Pennsylvania Department of Health
GRADUATE POST ACUTE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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GRADUATE POST ACUTE - 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 11, 2026, it was determined Graduate Post Acute had deficiencies which 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, the facility failed to maintain emergency Preparedness guidelines for one of one Emergency Preparedness Plan. Findings include: 1. Document review on August 11, 2026, at 9:30 a.m., revealed the facility failed to conduct the required annual-full scale exercise and additional exercise to test the emergency preparedness plan within the previous 12 months. Exit Interview with the Administrator and Maintenance Director on August 11, 2026, at 12:15 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 09/23/2026

1.The required annual full-scale or functional emergency preparedness exercise and the additional qualifying exercise were completed.

2.The Administrator/designee audited the Emergency Preparedness Plan and the previous 12 months of exercise records. Missing evaluations and documentation were identified and corrected, and an annual exercise schedule was established.

3.The Administrator, Maintenance Director, and department leaders were educated on emergency preparedness exercise requirements, documentation, evaluation, and follow-up responsibilities.

4.The Administrator/designee will audit the emergency exercise schedule and supporting documentation monthly for three months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendation.

Initial comments:Name: MAIN BUILDING 01 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0000
Facility ID #200402Component 01Main BuildingBased on a Medicare/Medicaid Recertification Survey completed on August 11, 2026, it was determined that Graduate Post Acute 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 six-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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: MAIN BUILDING 01 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0100 Based on observation and interview, it was determined the facility failed to maintain portable floor plans outlining designated rated partitions, affecting one life safety floor plan. Findings Include: Document review on August 11, 2026, at 9:00 am, revealed the facility failed to provide a set of accurate portable floor plans. The Division of Safety Inspection requires that all facilities under our jurisdiction provide a portable, accurate floor plan on site to be used during the Life Safety Code Survey. The Life Safety Code Floor Plan shall include the following: a. Smoke Barrier Walls (outside wall to outside wall) b. Fire Barrier Walls (2-hour walls) c. Horizontal Exits d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan. e. Required Exits should be clearly noted; and f. Shafts Walls Exit Interview with the Administrator and Maintenance Director on August 11, 2026, at 12:15 p.m., confirmed required floor plans were not available at time of survey.

Plan of Correction - To be completed: 09/23/2026

1. Facility requested a Time Limited Waiver regarding the life safety floor plans of Graduate Post Acute.

2. The Administrator and Maintenance Director audited the facility's existing floor plans for accuracy. Any discrepancies were documented and submitted to the architect for correction.

3. Facility educated Plant Ops and Administration that floor plans are always updated timely to reflect the floor plan layout of the building.

4. Facility will follow-up once a week with the architect until the updated floor plans are completed and accepted.

NFPA 101 STANDARD Building Construction Type and Height:

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.

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

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

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

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

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

Observations:
Name: MAIN BUILDING 01 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0161 Based on observation and interview, the facility failed to maintain the building construction requirements, affecting one of seven levels. Findings Include: 1. Observation on August 11, 2026, at 10:30 a.m., revealed above the suspended ceiling in ground floor lobby, an unknown expanding foam product was installed around ceiling penetrations. Exit Interview with the Administrator and Maintenance Director on August 11, 2026, at 12:15 p.m., confirmed the unknown foam substance.

Plan of Correction - To be completed: 09/23/2026

1. The expanding foam around the ceiling penetrations above the ground-floor lobby was removed.

2. The Maintenance Director/designee inspected all construction and renovation areas for unapproved foam and improperly sealed penetrations.
Identified concerns were corrected.

3. Maintenance staff and contractors were educated on approved penetration-sealing materials and the prohibition against using unapproved expanding foam.

4. The Maintenance Director/designee will audit active construction areas weekly x 4 and monthly for two months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendation.

NFPA 101 STANDARD Cooking Facilities:

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 01 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0324 Based on document review and interview, it was determined the facility failed to ensure the kitchen suppression system was maintained, affecting one of seven levels. Findings include: 1. Document review on August 11, 2026, at 9:30 am, revealed the July 2026 kitchen suppression inspection report noted the following deficiency: "System is not UL needs to be replaced". Evidence of corrective action was unavailable at time of survey. Exit Interview with the Administrator and Maintenance Director on August 11, 2026, at 12:15 p.m., confirmed the kitchen suppression system deficiency.

Plan of Correction - To be completed: 09/23/2026

1.Facility completed a clean kitchen suppression system report. Updated documentation confirming the system's compliant condition was obtained and placed in the Life Safety binder.

2.The Maintenance Director/designee reviewed all kitchen suppression inspection, testing, maintenance, and repair records. Unresolved deficiencies and missing documentation were identified and corrected.

3.Maintenance staff were educated on reviewing vendor reports, tracking deficiencies through completion, and maintaining final corrective-action documentation.

4.The Maintenance Director/designee will audit the Life Safety binder and Kitchen Suppression Inspections monthly for three months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendation.

NFPA 101 STANDARD Smoke Detection:

Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2

Observations:
Name: MAIN BUILDING 01 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0347 Based on observation and interview, it was determined the facility failed to maintain the automatic smoke detectors within a smoke tight assembly, affecting one of seven levels. Findings include: 1. Observation on August 11, 2026, at 10:45 a.m., revealed, on the fifth floor, Physical Therapy suspended ceiling was removed and the smoke detectors were left hanging and unsupported. Exit Interview with the Administrator and Maintenance Director on August 11, 2026, at 12:15 p.m., confirmed the open ceiling assembly.

Plan of Correction - To be completed: 09/23/2026

1. A fire watch was initiated for the fifth-floor Physical Therapy area while the system was impaired. The ceiling assembly was restored, and the affected smoke detectors were properly supported, installed, and tested for correct operation on September 23rd.

2. The Maintenance Director/designee inspected all construction areas to ensure smoke detectors were properly installed and working in enclosed rated ceilings. Identified deficiencies were corrected.

3. Maintenance staff and contractors were educated on protecting smoke detection systems during construction and implementing interim fire-safety measures when systems are impaired.

4. The Maintenance Director/designee will audit construction areas weekly until construction is completed. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendation.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

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

Observations:
Name: MAIN BUILDING 01 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0353 Based on document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire facility. Findings include: 1. Document review on August 11, 2026, at 9:30 am, revealed the facility lacked documentation indicating monthly fire pump runs had been performed during the prior 12 months. Exit Interview with the Administrator and Maintenance Director on August 11, 2026, at 12:15 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 09/23/2026

1. The required fire-pump run was completed and documented.

2. The Maintenance Director/designee audited the available fire-pump testing records for the previous 12 months. Missing documentation was identified, and the testing calendar was verified.

3. Maintenance staff were educated on the required frequency, duration, documentation, and retention of fire-pump testing records.

4. The Administrator/designee will audit fire-pump testing records monthly for three months. Missed testing or documentation will be immediately addressed. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendation.

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 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0372 Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations affecting one of seven levels. Findings include: 1. Observation on August 11, 2026, revealed unsealed penetrations of smoke barrier walls in the following locations: a. 11:20 a.m., above smoke doors by room 211, open hole. b. 11:50 a.m., above smoke doors by room 205, missing section. Exit Interview with the Administrator and Maintenance Director on August 11, 2026, at 12:15 p.m., confirmed the unsealed penetrations.

Plan of Correction - To be completed: 09/23/2026

1. Maintenance will use an approved fire system through the wall penetrations system number W-L 3195 on Room 211 and Room 205.

2. The Maintenance Director/designee inspected smoke-barrier walls throughout the facility for additional open or improperly sealed penetrations. Identified deficiencies were corrected using approved systems.

3. Maintenance staff and contractors were educated on preserving smoke-barrier integrity and properly sealing penetrations following construction, electrical, plumbing, or cabling work.

4. The Maintenance Director/designee will audit smoke barriers monthly for three months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendation.

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: MAIN BUILDING 01 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0521 Based on observation and interview, it was determined the facility failed to maintain Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting one of seven levels. Findings include: 1. Document review on August 11, 2026, at 10:10 a.m., revealed a portable AC unit was vented directly above the suspended ceiling, basement laundry. Exit Interview with the Administrator and Maintenance Director on August 11, 2026, at 12:15 p.m., confirmed the deficient venting.

Plan of Correction - To be completed: 09/23/2026

1. The portable air-conditioning unit that was improperly vented above the suspended ceiling in the basement laundry was removed from service.

2. The Maintenance Director/designee inspected the facility for other portable HVAC units that were improperly installed or vented. Identified concerns were corrected.

3. Maintenance staff were educated on properly installing and venting portable HVAC equipment according to manufacturer instructions and applicable Life Safety requirements.

4. The Maintenance Director/designee will audit the facility for improperly installed or vented portable HVAC equipment monthly for three months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendation.

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 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0541 Based on observation and interview, it was determined the facility failed to maintain the fire protection rating for linen chutes, affecting one of seven levels. Findings include: 1. Observation on August 11, 2026, at 10:00 a.m., revealed on the first floor the linen chute door failed to self-close and positively latch, due to missing self-closer. Exit Interview with the Administrator and Maintenance Director on August 11, 2026, at 12:15 p.m., confirmed the chute door failed to self-close.

Plan of Correction - To be completed: 09/23/2026

1. A self-closing device was installed on the first-floor linen chute door. The door was adjusted and tested to ensure it fully self-closed and positively latched.

2. The Maintenance Director/designee inspected all linen and laundry chute doors throughout the facility. Identified deficiencies were immediately corrected.

3. Maintenance staff were educated on inspecting, testing, and maintaining linen and laundry chute doors, including self-closing and positive-latching functionality.

4. The Maintenance Director/designee will audit all linen and laundry chute doors monthly for three months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendation.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0918 Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, affecting the entire facility. Findings include: 1. Document review on August 11, 2026, at 9:30 a.m., revealed the facility lacked documentation indicating performance of monthly testing and recording of battery conductance of the generator's maintenance free batteries. (Refer to NFPA 110.8.3.7.1) Exit Interview with the Administrator and Maintenance Director on August 11, 2026, at 12:15 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 09/23/2026

1. An appropriate battery conductance tester was obtained. The generator's maintenance-free batteries were tested, and the required conductance results were recorded in the generator maintenance records.

2. The Maintenance Director/designee reviewed the generator maintenance records. Missing battery tests and maintenance documentation were identified and corrected.

3. Maintenance staff were educated on generator battery conductance testing, required frequency, proper documentation, and record-retention requirements.

4. The Administrator/designee will audit generator maintenance records monthly for three months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendation.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0923 Based on observation and interview, it was determined the facility failed to maintain oxygen cylinder storage on one of seven levels. Findings include: 1. Observations on August 11, 2026, at 10:15 a.m., revealed an unsecured oxygen cylinder, ground floor Dialysis. Exit Interview with the Administrator and Maintenance Director on August 11, 2026, at 12:15 p.m., confirmed the freestanding oxygen cylinder.

Plan of Correction - To be completed: 09/23/2026

1. The freestanding oxygen cylinder identified in the ground-floor Dialysis area was properly secured.

2. The Maintenance Director/designee inspected all resident-care and oxygen-storage areas for unsecured or improperly stored cylinders. Identified concerns were immediately corrected.

3. Dialysis staff and applicable facility staff were educated on safely handling and storing oxygen cylinders, including the requirement that all cylinders remain properly secured.

4. The Maintenance Director/designee will audit oxygen-cylinder storage monthly for three months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendation.

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