed: 07/29/2026

It is the practice of the facility to ensure smoke, Fire and are free from penetrations, and all residents had the potential to be affected by this deficiency.
1. The penetration above the 3rd floor above smoke door by room 319 has been sealed using UL rated approved fire caulk.
2. Smoke Barrier walls throughout the facility have been inspected for penetration and are free from any penetration, all residents are free from hazards and all systems are operating.
3. The Director of Maintenance has completed education with Maintenance staff regarding monitoring penetrations through smoke walls and following behind vendors as work is completed to close any penetrations using approved fire caulk.
4. Every quarter for a year the Maintenance Director or designee will check random smoke walls throughout the facility to ensure they are free from penetration. This information will then be entered on a log and will be presented to the monthly QAPI meeting.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: MAIN BUILDING 01 (MAIN & PAVILION BUILDINGS) - Component: 01 - Tag: 0374 Based on observation and interview, it was determined the facility failed to ensure doors in smoke barrier walls were maintained to resist the passage of smoke, affecting one of five levels. Findings include: 1. Observation on June 9, 2026, at 9:15 a.m., revealed, on the first floor, the smoke doors to Administration Suite failed to close smoke tight when tested due to coordinator malfunction. Exit interview with the Administrator and Regional Maintenance Manager, on June 9, 2026, at 11:45 a.m., confirmed the doors failed to close smoke tight.

Plan of Correction - To be completed: 07/29/2026

It is the practice of the facility to ensure smoke barrier door is free to close to resist smoke passage all residents had the potential to be affected by this deficiency.
1. The smoke door by administration suite now closes properly seals after release from hold open devices providing a smoke tight seal. And functions as designed as smoke doors.
2. All other Doors throughout the facility were checked to sealing smoke tight on 06/29/2026.
3. The Director of Maintenance has completed education with Maintenance staff regarding monitoring doors to remain smoke tight when closed.
4. Every quarter for a year the Maintenance Director or designee will check smoke and fire doors throughout the facility to ensure the doors are closing smoke tight into each other. This information will then be entered on a log and will be presented by the director to the monthly QAPI meeting for one year.

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 01 (MAIN & PAVILION BUILDINGS) - Component: 01 - Tag: 0511 Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting three of four levels in the facility. Findings include: Observations on June 9, 2026, between 10:14 a.m. and 10:51 a.m., revealed storage within three feet of the electrical panels in the below locations. Per NFPA70 110.26(A)(1), a 3 ft. depth clearance is required in front of electrical equipment with a nominal voltage to ground of 0 to 150 volts. a. 10:14 a.m., on the third floor, Electrical Closet next to resident room 350; b. 10:21 a.m., on the second floor, Electrical Closet next to resident room 250; c. 10:49 a.m., on the first floor, Rehabilitation Services; d. 10:51 a.m., on the first floor, Activities. Exit interview with the Administrator and Regional Maintenance Manager, on June 9, 2026, at 11:45 a.m., confirmed the above deficiencies.

Plan of Correction - To be completed: 07/29/2026

It is the practice of the facility to ensure electrical systems are free from storage nearby.
1. 3rd floor electrical closet, 2nd floor electrical closet, 1st floor rehab office, 1st floor activities room all have had the storage around the electrical panel removed.
2. All other electrical panels have been inspected to confirm no storage within 3 feet around the panel. All residents are free from hazards and all systems operate as designed.
3. The Director of Maintenance has completed education with Maintenance regarding storage and locking of electrical panels.
4. Every quarter of a year the Maintenance Director or designee will check electrical panel areas for storage. This information will then be entered on a log and will be presented to the QAPI meeting.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu:

Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82

Observations:
Name: MAIN BUILDING 01 (MAIN & PAVILION BUILDINGS) - Component: 01 - Tag: 0541 Based on observation and interview, it was determined the facility failed to maintain the fire rating of laundry chutes, affecting one of four levels in the facility. Findings include: Observation on June 9, 2026, at 11:15 a.m., revealed the basement Soiled Linen discharge room door did not have fire rated door hardware.Exit interview with the Administrator and Regional Maintenance Manager, on June 9, 2026, at 11:45 a.m., confirmed the lack of fire rated door hardware.

Plan of Correction - To be completed: 07/29/2026

It is the practice of the facility to have proper closing and latching of all rubbish chutes all residents had the potential to be affected by this deficiency.
1. The basement soiled linen discharge door has had the hardware replaced with fire rated door hardware.
2. All linen and trash chutes have been checked and adjustments made to allow for proper closing and latching with proper hardware. All resident areas are free from hazard, and all systems are operating as designed.
3. The Director of Maintenance has completed education and training with Maintenance staff to confirm proper operations of linen and trash chutes.
4. Every quarter for a year the Maintenance Director or designee review linen and trash chutes for proper function. This information will then be entered on a log and will be presented by the director to the monthly QAPI meeting for one year.

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 (MAIN & PAVILION BUILDINGS) - Component: 01 - Tag: 0911 Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, affecting two of four levels. Findings include: 1. Observation on June 9, 2026, between 9:35 a.m., and 11:05 a.m., revealed electrical deficiencies at the following locations: a. 9:35 a.m., on the fourth floor Trash Room has electrical panel missing a protective blank. b. 11:05 a.m., Two quad outlets missing their cover plates, Kitchen behind the range/stovetop area. Exit interview with the Administrator and Regional Maintenance Manager, on June 9, 2026, at 11:45 a.m., confirmed the electrical deficiencies.

Plan of Correction - To be completed: 07/29/2026

It is the practice of the facility to ensure electrical systems are functioning as per design.
1. The 4th floor trash room has had a protective plate installed, and the two quads behind kitchen range/stovetop has had the cover plates replaced.
2. All Outlets in the entire building have been inspected and are functioning as designed to maintain the safety of residents.
3. The Director of Maintenance has completed education with Maintenance staff regarding monitoring Outlets to ensure they are functioning as designed and with proper protection installed.
4. Every quarter for a year the Maintenance Director or designee will check outlets throughout the facility to ensure outlets are functioning and installed correctly. This information will then be entered on a log and will be presented to the monthly QAPI meeting.

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