Pennsylvania Department of Health
VALLEY MANOR REHABILITATION AND HEALTHCARE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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VALLEY MANOR REHABILITATION AND HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on a Revisit to an Emergency Preparedness Survey completed on March 12, 2025, it
was determined Valley Manor Rehabilitation And Healthcare Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(d), 416.54(d), 418.113(d), 441.184(d), 482.15(d), 483.475(d), 483.73(d), 484.102(d), 485.542(d), 485.625(d), 485.68(d), 485.727(d), 485.920(d), 486.360(d), 491.12(d), 494.62(d) STANDARD EP Training and Testing:

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.

§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.

*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).

*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.

Observations:
Name: - Component: -- - Tag: 0036

Based on documentation review and interview, it was determined the facility failed to provide documentation of the development and maintenance of emergency preparedness training program that is based on the emergency plan, risk assessment, policies and procedures, and the communication plan.

Findings include

1. Document review on March 12, 2025, at 3:15 p.m., revealed the facility failed to provide documentation of an emergency preparedness training program based on the Emergency Preparedness Plan, and to include initial and annual training of all staff.

Exit interview with the Administrator, Director of Maintenance and Assistant on March 12, 2025, at 3:15 p.m., confirmed the facility failed to develop an Emergency Preparedness Plan to include a training program.

****************************************

Based on an onsite Revisit conducted on May 8, 2025, the following was determined:

Item 1 - Not Completed. Documentation of an emergency preparedness training program based on the Emergency Preparedness Plan, and to include initial and annual training of all staff was not available.

Exit Interview with the Director of Maintenance on May 8, 2025, at 11:30 a.m., confirmed the facility failed to develop an Emergency Preparedness Plan to include a training program.

Plan of Correction - To be completed: 05/23/2025

Facility does complete initial and annual training to staff on the emergency training program.

Facility will update the EPM policy to include staff are trained initially and annual.

Facility will complete and maintain records of required annual training on the facility disaster plan.

Facility will conduct an audit of education records to ensure staff are trained initially and at least annually thereafter. Audit will be conducted monthly x 4 months, then quarterly x4 months. All results will be reviewed by the QAPI Committee.

403.748(d)(1), 416.54(d)(1), 418.113(d)(1), 441.184(d)(1), 482.15(d)(1), 483.475(d)(1), 483.73(d)(1), 484.102(d)(1), 485.542(d)(1), 485.625(d)(1), 485.68(d)(1), 485.727(d)(1), 485.920(d)(1), 486.360(d)(1), 491.12(d)(1) STANDARD EP Training Program:

§403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:]
(1) Training program. The [facility] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures.

*[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least every 2 years.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.
(v) Maintain documentation of all emergency preparedness training.
(vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and
procedures.

*[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures.

*[For PACE at §460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures.

*[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.

*[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.
(v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures.

*[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures.

*[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.

Observations:
Name: - Component: -- - Tag: 0037

Based on document review and interview, it was determined that the facility failed to provide documentation of initial and annual Emergency Preparedness training for staff and individuals providing services to the facility including volunteers, in one of one facility.

Findings include:

1. Document review on March 12, 2025, at 3:15 p.m., revealed the facility failed to provide the maintained annual documentation of Emergency Preparedness training of staff members demonstrating their knowledge of emergency procedures.

Exit interview with the Administrator, Director of Maintenance and Assistant on March 12, 2025, at 3:15 p.m., confirmed the facility failed to to provide annual records of employee training.

****************************************

Based on an onsite Revisit conducted on May 8, 2025, the following was determined:

Item 1 - Not Completed. The facility failed to provide the maintained annual documentation of Emergency Preparedness training of staff members demonstrating their knowledge of emergency procedures.

Exit Interview with the Director of Maintenance on May 8, 2025, at 11:30 a.m., confirmed the facility failed to to provide annual records of employee training.

Plan of Correction - To be completed: 05/23/2025

Facility does complete initial and annual training to staff on the emergency training program.

Facility will complete and maintain records of required annual training on the facility disaster plan.

Facility will conduct an audit of education records to ensure staff are trained initially and at least annually thereafter. Audit will be conducted monthly x 4 months, then quarterly x4 months. All results will be reviewed by the QAPI Committee

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:

§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).

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

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

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

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

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

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

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

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

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

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

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

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

Observations:
Name: - Component: -- - Tag: 0039

Based on document review and interview, it was determined the facility failed to conduct the required annual-full scale exercise and additional exercise to test the emergency preparedness plan, affecting the entire facility.

Findings include:

1. Document review on March 12, 2025, at 3:15 p.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, Director of Maintenance, and assistant on March 12, 2025, at 3:15 p.m., confirmed the lack of documentation.

****************************************

Based on an onsite Revisit conducted on May 8, 2025, the following was determined:

Item 1 - Not Completed. 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 Director of Maintenance on May 8, 2025, at 11:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 05/23/2025

Facility conducted a tabletop exercise on an active shooter event and will conduct an additional exercise to test the emergency preparedness plan.

The Director of maintenance will create a schedule to have tabletop exercises annually.

Facility will conduct an audit of table top and additional exercises of the emergency preparedness plan. Audit will be conducted monthly x 4 months, then quarterly x4 months. All results will be reviewed by the QAPI Committee.

Initial comments:Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0000

Facility ID# 480202
Component 01
Main Building (North & South Wings)

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on March 12, 2025, it was determined that Valley Manor Rehabilitation And Healthcare Center was not in substantial 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 one-story, Type V (000), unprotected wood frame building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Egress Doors:

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

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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0222

Based on observation and interview, it was determined the facility failed to maintain exit egress doors equipped with delayed egress locking arrangements, affecting two of four smoke compartments..

Findings include:

Observation on March 12, 2025, at the following time and locations, revealed the exit door equipped with delayed egress locking arrangements did not release after 15 seconds of applying pressure against the crash bar.

a) 1:35 p.m., on the first floor, door # EM-1 Next to basement stairwell.
b) 2:15 p.m., on the first floor, door # E4 - Dining room.

Exit interview with the Administrator, Director of Maintenance, and Assistant on March 12, 2025, at 3:15 p.m., confirmed the doors did not release after 15 seconds of pressure against the crash bar.

******************************************

Based on an onsite Revisit conducted on May 8, 2025, the following was determined:

Items a and b - Not Completed. The exit door equipped with delayed egress locking arrangements did not release after 15 seconds of applying pressure against the crash bar.

a) 1:35 p.m., on the first floor, door # EM-1 Next to basement stairwell.
b) 2:15 p.m., on the first floor, door # E4 - Dining room.

Exit Interview with the Director of Maintenance on May 8, 2025, at 11:30 a.m., confirmed the doors did not release after 15 seconds of pressure against the bar.

Plan of Correction - To be completed: 05/23/2025

Facility will submit a request for a TLW for items K222-A and K222-B.

The electrician came out and looked at the door and recommended getting a new door because the door is bent and preventing delayed egress.

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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0291

Based on observation, interview, and review of documentation, it was determined the facility failed to maintain that Emergency lighting of at least 1-1/2-hour duration was tested and inspected on one of two levels within this facility.

Findings include:

1. Review of documentation on March 12, 2025, between 9:15 a.m. and 12:30 p.m., revealed the facility lacked documentation verifying emergency backup lights were tested monthly and a 90 minute test was performed annually.

Exit interview with the Administrator, Director of Maintenance and Assistant on March 12, 2025, at 3:15 p.m., confirmed the facility lacked documentation verifying emergency backup lighting was tested.

*****************************************

Based on an onsite Revisit conducted on May 8, 2025, the following was determined:

Item 1 - Not Completed. The Facility failed to complete a 90 minute test on the emergancy backup lights.

Exit Interview with the Director of Maintenance on May 8, 2025, at 11:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 05/23/2025

Maintenance Director has completed the required 90 min testing on the emergency backup lights in the facility.

Maintenance has been re-educated on the testing requirements of emergency backup lighting.

Facility will audit areas containing battery backup lighting and documentation to support the required annual testing is completed.

Maintenance will audit emergency back up lighting tests to ensure compliance is maintained. Audit will be conducted monthly x 4 months, then quarterly x4 months. All results will be reviewed by the QAPI Committee.

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: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed to ensure that exit signs were maintained, affecting one of two levels.

Findings include:

1. Observation made on March 12, 2025, at Great Room entrance from corridor, revealed that there were two exit signs ( One operable and another disabled ) that instructed conflicting instructions on nearest possible emergency exit through Great Room.

Exit interview with the Administrator, Director of Maintenance and Assistant on March 12, 2025, at 3:15 p.m., confirmed the disabled exit signage.

****************************************

Based on an onsite Revisit conducted on May 8, 2025, the following was determined:

Item 1 - Not Completed. The exit sign was installed at the Great Room entrance but it was not able to illuminate at the time of revisit inspection.

Exit Interview with the Director of Maintenance on May 8, 2025, at 11:30 a.m., confirmed the exit sign failed to illuminate.

Plan of Correction - To be completed: 05/23/2025

Maintenance Director repaired the exit sign at the Great Room; the sign does illuminate as required.

Maintenance has been re-educated on maintaining exit signs.

Maintenance director will conduct an audit of exit signs to verify they are maintained and illuminate as required.

Maintenance will audit exit signs to ensure they are properly maintained. Audit will be conducted monthly x 4 months, then quarterly x4 months. All results will be reviewed by the QAPI Committee.

NFPA 101 STANDARD Cooking Facilities:

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.

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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0324

Based on document review and interview, it was determined the facility failed to ensure the kitchen suppression system was inspected and serviced at required intervals, for one of two required inspections.
Findings include:
1. Document review on March 12, 2025, between 9:15 a.m. and 12:30 p.m., revealed the facility could not produce documentation showing that the kitchen suppression system had been tested and maintained twice in the prior year. Only Inspection report 1/17/25 was provided.
Exit interview with the Administrator, Director of Maintenance and Assistant on March 12, 2025, at 3:15 p.m., confirmed the missing documentation.

***************************************

Based on an onsite Revisit conducted on May 8, 2025, the following was determined:

Item 1 - Not Completed. The facility could not produce documentation showing that the kitchen suppression system had been tested and maintained twice in the prior year. Only Inspection report 1/17/25 was provided.
Exit Interview with the Director of Maintenance on May 8, 2025, at 11:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 05/23/2025

Facility contacted the vendor that performs the required testing of the Kitchen Suppression System. Vendor verified and sent the reports that the system was tested and maintained twice in the prior year. The system was tested/maintained by the vendor on 1.16.24 and 10.8.24. The system is also current on the required testing for 2025.
Maintenance Director was re-educated on maintaining reports of required testing on the kitchen suppression system.

Maintenance director will review binder of records for required testing to ensure reports are maintained and up to date.

Maintenance will audit kitchen suppression system testing/maintenance documentation to ensure copies are maintained. Audit will be conducted monthly x 4 months, then quarterly x4 months. All results will be reviewed by the QAPI Committee.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to maintain fire alarm system components in operable condition, affecting the entire facility.
Findings include:
1. Documentation reviewed on March 12, 2025, between 9:15 a.m., and 12:30 p.m., revealed the fire alarm annual report dated 5/15/2024 listed the following:
a) The pull station at nurses station could not be tested due to no keys were available to reset;
b) The smoke detector sensitivity values documented on the device list (with the exception of the smoke detectors in the basement) were recorded during sensitivity testing.* Note: Customer needs to contact Simplex to acquire sensitivity values for the simplex smoke detectors in the basement;*
c) Zone 4 needs to be investigated to why detectors don't automatically reset.
Exit interview with the Administrator, Director of Maintenance and Assistant on March 12, 2025, at 3:15 p.m., confirmed the fire alarm deficiency had not been resolved.
2. Documentation reviewed on March 12, 2025, between 9:15 a.m., and 12:30 p.m., revealed the facility could not provide sensitivity testing on basement smoke detectors.
Exit interview with the Administrator, Director of Maintenance and Assistant on March 12, 2025, at 3:15 p.m., confirmed the lack of testing documentation.

***************************************

Based on an onsite Revisit conducted on May 8, 2025, the following was determined:

Item 1b, 1c and 2 - Not Completed. The above deficiencies remained during the time of the revisit.

Exit Interview with the Director of Maintenance on May 8, 2025, at 11:30 a.m., confirmed the lack of documentation.

All other deficiencies listed under this tag were corrected.

Plan of Correction - To be completed: 05/23/2025

Facility will submit a request for a TLW for items: K345-1b, K345-1c, and K345-2.

We have contracted with the fire alarm company to complete the required testing in the basement. Awaiting scheduled date from Vendor.

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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0353

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

Findings include:

1. Documentation reviewed on March 12, 2025, revealed the following:

a) Only record of two quarterly external water tank inspections dated 12/23/2024 and 5/15/2024 were provided.

b) Only record of two quarterly wet sprinkler inspections dated 12/23/2024 and 5/15/2024 were provided.

Exit interview with the Administrator, Director of Maintenance and Assistant on March 12, 2025, at 3:15 p.m., confirmed the missing report documentation.

2. Documentation reviewed on March 12, 2025, revealed the 4th quarter sprinkler inspection dated 12/23/2024 reported the following:

a) Sprinkler in Dietary needs to be replaced due to corrosion per the state inspector(2/09/23);

b) At the time of inspection the fire department connection. Hydro test has not been performed. This needs to be performed as soon as possible;

c) Could not flow water for main drain or ITV's due to temperatures in fire pump room being below 40 degrees (32 degrees) with temperatures in the area being extremely low it is unknown if temperature has been below freezing where wet sprinkler piping is located. With water flowing there is a risk of broken pipes if ice is present. This area of the sprinkler system is required to to always be above 40 degrees fahrenheit and needs to be corrected as soon as possible (12/23/24);

d) The customer needs to monitor the water level in the tank and keep it filled at all times;

e) A full visual inspection was preformed 1/18/24 due to freezing outside air temperatures. No water was flowed;

Exit interview with the Administrator, Director of Maintenance and Assistant on March 12, 2025, at 3:15 p.m., confirmed records of repairs and mandatory sprinkler external water tank level inspections had not occurred.

3). Observation made on March 12, 2025 at 12:55 p.m., revealed two sprinkler heads, inside the basement laundry chute room, were recessed into the ceiling, which could prevent immediate water spread.

Exit interview with the Administrator, Director of Maintenance and Assistant on March 12, 2025, at 3:15 p.m., confirmed the impeded sprinkler heads in the basement.

4) Observation made on March 12, 2025 at 1:00 p.m., revealed the fire alarm panel had a supervisory with description of: 11:27 am 3/12/25 - Water Tower Low Water M1-8.

Exit interview with the Administrator, Director of Maintenance and Assistant on March 12, 2025, at 3:15 p.m., confirmed the low water in water tower indicated from notification of monitoring equipment.

************************************

Based on an onsite Revisit conducted on May 8, 2025, the following was determined:

Item 1a, 2a, 2b, 2d, 2e - Not Completed. The above deficiencies remained during the time of the revisit.

Item 3 - Not Completed. Two sprinkler heads, inside the basement laundry chute room, were recessed into the ceiling, which could prevent immediate water spread.

Item 4 - Not Completed. The fire alarm panel had a supervisory with description of: 11:27 am 3/12/25 - Water Tower Low Water M1-8.

Exit Interview with the Director of Maintenance on May 8, 2025, at 11:30 a.m., confirmed the above listed deficiencies.

All other deficiencies listed under this tag were corrected.

Plan of Correction - To be completed: 05/23/2025

Facility will submit a request for a TLW for items: K353-2a, K353-2b, K353-3

K353-1a: Facility spoke with vendor that conducts Fire System testing and maintenance. They stated that they do complete a quarterly visual inspection of the Water Tank and need to maintain accurate documentation. The account manager is going to re-educate their technicians on proper documentation of the inspection.

K353-1a AND K353-2e: Facility will conduct and document a quarterly visual inspection of the water tank.

K353-2d AND K353-4: Maintenance will monitor fire panel for supervisory warning of low water level of the water tank.

Maintenance Director will be re-educated on conducting and maintaining proper documentation of required testing requirements of the sprinkler system.

Facility will conduct an audit to ensure required testing has been completed and testing reports have been maintained. Audit will be conducted monthly x 4 months, then quarterly x4 months. All results will be reviewed by the QAPI Committee.

Item1A- Yes
Item2A- The fire alarm vendor has come out and is sourcing the proper sprinkler head. Awaiting quote and schedule date.
Item2B-Signed quote. Awaiting schedule time, parts are on order.
Item2e- Fire alarm system company came out and reviewed sprinkler heads. Awaiting fire alarm system to schedule correction.
Item 4- Yes

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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0355

Based on documentation review and interview, it was determined the facility failed to maintain portable fire extinguishers, affecting 15 of 32 portable fire extinguishers.

Findings include:

1. Document review on March 12, 2025, between 9:15 a.m., and 12:30 p.m., revealed the facility provided documentation that an annual portable fire extinguisher inspection had been performed, on 1/17/25. Per report, 15 out of the 32 fire extinguishers needed to be replaced.

Exit interview with the Administrator, Director of Maintenance, and Assistant on March 12, 2025, at 3:15 p.m., confirmed the portable fire extinguishers have not been replaced at time of survey.

***********************************

Based on an onsite Revisit conducted on May 8, 2025, the following was determined:

Item 1 - Not Completed. The facility provided documentation that an annual portable fire extinguisher inspection had been performed, on 1/17/25. Per report, 15 out of the 32 fire extinguishers needed to be replaced. The Facility could not produce documentation that they were replaced.

Exit Interview with the Director of Maintenance on May 8, 2025, at 11:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 05/23/2025

Facility completed an audit of fire extinguishers to ensure they are properly maintained. Facility order replacement fire extinguishers and are scheduled to be delivered and put into service on May 22, 2025.
Maintenance Director has been re-educated on maintaining fire extinguishers within the facility.

Facility will conduct an audit of fire extinguishers are maintained properly. Audit will be conducted monthly x 4 months, then quarterly x4 months. All results will be reviewed by the QAPI Committee.

NFPA 101 STANDARD Smoking Regulations:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0741

Based on observation and interview, it was determined the facility failed to follow smoking regulations at one of one designated smoking area.

Findings include:

1. Observation on March 12, 2025, at 9:00 a.m., revealed the facility had an accumulation of cigarette butts inside the mulch beds, outside the resident room windows, along building's side driveway, outside the designated smoking area.

Exit interview with the Administrator, Director of Maintenance and Assistant on March 12, 2025, at 3:15 p.m., confirmed discarded cigarette buts can accumulate in described area..

*****************************************

Based on an onsite Revisit conducted on May 8, 2025, the following was determined:

Item 1 - Not Completed. The facility had an accumulation of cigarette butts inside the mulch beds, outside the resident room windows, along building's side driveway, outside the designated smoking area.

Exit Interview with the Director of Maintenance on May 8, 2025, at 11:30 a.m., confirmed the accumulation of cigarette butts outside of the designated smoking area.

Plan of Correction - To be completed: 05/23/2025

Facility staff re-cleared the mulch beds along the driveway side of the building.

Staff were re-educated on cigarette smoking area. There are appropriate ashtrays and appropriate metal self-closing device to empty the ashtrays.

Director of maintenance will audit grounds 1x a week for 2 weeks.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Observations:
Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to ensure that rated fire door assemblies were inspected and tested annually, affecting the entire facility.

Findings include:

1. Document review on March 12, 2025, between 9:15 a.m., and 12:30 p.m., revealed the facility could not provide documentation that rated fire door assemblies were inspected and tested within the previous 12 months.

Exit interview with the Administrator, Director of Maintenance and Assistant on March 12, 2025, at 3:15 p.m., confirmed the facility could not provide documentation that fire door assemblies were inspected and tested within the previous 12 months.

***************************************

Based on an onsite Revisit conducted on May 8, 2025, the following was determined:

Item 1 - Not Completed. The facility could not provide documentation that rated fire door assemblies were inspected and tested within the previous 12 months.

Exit Interview with the Director of Maintenance on May 8, 2025, at 11:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 05/23/2025

Maintenance will conduct the required testing and inspections of the fire rated door assemblies through out the facility.

Maintenance has been re-educated on inspecting and maintaining records of these inspections.

Facility will conduct an audit to ensure fire rated door assemblies are inspected and tested as required. Audit will be conducted monthly x 4 months, then quarterly x4 months. All results will be reviewed by the QAPI Committee.

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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0911

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

Findings include:

1. Observation made on March 12, 2025, at 12:38 p.m., in the basement, at the outdoor dock area, revealed there was a large central supply order stored, leaning on, and in front the main
electrical high voltage switch gear handles.

Exit interview with the Administrator, Director of Maintenance and Assistant on March 12, 2025, at 3:15 p.m., confirmed storage blocking and leaning on high voltage electrical controls.

2. Observation made on March 12, 2025, at 3:10 p.m., inside kitchen, revealed an exposed 3-wire electrical conduit, coming from ceiling, not terminated into appliance, with wire nuts,
electrical tape on three wires and hanging above the dishwasher drying rack discharge.

Exit interview with the Administrator, Director of Maintenance, and Assistant on March 12, 2025, at 3:15 p.m., confirmed the exposed three wire conduit in kitchen.

3. Observation at 2:30 p.m., revealed, on the first floor, the mechanical room, across from room 330, had janitorial equipment in front of electrical panels.

Exit interview with the Administrator, Director of Maintenance and Assistant on March 12, 2025, at 3:15 p.m., confirmed the janitorial equipment in front of electrical panels.

*************************************

Based on an onsite Revisit conducted on May 8, 2025, the following was determined:

Item 2 - Not Completed. The exposed electrical conduit was placed above the ceiling tile and not properly terminated into a junction box or appliance.

Exit Interview with the Director of Maintenance on May 8, 2025, at 11:30 a.m., confirmed the electrical deficiencies.

All other deficiencies listed under this tag were corrected.

Plan of Correction - To be completed: 05/23/2025

Maintenance director properly terminated the exposed wires into a junction box above the dishwasher drying rack.

Maintenance will audit the facility to ensure wires are not exposed and properly terminated.

Maintenance will conduct audits of facility to ensure wires are not exposed. Audit will be conducted monthly x 4 months, then quarterly x4 months. All results will be reviewed by the QAPI Committee.

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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0918

Based on observation and interview, it was determined the facility failed to maintain required emergency generator components, affecting the entire facility.

Findings include:

1. Observation made on March 12, 2025, at 12:45 p.m., revealed the emergency generator set (ATS) location, the electrical room in the basement , lacked battery back-up emergency lighting.

Exit interview with the Administrator, Director of Maintenance and Assistant on March 12, 2025, at 3:15 p.m., confirmed the back-up lighting was not installed.

***************************************

Based on an onsite Revisit conducted on May 8, 2025, the following was determined:

Item 1 - Not Completed. The Facility failed to install an emergency back-up light in the ATS location.

Exit Interview with the Director of Maintenance on May 8, 2025, at 11:30 a.m., confirmed the missing emergency lighting.

Plan of Correction - To be completed: 05/23/2025

Facility will submit a request for a TLW for item K918-1. The facility has contracted with an electrical vendor to install back up lighting at the generator set location and is currently awaiting parts to arrive and for scheduling availability.

NFPA 101 STANDARD Electrical Equipment - Testing and Maintenanc:

Electrical Equipment - Testing and Maintenance Requirements
The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training.
10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Observations:
Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0921

Based on documentation review and interview, it was determined the facility failed to maintain required inspections of electrical wiring and receptacle systems, affecting all resident bed locations.
Findings include:
1. Review of documentation on March 12, 2025, between 9:15 a.m., and 12:30 p.m., revealed the required annual inspection of receptacles in resident care areas was not performed.
Exit interview with the Administrator, Director of Maintenance and Assistant on March 12, 2025, at 3:15 p.m., confirmed the testing was not performed.

************************************

Based on an onsite Revisit conducted on May 8, 2025, the following was determined:

Item 1 - Not Completed. The facility failed to complete an inspection of receptacles in resident care areas.

Exit Interview with the Director of Maintenance on May 8, 2025, at 11:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 05/23/2025

Maintenance department will conduct the required annual electrical outlet testing.

Maintenance re-educated on conducting the annual electrical outlet testing and maintaining records of the testing.

Maintenance will conduct audits of electrical outlet testing records. Audit will be conducted monthly x 4 months, then quarterly x4 months. All results will be reviewed by the QAPI Committee.

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