Pennsylvania Department of Health
AVENTURA AT PEMBROOKE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 53 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.


AVENTURA AT PEMBROOKE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000
Based on an Emergency Preparedness Survey conducted on July 7 &; 8, 2026, at Aventura at Pembrooke, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: SOUTH - Component: 02 - Tag: 0000
Facility ID #230602

Component 02

South Building

Based on a Medicare/Medicaid Recertification Survey conducted on July 7 &; 8, 2026, it was determined that Aventura at Pembrooke was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a four-story, Type II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

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

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

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

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

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

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

Observations:
Name: SOUTH - Component: 02 - Tag: 0161 Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire component. Findings include: 1. Observation on July 7, 2026, at 1:00 PM, revealed this is a four-story, Type II (000), unprotected noncombustible structure, which is fully sprinklered. This type of construction is not permitted under the 2012 Edition of the Life Safety Code to be more than two-stories for an existing sprinklered health care occupancy. Interview with the Director of Facilities on July 7, 2026, at 1:00 PM, confirmed the facility exceeded the allowable story height for the construction type.

Plan of Correction - To be completed: 08/12/2026

0161: FSES: NHA has submitted a request for a Time Limited Waiver to the DOH as part of the FSES request. The facility requests DSI Conduct the FSES survey.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: SOUTH - Component: 02 - Tag: 0225 Based on observation and interview, it was determined the facility failed to maintain the fire resistance of exit stairtower enclosures, affecting one of seven smoke compartments within the component. Findings include: 1. Observation on July 8, 2026, at 9:30 AM, revealed two unprotected penetrations of the stairtower located next to the Zone 1 Therapy Room, around a metallic-clad electrical cable and blue wires, above the suspended ceiling of the Therapy Room. Interview with the Director of Facilities on July 8, 2026, at 9:30 AM, confirmed the compromised fire resistance of the exit stairtower enclosure.

Plan of Correction - To be completed: 08/05/2026

0225 Stairways and Smokeproof Enclosures:
The facility had two unprotected penetrations of the stair tower located next to the Zone 1 Therapy Room around a metallic-clad electrical cable and blue wires, above the suspended ceiling of the Therapy Room.
No residents were identified.
All residents have the potential to be affected.
Maintenance Director sealed all open areas in Zone 1 Therapy Room using an approved through penetration fire stop system, and above the suspended ceiling of the Therapy Room with appropriate fire-resistant materials on 09JUL2026.

Facility wide audit was completed by the Maintenance Director/Designee on 09JUL2026 to address any unprotected penetrations.
21JUL2026, NHA educated Maintenance Staff and team on the requirements to ensure all penetrations are sealed appropriately/ Maintenance will maintain the rating of all stair towers per regulation.

Maintenance Director/Designee will conduct a compliance audit monthly x4 months, then quarterly to ensure requirements are met.

Results will be submitted to quarterly to the Quality Assurance Performance Improvement Committee for review and recommendations.

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: SOUTH - Component: 02 - Tag: 0291 Based on document review and interview, it was determined the facility failed to provide documentation verifying monthly testing of battery back-up emergency lighting fixtures had occurred, within the previous twelve months, affecting the entire component. Findings include: 1. Review of documentation on July 7, 2026, at 11:25 AM, revealed the facility failed to provide documentation verifying monthly testing of battery back-up emergency lighting fixtures had occurred, within the previous twelve months. Interview with the Director of Facilities on July 7. 2026, at 11:25 AM, confirmed the lack of documentation verifying monthly testing of battery back-up emergency lighting fixtures had occurred, within the previous twelve months.

Plan of Correction - To be completed: 08/05/2026

0291: Emergency Lighting:
The facility failed to provide documentation verifying monthly testing of battery back-up emergency lighting fixtures had occurred, within the previous twelve months.

No residents were identified.

All residents have the potential to be affected.

A 90-minute test to reset the battery operated light testing cycle was completed by 05AUG2026 to confirm functioning.

Facility wide audit was completed by the Maintenance Director/Designee on 09JUL2026 to ensure that all emergency lighting fixtures were operating during testing of the batter back up test.

21JUL2026, NHA educated the Maintenance Director on the importance of maintaining documentation per regulatory requirements.

The Maintenance Director/Designee will conduct quarterly compliance audits for 30 second testing monthly, and 90 minute testing annually to ensure that documentation of battery back-up emergency lighting fixtures meet the requirements.

NHA/Designee will audit Life Safety Binder with Maintenance Director Quarterly to confirm test results have been scheduled and/or filed.

Results will be submitted to quarterly to the Quality Assurance Performance Improvement Committee for review and recommendations

NFPA 101 STANDARD Exit Signage:

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: SOUTH - Component: 02 - Tag: 0293 Based on document review and interview, it was determined the facility failed to provide documentation verifying monthly inspections of exit signage had occurred, within the previous twelve months, affecting the entire component. Findings include: 1. Review of documentation on July 7, 2026, at 11:30 AM, revealed the facility failed to provide documentation verifying monthly inspections of exit signage had occurred, within the previous twelve months. Interview with the Director of Facilities on July 7, 2026, at 11:30 AM, confirmed the lack of documentation verifying monthly inspections of exit signage had occurred, within the previous twelve months.

Plan of Correction - To be completed: 08/05/2026

0293: Exit signage

The facility failed to provide documentation verifying monthly inspections of exit signage had occurred, within the previous twelve months.

No residents were identified.

All residents have the potential to be affected.

Facility wide audit was completed by the Maintenance Director/designee on 09JUL2026 to ensure that all exit signs were operating properly.

On 21JUL2026, NHA educated the Maintenance Director on the importance of maintaining documentation per regulatory requirements.

The Maintenance Director/Designee will conduct compliance audits monthly x 3 month and then quarterly, to ensure that documentation for exit signage inspection meet the requirement.

NHA/Designee to audit Life safety binder with Maintenance Director quarterly to confirm completion of documentation.

Results will be submitted to quarterly to the Quality Assurance Performance Improvement Committee for review and recommendations.

NFPA 101 STANDARD Cooking Facilities:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: SOUTH - Component: 02 - Tag: 0324 Based on document review and interview, it was determined the facility failed to provide documentation verifying semi-annual cleanings of kitchen exhaust ductwork and monthly inspections of the kitchen fixed fire suppression system had been performed within the previous twelve months, affecting one of seven smoke compartments within the component. Findings include: 1. Review of documentation on July 7, 2026, at 10:55 AM, revealed the facility failed to provide documentation verifying the kitchen exhaust ductwork had been cleaned, between January, 2024, and December 30, 2025. Additionally, the facility failed to provide documentation verifying the kitchen exhaust ductwork had been cleaned, since December 30, 2025. Interview with the Director of Facilities on July 7, 2026, at 10:55 AM, confirmed the lack of documentation verifying kitchen exhaust ductwork had been cleaned on a semi-annual basis, during the previous twelve months. 2. Review of documentation on July 7, 2026, at 10:57 AM, revealed the facility failed to provide documentation verifying monthly visual inspections of the Kitchen fixed fire suppression system had occurred, within the previous twelve months. Interview with the Director of Facilities on July 7, 2026, at 10:57 AM, confirmed the lack of documentation verifying monthly visual inspections of the kitchen fixed fire suppression system had been performed, within the previous twelve months.

Plan of Correction - To be completed: 08/05/2026

0324: Cooking Facilities:

The facility failed to provide documentation verifying semi-annual cleanings of kitchen exhaust ductwork and monthly inspections of the kitchen fixed fire suppression system had been performed within the previous twelve months, affecting one of seven smoke compartments within the component.

No residents were affected by this deficient practice.

All residents have the potential to be affected.

Maintenance Director confirmed certified vendor to perform semi-annual cleaning and inspection of kitchen exhaust ductwork and kitchen fixed fire suppression system prior to 05AUG2026.

On 21JUL2026, NHA educated the Maintenance Director on the importance of maintaining documentation per regulatory requirements.

The Maintenance Director/Designee will conduct compliance audits monthly x six months, to ensure that documentation verifying semi-annual cleanings of kitchen exhaust ductwork and kitchen fixed fire suppression system inspection meet the requirement per regulation.

NHA/Designee will Life Safety Binder with Maintenance Director to ensure compliance semi-annual inspection and cleaning schedule.

Results will be submitted to the quarterly to the Quality Assurance Performance Improvement Committee for review and recommendations.

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: SOUTH - Component: 02 - Tag: 0345 Based on document review, observation and interview, it was determined the facility failed to provide documentation verifying semi-annual inspections of the automatic fire alarm system occurred, and to maintain the automatic fire alarm system in a continuously reliable operating manner, which serves the entire component. Findings include: 1. Review of documentation on July 7, 2026, at 10:50 AM, revealed the facility failed to provide documentation verifying a visual inspection of the automatic fire alarm system occurred, within the previous twelve months. A single functional inspection occurred on 1/21/26. Interview with the Director of Facilities on July 8, 2026, at 10:50 AM, confirmed the lack of documentation verifying a visual inspection of the automatic fire alarm system occurred, within the previous twelve months. 2. Observation on July 7, 2026, at 9:51 AM, revealed the Zone 1 smoke detector, located at the fire alarm panel within the Generator Room, was not mounted and was suspended from internal wiring. Interview with the Director of Maintenance on July 7, 2026, at 9:51 AM, confirmed the smoke detector was not mounted and was suspended from internal wiring.

Plan of Correction - To be completed: 08/05/2026

0345: Fire Alarm System - Testing and Maintenance:

The facility failed to provide documentation verifying semi-annual inspections of the automatic fire alarm system occurred, and to maintain the automatic fire alarm system in a continuously reliable operating manner, which serves the entire component.

No residents were affected by this deficient practice.

All residents have the potential to be affected.

1. A semi-annual visual inspection of the fire alarm system to be completed and documented by 05AUG2026.

2. Certified Vendor to service Zone 1 smoke detector in generator room by 05AUG2026.

Fire alarm system, including smoke detectors, audited by the Maintenance Director/Designee by 05AUG2026 to ensure compliance with the regulation requirements and documented.

On 21JUL2026, the Maintenance Director was educated by the Administrator on the importance of completing semi-annual visual inspection of the fire alarm systems per regulatory requirements.

The Maintenance Director/Designee will conduct compliance audits semi-annually on ongoing basis to ensure that a semi-annual visual inspection of the fire alarm system is completed.

NHA/Designee will audit Life Safety Binder with Maintenance Director to ensure compliance with semi-annual inspection and testing schedule.

Results of audits will be reviewed at Quarterly Quality Assurance and Performance Improvement Committee Meeting over the duration of the audit process. Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting.

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: SOUTH - Component: 02 - Tag: 0353 Based on document review, observation and interview, it was determined the facility failed to provide documentation verifying quarterly inspections of mechanical waterflow devices had occurred within the previous twelve months, and to maintain the automatic sprinkler system in a continuously reliable operating condition, which serves the entire component. Findings include: 1. Review of documentation on July 7, 2026, at 10:51 AM, revealed the facility failed to provide documentation verifying inspections of mechanical waterflow devices had occurred, since 1/13/2026. Interview with the Director of Facilities on July 7, 2026, at 10:51 AM, confirmed the lack of documentation verifying inspections of mechanical waterflow devices had occurred, since 1/13/2026. 2. Observation on July 8, 2026, at 9:36 AM, revealed the suspended ceiling of the Zone 1 Closet, within the Salon, had been removed, leaving a pendant sprinkler head suspended in the void left, after the removal of the ceiling. Interview with the Director of Facilities on July 8, 2026, at 9:36 AM, confirmed the removal of the suspended ceiling, in which a sprinkler head was installed.

Plan of Correction - To be completed: 08/05/2026

353: Sprinkler System - Maintenance and Testing:

The facility failed to provide documentation verifying quarterly inspections of mechanical waterflow devices had occurred within the previous twelve months, and to maintain the automatic sprinkler system in a continuously reliable operating condition, which serves the entire component.

No residents were affected.

All residents have the potential to be affected.

Certified Sprinkler Vendor completed inspection of the water flow devices and supervisor switches on 10JUL2026.

Facility wide visual audit of the facilities mechanical waterflow devices was completed by the Maintenance Director and documented on 17JUL2026 per regulatory requirements.

The open area in the suspended ceiling of the salon was repaired by the Maintenance Director/designee on 21JUL2026.

On 21JUL2026, NHA educated the Maintenance Director on the importance of maintaining documentation per regulatory requirements.

The Maintenance Director/Designee will conduct compliance audits weekly x4 weeks then monthly x2 months, to ensure that documentation for mechanical waterflow devices meet the regulatory requirement.

The Maintenance Director/Designee will conduct compliance audits weekly x4 weeks to ensure that there are no open areas in walls, then monthly x2 months and quarterly x 4 quarters.

NHA/Designee will audit quarterly Life Safety Binder with Maintenance Director to ensure compliance.

Results will be submitted to quarterly Quality Assurance Performance Improvement Committee for review and recommendations.

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: SOUTH - Component: 02 - Tag: 0355 Based on observation and interview, it was determined the facility failed to maintain portable fire extinguisher locality indicating signage, affecting one of seven smoke compartments within the component. Findings include: 1. Observation on July 8, 2026, at 9:45 AM, revealed the Zone 1 portable fire extinguisher, located beside the Laundry Chemical Room, was installed within a flush-mounted cabinet and lacked locality indicating signage. Interview with the Director of Facilities on July 8, 2026, at 9:45 AM, confirmed the lack of portable fire extinguisher locality indicating signage.

Plan of Correction - To be completed: 08/05/2026

0355: Portable Fire Extinguishers:

The facility failed to maintain portable fire extinguisher locality indicating signage, affecting one of seven smoke compartments within the component

No residents were affected.

All residents have the potential to be affected.

Signage to be installed by the Maintenance Director/designee near the Laundry Chemical Room to identify the portable fire extinguisher by 05AUG2026.

Maintenance Director/Designee completed an audit of all portable fire extinguishers in the facility on 09JUL2026 to ensure proper identifying signage.

On 21JUL2026, NHA educated the Maintenance Director and maintenance department on the importance of maintaining proper identifying signage for portable fire extinguishers per regulatory requirements.

The Maintenance Director/Designee will conduct compliance audits weekly x4 weeks then monthly x 2 months to ensure fire extinguisher signage meets the regulatory requirement.

Results will be submitted to the quarterly Quality Assurance Performance Improvement Committee for review and recommendations.

NFPA 101 STANDARD Corridor - Doors:

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

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

Observations:
Name: SOUTH - Component: 02 - Tag: 0363 Based on observation and interview, it was determined the facility failed to maintain the positive latching of corridor doors, affecting two of seven smoke compartments within the component. Findings include: 1. Observation on July 7, 2026, between 12:40 PM and 1:15 PM, revealed the following corridor doors did not positively latch within their respective door frames: a. 12:40 PM, Zone 6, door to Employee Lounge. Latching hardware had been removed; b. 1:15 PM, Zone 4, door to Housekeeping Closet across from the elevators. Paper towel had been placed within the door frame strike plate. Interview with the Director of Facilities on July 7, 2026, at 1:15 PM, confirmed the corridor doors did not positively latch within their respective door frames.

Plan of Correction - To be completed: 08/05/2026

0363: Corridor - Doors:

The facility failed to maintain the positive latching of corridor doors, affecting two of seven smoke compartments within the component

No residents were affected.

All residents have the potential to be affected.

The hardware was replaced to the door opening to the Employee lounge by the Director of Maintenance.

A whole house audit was completed by the Director of Maintenance/designee on 17JUL2026 to ensure all door strike plates are free from obstruction and close without impairment.

An audit of the facility's remaining resident corridor doors was completed on 17JUL2026 by the Director of Maintenance/designee to ensure that all doors meet the regulatory requirement for latching hardware.

On 21JUL2026, NHA educated Director of Maintenance and maintenance staff on maintaining corridor doors to meet the requirement of smoke tight integrity and latch properly.

The Maintenance Director/Designee will conduct monthly random audits of corridor doors to check function and integrity.

NHA/Designee will audit quarterly Life Safety Binder with Maintenance Director to ensure compliance.

Results will be submitted to the quarterly Quality Assurance Performance Improvement Committee for review and recommendations.

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: SOUTH - Component: 02 - Tag: 0372 Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of smoke barrier doors, affecting two of seven smoke compartments within the component. Findings include: 1. Observation on July 7, 2026, at 12:20 PM, revealed the cross-corridor smoke barrier door, by Resident Room 321, was binding with the floor and did not automatically close after release from a magnetic hold-open device. Interview with the Director of Facilities on July 7, 2026, at 12:20 PM, confirmed the compromised smoke resistance of the smoke barrier door.

Plan of Correction - To be completed: 08/05/2026

0372: Subdivision of Building Spaces - Smoke Barrier:

The facility failed to maintain the smoke resistance of smoke barrier doors, affecting two of seven smoke compartments within the component.

No residents were affected.

All residents have the potential to be affected.

The cross-corridor smoke barrier door, near Resident Room 321, was adjusted on 08JUL2026 to latch and release from the magnetic hold-open device by the Maintenance Director/designee as designed.

Maintenance Director/designee audited all smoke barrier doors on 10JUL2026 to ensure proper latch and release function per regulatory requirements.

On 21JUL2026, NHA educated Director of Maintenance and maintenance staff on maintaining corridor doors to meet the requirement of smoke tight integrity and latch properly.

The Maintenance Director/Designee will conduct audit monthly x 3, of corridor doors to check function and integrity. The audits will continue Quarterly.

NHA/Designee will audit quarterly Life Safety Binder with Maintenance Director to ensure compliance.

Results will be submitted to the quarterly Quality Assurance Performance Improvement Committee for review and recommendations.

NFPA 101 STANDARD Electrical Systems - Maintenance and Testing:

Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)

Observations:
Name: SOUTH - Component: 02 - Tag: 0914 Based on document review and interview, it was determined the facility failed to provide documentation verifying non-hospital grade electrical receptacles had been inspected, in seven of seven smoke zones within the component. Findings include: 1. Review of documentation on July 7, 2026, at 11:35 AM, revealed the facility failed to provide documentation verifying non-hospital grade electrical receptacles had been inspected, within the previous twelve months. Interview with the Director of Facilities on July 7, 2026, at 11:35 AM, confirmed the lack of documentation provide documentation verifying non-hospital grade electrical receptacles had been inspected, within the previous twelve months.

Plan of Correction - To be completed: 08/05/2026

0914: Electrical Systems - Maintenance and Testing:

The facility failed to provide documentation verifying non-hospital grade electrical receptacles had been inspected, in seven of seven smoke zones within the component.

No residents were affected.

All residents have the potential to be affected.

Facility wide audit to be completed by the Maintenance Director/Designee by 05AUG2026 to ensure that all receptacles are operating properly and documented.

On 21JUL2026, NHA educated the Maintenance Director on the importance of maintaining documentation per regulatory requirements.

The Maintenance Director/Designee will conduct compliance audits monthly x 3 weeks then annually, to ensure that documentation for electrical receptacle inspection meet the requirement per regulation.

NHA/Designee will audit quarterly Life Safety Binder with Maintenance Director to ensure compliance.

Results will be submitted to quarterly to the Quality Assurance Performance Improvement Committee for review and recommendations.

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: SOUTH - Component: 02 - Tag: 0918 Based on document review and interview, it was determined the facility failed to provide documentation verifying a four-hour exercise, under load, of the emergency generator had occurred, within the previous 36 months, and to provide documentation verifying the quality of the diesel fuel servicing the emergency generator had been tested, which serves the entire component. Findings include: 1. Review of documentation on July 7, 2026, at 11:02 AM, revealed the facility failed to provide documentation verifying a continuous four-hour exercise, under load, of the emergency generator had occurred, since September, 2022. Interview with the Director of Maintenance on July 7, 2026, at 11:02, confirmed the lack of documentation verifying a continuous four-hour exercise, under load, of the emergency generator had occurred, since September, 2022. 2. Review of documentation on July 7, 2026, at 11:09 AM, revealed the facility failed to provide documentation verifying the quality of the diesel fuel servicing the emergency generator had been tested, within the previous twelve months. Interview with the Director of Facilities on July 7, 2026, at 11:09 AM, confirmed the lack of documentation verifying the quality of the diesel fuel servicing the emergency generator had been tested, within the previous twelve months.

Plan of Correction - To be completed: 08/05/2026

0918: Electrical Systems - Essential Electric System:

The facility failed to provide documentation verifying a four-hour exercise, under load, of the emergency generator had occurred, within the previous 36 months, and to provide documentation verifying the quality of the diesel fuel servicing the emergency generator had been tested.

No residents were affected.

All residents have the potential to be affected.

A four-hour exercise, under load, of the emergency generator was performed per regulation and documented by the Maintenance Director on 15JUL2026.

Diesel fuel servicing the generator was tested and documented per regulatory requirements on 15JUL2026 by the Maintenance Director.

On 21JUL2026, NHA educated the Maintenance Director on the importance of performing required generator testing every 36 months and diesel fuel testing monthly, while maintaining documentation per regulatory requirements.

The Maintenance Director/Designee will conduct compliance audits monthly, to ensure that documentation for generator testing and diesel fuel testing meet the regulatory requirement.

NHA/Designee will audit annually Life Safety Binder with Maintenance Director to ensure compliance.

Results will be submitted to the quarterly Quality Assurance Performance Improvement Committee for review and recommendations.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: SOUTH - Component: 02 - Tag: 0920 Based on observation and interview, it was determined the facility failed to monitor the use of extension cords and surge suppressors within the facility, affecting two of seven smoke compartments within the component. Findings include: 1. Observation on July 7, 2026, at 1:11 PM, revealed an extension cord, running from a receptacle within the Zone 4 IT Room, behind the Nurses' Station, into the interstitial space above the suspended ceiling and down into the wall, separating the Dining Room from the IT Room. Interview with the Director of Facilities on July 7, 2026, at 1:11 PM, confirmed the extension cord traversed the interstitial space above the suspended ceiling, within the IT Room. 2. Observation on July 7, 2026, at 1:40 PM, revealed a surge suppressor, supplying electrical power to a microwave, within the Zone 2 Dialysis Room. Interview with the Director of Facilities on July 7, 2026, at 1:40 PM, confirmed the high draw appliance was plugged into a surge suppressor.

Plan of Correction - To be completed: 08/05/2026

920: Electrical Equipment - Power Cords and Extens:

The facility failed to monitor the use of extension cords and surge suppressors within the facility, affecting two of seven smoke compartments within the component.

No residents were affected.

All residents have the potential to be affected.

The extension cord was removed from the interstitial space, above the suspended ceiling, behind the nurse's station by the Maintenance Director and permanent electrical outlet put in place by 05AUG2026.

The surge suppressor was removed from the Dialysis room by the maintenance director on 08JUL2026.

Maintenance Director/Designee completed an audit 08JUL2026 to ensure that no unauthorized surge protectors or extension cords in use.

On 21JUL2026, NHA educated the Maintenance Director and maintenance team on the importance of ensuring safe usage of extension cords and surge suppressors per regulatory requirements.

The Maintenance Director/Designee will conduct compliance audits monthly x 12 months, to ensure the facility meets regulatory requirements.

NHA/Designee will audit quarterly Life Safety Binder with Maintenance Director to ensure compliance.

Results will be submitted to the quarterly Quality Assurance Performance Improvement Committee for review and recommendations.

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