Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT CAMPBELLTOWN
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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KADIMA REHABILITATION & NURSING AT CAMPBELLTOWN - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Based on an Emergency Preparedness Survey completed on June 25, 2025, it was determined that Kadima Rehabilitation & Nursing at Campbelltown had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:

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

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.

Observations:
Name: - Component: -- - Tag: 0004

Based on document review and interview, it was determined the facility failed to review and update the emergency preparedness program within the previous twelve months, affecting the entire component.

Findings include:

1. Review of documentation on June 25, 2025, at 1:30 PM, revealed the facility had not reviewed and updated the emergency preparedness program, annually.

Interview with the Administrator and Regional Facility Manager on June 25, 2025, at 1:30 PM, confirmed the emergency preparedness program had not been reviewed and updated, annually.

Plan of Correction - To be completed: 08/21/2025

1. The Emergency Preparedness Plan was reviewed and updated by the Administrator. Documentation was completed and filed.
2. All residents could be impacted if the plan is not kept current.
3. The annual review is now on the facility's compliance calendar for every July.
4. The Emergency Preparedness Committee will meet each year to ensure the plan is updated and complete. The Administrator will verify the annual review is completed and report to QAPI.

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000

Facility ID# 720502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 25, 2025, it was determined that Kadima Rehabilitation & Nursing at Campbelltown 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 one-story, Type V(111), protected wood frame structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0100

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on document review and interview, it was determined the following items did not meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component.

Findings include:

1. Review of documentation and interview on June 25, 2025, between 10:00 AM and 11:30 AM, revealed the facility life safety drawings lacked fire wall boundaries, smoke wall boundaries, hazardous areas, and compartment designation.

Interview with the Administrator and Regional Facility Manager on June 25, 2025, at 1:30 PM, confirmed the life safety drawings of the facility lacked required information.

2. Review of documentation and interview, on June 25, 2025, between 10:00 AM and 11:30 AM, revealed the facility lacked documentation of annual testing and inspection of installed Carbon Monoxide Alarms, per manufacturer's instructions, in accordance with the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act.

Interview with the Administrator and Regional Facility Manager on June 25, 2025, at 1:30 PM, confirmed the lack of documentation confirming annual inspections were not done, per manufacturer's instructions.

3. Review of documentation and interview, on June 25, 2025, between 10:00 AM and 11:30 AM, revealed the facility lacked documentation confirming installed carbon monoxide alarms could be heard by on duty staff, in accordance with the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act.

Interview with the Administrator and Regional Facility Manager on June 25, 2025, at 1:30 PM, confirmed the lack of documentation, verifying the carbon monoxide detectors could be heard by on duty staff.

4. Review of documentation on June 25, 2025, between 10:00 AM and 11:30 AM, revealed the facility lacked documentation verifying evacuation and alarm protocols in accordance with the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act.

Interview with the Administrator and Regional Facility Manager on June 25, 2025, at 1:30 PM, confirmed the lack of documentation of evacuation and alarm protocols.

Plan of Correction - To be completed: 08/21/2025

Drawings

1. Facility will revise life safety drawings. Updated drawings will include fire wall boundaries, smoke wall boundaries, hazardous areas, and compartment designations.
2. Updated life safety plans will be reviewed annually by the Administrator and Regional Facility Manager or designee for completeness.
3. Annual review of life safety plans to be added to the facility compliance calendar. Findings reported at QAPI

Carbon Monoxide Alarm Inspection

1. All carbon monoxide alarms were inspected by maintenance
2. Annual inspection schedule has been created and added to the preventive maintenance system.
3. Administrator will review documentation each year and sign off.
Verifying CO Alarms and Audible to Staff
1. Sound checks were completed on all installed alarms with staff stationed in all shifts.
2. Annual alarm audibility checks added to inspection protocol.
3. Maintenance Director will complete and document annually. Reviewed during QAPI.

Evacuation and Alarm Protocols for CO Alarms

1. Carbon monoxide alarm response and evacuation protocols have been updated and included in the Emergency Preparedness Plan.
2. Staff educated on CO-specific evacuation plans.
3. Fire drills and CO protocol drills conducted quarterly. Documentation reviewed by Administrator.

NFPA 101 STANDARD Means of Egress - General:

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.

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

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain the maximum force required to operate exit discharge doors, affecting one of four compartments within the component.

Findings include:

1. Observation on June 25, 2025, between 12:00 PM, revealed the exit discharge door required a force of more than 30 pounds to set the door in motion, at the Main Kitchen back exterior door.

Interview with the Administrator and Regional Facility Manager on June 25, 2025, at 1:30 PM, confirmed the doors did not begin to swing with an applied force of 30 pounds.

Plan of Correction - To be completed: 08/21/2025

1. Door will be adjusted by maintenance to meet the required force limit.

2. All other exit doors were checked and will be within compliance.

3. Monthly checks by maintenance. Results reviewed in Safety Committee meetings.

NFPA 101 STANDARD Emergency Lighting:

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.

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 - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to inspect and test the battery-powered emergency lighting sources, affecting the entire component.

Findings include:

1. Review of documentation on June 25, 2025, between 10:00 AM and 11:30 AM, revealed the facility failed to perform monthly and annual testing of the battery-powered emergency lighting, in the last 12 months.

Interview with the Administrator and Regional Facility Manager on June 25, 2025, at 1:30 PM, confirmed the lack of installed back-up emergency lighting testing.

Plan of Correction - To be completed: 08/21/2025

1.All battery-powered emergency lighting throughout the facility tested results were documented and placed on file.

2.Maintenance staff received re-education on CMS and NFPA requirements for monthly 30-second functional tests and annual 90-minute full-duration tests.

3.A tracking log was implemented. The Administrator or designee will verify monthly and annual testing is completed and documented as required.

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 - Component: 01 - Tag: 0293

Based on document review and interview, it was determined the facility failed to provide documentation verifying exit signs had been subjected to monthly inspections, affecting the entire component.

Findings include:

1. Review of documentation on June 25, 2025, between 10:00 AM and 11:30 AM, revealed the facility failed to provide documentation verifying exit signs had been visually inspected for one full year.

Interview with the Administrator and Regional Facility Manager on June 25, 2025, at 1:30 PM, confirmed the facility could not provide documentation of the monthhly exit sign inspections.

Plan of Correction - To be completed: 08/21/2025

1. All exit signs will be inspected, and findings documented.

2. Monthly visual inspections added to the facility's maintenance checklist.

3. Administrator to audit inspection log quarterly for compliance.

NFPA 101 STANDARD Cooking Facilities:

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

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0324

Based on document review and interview, it was determined the facility failed to provide documentation of the semi-annual hood cleanings, owner's quick checks, and semi-annual testing of the fixed chemical fire suppression system, in one of four smoke zones within the component.

Findings include:

1. Review of documentation on June 25, 2025, between 10:00 AM and 11:30 AM, revealed the facility lacked documentation of owner's quick check of the fixed chemical fire suppression system, installed in the Kitchen.

Interview with the Administrator and Regional Facility Manager on June 25, 2025, at 1:30 PM, confirmed the facility failed to provide documentation of owner's quick checks, on the Kitchen's fixed chemical fire suppression system.

2. Review of documentation on June 25, 2025, between 10:00 AM and 11:30 AM, revealed the facility could not provide documentation verifying the Kitchen exhaust ductwork had been cleaned on a semi-annual basis. Documentation verified last cycle was completed on 9/10/2024.

Interview with the Administrator and Regional Facility Manager on June 25, 2025, at 1:30 PM, confirmed the facility could not provide Kitchen ductwork had been cleaned, semi-annually.

3. Review of documentation on June 25, 2025, between 10:00 AM and 11:30 AM, revealed the facility could not provide documentation verifying the Kitchen's fixed chemical fire suppression system had been tested/maintained, semi-annually.

Interview with the Administrator and Regional Facility Manager on June 25, 2025, at 1:30 PM, confirmed the facility could not provide one full year of semi-annual suppression system documentation.

Plan of Correction - To be completed: 08/21/2025

1. The Facility Maintenance Director completed and documented an Owner's Quick Check of the fixed chemical fire suppression system.

2. The Facility Maintenance Director was re-educated on NFPA 17A requirements regarding monthly Owner's Quick Checks, including documentation, dating, and verification. A monthly checklist log was created and implemented to document each Owner's Quick Check.

3. The Maintenance Director or designee will audit completion of the Owner's Quick Check and log entry monthly for 6 months, reporting compliance to the Quality Assurance and Performance Improvement (QAPI) Committee.

Hood/Ductwork Cleaning
1. Service provider contacted to clean kitchen exhaust.
2. The Administrator will maintain a schedule and invoice of future cleanings to ensure no lapses occur and documentation is provided.
3. The Administrator or designee will verify future scheduled cleanings are completed and documented every six months. This will be reviewed during quarterly Life Safety audits and reported at QAPI meetings.

Semi Annual Testing of fixed chemical Fire Suppression

1. An inspection of the kitchen suppression system will be conducted.
2. Moving forward, with auto-scheduling in place as provider allows.
3. The Administrator or designee will verify completion of semi-annual inspections via documentation, to be reviewed during the facility's quarterly compliance review. Reports will be submitted to QAPI for 3 consecutive cycles.

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 - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to provide documentation,verifying that semi-annual and annual inspection/testing was performed, affecting the entire component.

Findings include:

1. Review of documentation on June 25, 2025, between 10:00 AM and 11:30 AM, revealed the facility failed to provide documentation verifying the semi-annual visual inspection and the annual test of the fire alarm system had occurred within the previous twelve months.

Interview with the Administrator and Regional Facility Manager on June 25, 2025, at 1:30 PM, confirmed facility lacked documentation verifying semi-annual visual inspection and annual testing of the fire alarm system.

Plan of Correction - To be completed: 08/21/2025

1. Fire protection testing of the fire alarm system will be completed.
2. The Administrator and Maintenance Director reviewed NFPA 72 requirements and received education regarding inspection and testing schedules for the facility's fire alarm system. A Life Safety Compliance Calendar has been implemented to track all recurring inspection and testing deadlines, including semi-annual and annual fire alarm system requirements.
3. The Administrator or designee will verify that semi-annual and annual inspections are scheduled, completed, and documented Copies of inspection reports will be reviewed during quarterly Quality Assurance and Performance Improvement (QAPI) meetings for six months to ensure continued compliance.

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 - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to provide the quarterly, semi-annual, annual, 3-year, and 5-year sprinkler maintenance documentation for the wet and dry sprinkler systems, affecting the entire component.

Findings include:

1. Review of documentation on June 25, 2025, between 10:30 AM and 10:40 AM, revealed the facility lacked documentation, for the following:

a. 10:30 AM. wet system, semi-annual, Valve Supervisory Switches and Pressure Switch Waterflow Alarm;
b. 10:33 AM, 1st, 2nd, 3rd and 4th quarterly wet/dry inspections;
c. 10:35 AM, annual, wet, main drain/control valve test;
d. 10:37 AM, 3-year dry system, full trip test;
e. 10:38 AM, 5-year gauge calibration/replacement;
f. 10:40 AM, 5- year internal valve/pipe inspection.

Interview with the Administrator and Regional Facility Manager on June 25, 2025, at 1:30 PM, confirmed the facility lacked documentation of the required testing of the facility's installed sprinkler systems.

Plan of Correction - To be completed: 08/21/2025

1.The facility contacted the fire safety contractor to obtain and review all required sprinkler system maintenance reports (quarterly, semi-annual, annual, 3-year, and 5-year). Missing documentation has been requested or scheduled for immediate completion.

2.The Maintenance Director was re-educated on the required sprinkler system inspection intervals and documentation retention per NFPA 25 standards.

3.A compliance calendar and binder have been implemented to track due dates and store all sprinkler system inspection records. The Administrator will audit the binder quarterly.

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 - Component: 01 - Tag: 0355

Based on document review and interview, it was determined the facility failed to provide one full year of monthly inspections, and the Fire Extinguisher Technician Certificate, affecting three of three smoke zones within the component.

Findings include:

1. Review of documentation on June 25, 2025, between 10:00 AM and 11:30 AM, revealed the facility lacked documentation of one full year of monthly inspections being completed. Facility lacked documentation of monthly inspection from 6/24 to 10/24.

Interview with the Administrator and Regional Facility Manager on June 25, 2025, at 1:30 PM, confirmed the facility lacked documentation of one full year of monthly inspections.

2. Review of documentation on June 25, 2025, between 10:00 AM and 11:30 AM, revealed the facility lacked documentation of the annual inspection being completed, by a Certified Fire Extinguisher Inspector.

Interview with the Administrator and Regional Facility Manager on June 25, 2025, at 1:30 PM, confirmed the facility could not provide a current certificate for the Certified Fire Extinguisher Inspector.

Plan of Correction - To be completed: 08/21/2025

1.The facility contacted the fire extinguisher service vendor to complete any missing monthly inspections and provide the technician's certification.

2.The Maintenance Director was re-educated on the monthly inspection requirements and the need to maintain updated technician certification documentation on file.

3. A monthly checklist and log have been implemented. The Administrator or designee will review the log quarterly to ensure compliance and documentation is maintained.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain the smoke barrier doors, affecting two of three smoke compartments within the component.

Findings include:

1. Observation on June 25, 2025, between 12:05 PM and 12:17 PM, revealed double smoke barrier doors, with latching hardware, did not latch at the following locations:

a. 12:05 PM, main hall, main Kitchen door, left leaf, lacked a coordinator;
b. 12:15 PM, main hall, dining room, left leaf, faulty coordinator.
a. 12:17 PM, main hall, community room, left leaf, faulty coordinator;

Interview with the Administrator and Regional Facility Manager on June 25, 2025, at 1:30 PM, confirmed the doors did not positively latch in frame.

2. Observation on June 25, 2025, at 12:35 PM, revealed the smoke barrier door closest to Resident Room 25 failed to open, due faulty panic hardware.

Interview with the Administrator and Regional Facility Manager on June 25, 2025, at 1:30 PM, confirmed the door failed to open.

Plan of Correction - To be completed: 08/21/2025

1. Faulty or missing door coordinators will be repaired or replaced, and all doors were re-tested to ensure positive latching when closed.
2. The Maintenance Director was re-educated on NFPA 101, which requires fire and smoke barrier doors to positively latch.
3. A quarterly smoke/fire door inspection log has been implemented and will be maintained by the Maintenance Department.
4. The Administrator or designee will conduct quarterly visual inspections of all smoke barrier doors for proper function and latching, with results reviewed during QAPI meetings for 3 months.

NFPA 101 STANDARD Fire Drills:

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to perform fire drills (one per shift, per quarter), which affects the entire component.

Findings include:

1. Review of documentation on June 25, 2025, between 10:00 AM and 11:30 AM, revealed the facility did not perform fire drills, during the following:

a. 1st quarter 2025, 1st, 2nd and 3rd shift;
b. 2nd quarter 2024, 1st and 2nd shift;
c. 3rd quarter 2024, 1st shift;
d. 4th quarter 2024, 1st shift.

Interview with the Administrator and Regional Facility Manager on June 25, 2025, at 1:30 PM, confirmed the lack of documentation, verifying fire drills were not performed.

Plan of Correction - To be completed: 08/21/2025

1. Fire drills will be completed on all three shifts. Staff on all shifts received refresher training on fire drill procedures and emergency response.
2. A Fire Drill Compliance Log has been created to track and document.
3. Maintenance Director will be re educated on fire drill regulations.
4. The Administrator or designee will review the completed Fire Drill Log each month to ensure compliance with quarterly shift requirements. Drill documentation will be reviewed during monthly QAPI meetings for one year to ensure no further lapses.

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 - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to provide documentation of the annual fire door inspection, in four of four smoke compartments within the component.

Findings include:

1. Review of documentation on June 25, 2025, between 10:00 AM and 11:30 AM, revealed the facility lacked documentation of the annual fire-rated door inspection.

Interview with the Administrator and Regional Facility Manager on June 25, 2025, at 1:30 PM, confirmed the facility could not provide documentation verifying the annual fire door inspection.

Plan of Correction - To be completed: 08/21/2025

1. A comprehensive annual inspection of all fire-rated doors will be completed.

2. The Maintenance Director and Administrator received training on the importance of timely fire door inspections per NFPA 80 and NFPA 101 standards.

3. The Administrator or designee will review inspection documentation annually to verify compliance. Documentation and compliance status will be reviewed quarterly during Quality Assurance and Performance Improvement (QAPI) meetings.

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: MAIN BUILDING - Component: 01 - Tag: 0914

Based on document review and interview, it was determined the facility failed to inspect all electrical receptacles in resident care areas, affecting the entire component.

Findings include:

1. Review of documentation on June 25, 2025, between 10:00 AM and 11:30 AM, revealed the facility failed to test electrical receptacles in the last 12 months.

Interview with the Administrator and Regional Facility Manager on June 25, 2025, at 1:30 PM, confirmed the receptacles were not tested in the last 12 months.

Plan of Correction - To be completed: 08/21/2025

1. All electrical receptacles in resident care areas will be tested. Any identified issues were corrected, and testing was documented.

2.The Maintenance Director was re-educated on the annual requirement for testing electrical receptacles in accordance with NFPA and CMS guidelines.

3.A log was created to track annual receptacle testing. The Administrator or designee will review compliance quarterly to ensure ongoing adherence.

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 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to provide required maintenance and testing documentation for the emergency generator, which serves the entire component.

Findings include:

1. Review of documentation on June 25, 2025, between 10:00 AM and 11:30 AM, revealed the facility lacked documentation, for the following:

a. 9:30 AM, one full year, weekly maintenance;
b. 9:33 AM, one full year, monthly maintenance, 30-minute load w/transfer switch.

Interview with the Administrator and Regional Facility Manager on June 25, 2025, at 1:30 PM, confirmed the lack of documentation for emergency generator.

Plan of Correction - To be completed: 08/21/2025

1.Facility cannot retroactively correct deficient practice. Generator service vendor contacted to verify and supply any missing reports.

2.All residents had the potential to be affected. No generator failures occurred during the review period.

3.Maintenance staff re-educated on required documentation and testing per NFPA 110 and CMS requirements. A new tracking log has been implemented for weekly and monthly generator testing. Results to be reviewed at quarterly QAPI meetings.

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