Pennsylvania Department of Health
EMBASSY OF WYOMING VALLEY
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 40 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


EMBASSY OF WYOMING VALLEY - 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 March 25, 2025, it was determined that Embassy at Wyoming Valley had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(b)(6), 416.54(b)(5), 418.113(b)(4), 441.184(b)(6), 482.15(b)(6), 483.475(b)(6), 483.73(b)(6), 484.102(b)(5), 485.542(b)(6), 485.625(b)(6), 485.68(b)(4), 485.727(b)(4), 485.920(b)(5), 491.12(b)(4), 494.62(b)(5) STANDARD Policies/Procedures-Volunteers and Staffing:

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(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5).

[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]

(6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

*[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency.

*[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Observations:
Name: - Component: -- - Tag: 0024

Based on documentation review and interview, it was determined the facility failed to maintain volunteer certification or credentialing.

Findings include:

1. Observation on March 25, 2025, at 12:32 p.m., revealed the facility lacked a plan for use of volunteers in an emergency.

Exit interview with the Facility Administrator, Facilities Manager, and Facilities Director, on March 25, 2025, between 1:15 p.m., and 1:30 p.m., confirmed the above deficiency.

Plan of Correction - To be completed: 06/01/2025

The policy / plan for use of volunteers in an emergency was located and inserted into the disaster manual.
Staff were educated on the scope of the policy.
The administrator or designee will monitor compliance and report any issues to the facility QAPI.

403.748(b)(8), 416.54(b)(6), 418.113(b)(6)(C)(iv), 441.184(b)(8), 482.15(b)(8), 483.475(b)(8), 483.73(b)(8), 485.542(b)(7), 485.625(b)(8), 485.920(b)(7), 494.62(b)(7) STANDARD Roles Under a Waiver Declared by Secretary:

§403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7).

[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]

(8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

*[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Observations:
Name: - Component: -- - Tag: 0026

Based on documentation review and interview, it was determined the facility failed to include the role of the facility under a waiver declared by the Secretary of the Department of Health.

Findings include:

1. Observation on March 25, 2025, at 12:34 p.m., revealed the facility lacked 1135 waiver information within the Emergency Preparedness Plan.

Exit interview with the Facility Administrator, Facilities Manager, and Facilities Director on March 25, 2025, between 1:15 p.m., and 1:30 p.m., confirmed the above deficiency.

Plan of Correction - To be completed: 06/01/2025

The policy / plan for an 1135 Waiver was located and inserted into the disaster manual.
Staff were educated on the scope of the 1135 Waiver policy.
The administrator or designee will monitor compliance and report any issues to the facility QAPI.

403.748(c)(3), 416.54(c)(3), 418.113(c)(3), 441.184(c)(3), 482.15(c)(3), 483.475(c)(3), 483.73(c)(3), 484.102(c)(3), 485.542(c)(3), 485.625(c)(3), 485.68(c)(3), 485.727(c)(3), 485.920(c)(3), 486.360(c)(3), 491.12(c)(3), 494.62(c)(3) STANDARD Primary/Alternate Means for Communication:

§403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3).

[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:

(3) Primary and alternate means for communicating with the following:
(i) [Facility] staff.
(ii) Federal, State, tribal, regional, and local emergency management agencies.

*[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies.

Observations:
Name: - Component: -- - Tag: 0032

Based on documentation review and interview, it was determined the facility failed to address alternate means of communication.

Findings include:

1. Observation on March 25, 2025, at 12:42 p.m., revealed the facility lacked an alternate means of communication in the event of an emergency.

Exit interview with the Facility Administrator, Facilities Manager, and Facilities Director on March 25, 2025, between 1:15 p.m., and 1:30 p.m., confirmed the above deficiency.

Plan of Correction - To be completed: 06/01/2025

Walkie talkies (12) were purchased and delivered on 3/31/2025 (6) and 4/10/2025 (6).
Staff were educated on the proper use of the walkie talkies.
The administrator or designee will monitor proper use and compliance and report any issues to the facility QAPI.

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

Facility ID# 971402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 25, 2025, it was determined that Embassy of Wyoming Valley 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 three story, Type II (111), protected, noncombustible building, with rooftop mechanical spaces, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

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

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

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain one exit stair tower enclosure in two locations, affecting four of four floors.

Findings include:

1. Observation on March 25, 2025, between 10:46 a.m., and 10:49 a.m., revealed the following:

a. 10:46 a.m., an emergency electrical supply box was located within the third floor portion of the front stair tower enclosure.
b. 10:49 a.m., the fourth floor (penthouse-level) stair tower vestibule door label was painted and the required 1.5 hour, fire resistive nature of the door could not be determined.

Exit interview with the Facility Administrator, Facilities Manager, and Facilities Director on March 25, 2025, between 1:15 p.m., and 1:30 p.m., confirmed the stair tower deficiencies.

Plan of Correction - To be completed: 05/24/2025

On 4/4/2025, the emergency electrical box was removed from the stairwell.
On 4/5/2025 the tape (painted over) was removed from the fire label from the stair tower vestibule door.
The door has a 90 minute FRR.
Staff were educated on proper storage in stairwell as well as ensuring that door labels are not to be painted /covered.
The administrator or designee will monitor proper storage / compliance and report any issues to the facility QAPI.

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 - Component: 01 - Tag: 0291

Based on documentation review and interview, it was determined the facility failed to maintain emergency lighting, affecting three of three floors.

Findings include:

1. Observation on March 25, 2025, between 1:06 p.m., and 1:07 p.m., revealed the facility lacked the following:

a. 1:06 p.m., monthly emergency lighting, thirty-second testing data prior to 12/30/2024.
b. 1:07 p.m., annual ninety-minute bleed (or drain) testing data.

Exit interview with the Facility Administrator, Facilities Manager, and Facilities Director on March 25, 2025, between 1:15 p.m., and 1:30 p.m., confirmed the emergency lighting inspection deficiencies.

Plan of Correction - To be completed: 05/24/2025

On 4/7/2025 the 30 second and 90 minute tests were conducted and the emergency lighting fixture did pass.
Staff were educated on process and frequency of tests. The inspection schedule has been updated in TELS, the facility preventive maintenance program.
The administrator or designee will monitor proper inspection process, frequency and compliance and report any issues to the facility QAPI.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of three floors.

Findings include:

1. Observation on March 25, 2025, at 11:42 a.m., revealed the first floor Housekeeping Office door was held open by unapproved means (door chock).

Exit interview with the Facility Administrator, Facilities Manager, and Facilities Director on March 25, 2025, between 1:15 p.m., and 1:30 p.m., confirmed the hazardous area enclosure deficiency.

Plan of Correction - To be completed: 05/24/2025

The door chock was removed from under the housekeeping office door.
Staff were educated on importance of not utilizing unapproved means to hold doors open.
The administrator or designee will monitor compliance and report any issues to the facility QAPI.

NFPA 101 STANDARD Cooking Facilities:

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

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

Based on documentation review and interview, it was determined the facility failed to maintain cooking facilities in one instance, affecting one of three floors.

Findings include:

1. Observation on March 25, 2025, between 12:58 p.m., and 1:00 p.m., revealed the following:
a. 12:58 p.m., the facility lacked one of two required kitchen suppression system testing/maintenance reports (last inspection performed 9/11/24).
b. 1:00 p.m., the kitchen suppression inspection form, dated 9/11/2024, stated the following:
b1-The pull station is too high and requires to be recabled and lowered to proper height.
b2-the tension line conduit does not have a hood seal for going through the hood itself.
b3-there are only (2) link housings and should have (3) for proper protection and old housing and cable is corroded.
b4-the nozzles for ranges to be LPR for proper protection and for flattop griddle all surface pipe need to be lifted for proper protection.
b5-nozzles in plenum need to be installed in a different location for proper protection.
b6-both appliances have a back shelf that is 9 1/4 in over appliances. These need to be removed or nozzles adjusted for proper protection.

Exit interview with the Facility Administrator, Facilities Manager, and Facilities Director on March 25, 2025, between 1:15 p.m., and 1:30 p.m., confirmed the kitchen suppression system deficiencies.

Plan of Correction - To be completed: 05/24/2025

The Administrator met with Tustin Fire Solutions on 4/10/2025 and has arranged for all above deficiencies to be remedied as soon as possible.
Areas to be addressed include, but not limited to, vestibule pull station to be lowered, dietary hood ANSUL system nozzles to be properly arranged, a third housing will be added, tension line will be replaced, link housing cable assembly to be replaced. System to be fully tested and inspected after work is completed.
Approved service agreements are in place.
The inspection schedule has been updated in TELS, the facility preventive maintenance program.
The administrator or designee will monitor compliance and report any issues to the facility QAPI.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on observation and interview, it was determined the facility failed to maintain the building fire alarm system in multiple instances, affecting three of three floors.

Findings include:

1. Observation on March 25, 2025, between 12:30 p.m., and 12:45 p.m., revealed the following:

a. 12:30 p.m., the fire alarm inspection report, dated 9/19/2024, listed the following deficiencies (there was no record of the below deficiencies being remediated).
b. 12:31 p.m., "The four devices in the elevator shaft were not tested due to no access to the shafts. The customer shall contact their elevator company to test."
b2-"The duct detector was not tested due to no key available to test the remote key switch."
b3- "There were smoke dampers listed on the disables for the panel, but no smoke dampers could be located. These shall be located and tested ASAP."
b4- "There were (8) firelights that did not activate in general alarm. They are believed to be old devices. They shall be investigated and removed or marked "out of service."
b5- "There was an old annunciator in the HR Office that did not function and shall be investigated and removed or marked "out of service."
b6-"It is unknown if there is a shunt trip. The customer insisted it be verified with the elevator company on site."
b7- "The pull station in the trash room was blocked by scrap and not easily accessible. This shall be made accessible at all times."
b8-"The pull station at the main entrance is recessed and not visible. This shall be moved out to be made easily accessible."
b9- M1-97 (smoke in second floor Med Room) was found with its LED light lit on arrival. The device was removed and reinstalled and the LED cleared. It was told to the technician that it went into trouble recently. Monitor and contact for replacement if needed."
b10- "9/19/2024 Visit 708973. "Started annual fire alarm inspection. System placed on test by (maintenance director). System in trouble for communications on arrival. System disabled by technician. System re-enabled by technician. System still in trouble for communications. This is a known issue by maintenance. The system is not reporting to monitoring. Fire watch procedures explained and signed by (maintenance director). System placed back on upon departure by (maintenance director). Technicians to return next day to continue inspections."
09/20/2024 Visit 708724 "Continued annual fire alarm inspection. Fire alarm panel in trouble for phone lines and communication upon arrival. Customer already on fire watch due to this issue. System placed on test by (technician). System bypassed by technicians."

Exit interview with the Facility Administrator, Facilities Manager, and Facilities Director on March 25, 2025, between 1:15 p.m., and 1:30 p.m., confirmed the fire alarm deficiencies.

Plan of Correction - To be completed: 05/24/2025

The Administrator met with Tustin Fire Solutions on 4/10/2025 and has arranged for all above deficiencies to be remedied.
Approved service agreements are in place.
"The four devices in the elevator shaft will be tested.
The duct detector will be tested.
Smoke dampers that were due for inspection were tested.
The firelights will be corrected.
The old system monitor will be marked as out of service.
The shunt trip will be verified and remedied.
The pull station in the trash room was cleared.
The pull station at the main entrance was lifted to be flush with the wall surface.
The somke detector in the med room was cleared.
The fire alarm panel deficiencies will be remedied.
System to be fully tested and inspected after work is completed.
The inspection schedule has been updated in TELS, the facility preventive maintenance program.
The administrator or designee will monitor compliance and report any issues to the facility QAPI.

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 - Component: 01 - Tag: 0353

Based on documentation review, observation, and interview, it was determined the facility failed to maintain the automatic sprinkler system in multiple instances, affecting three of three floors.

Findings include:

1. Observation on March 25, 2025, between 11:30 a.m., and 12:50 p.m., revealed the following:

a. 11:30 a.m., BX wiring atop branch sprinkler piping within the Administration Suite.
b. 11:35 a.m., sprinkler heads "loaded" with lint, located within the first floor, Linen Chute Room.
c. 11:55 a.m., ceiling tiles missing within the Chapel.
d. 12:37 p.m., the facility lacked one of four required quarterly automatic sprinkler system testing and inspection reports (last inspection performed 12/12/2024).
e. 12:40-12:50 p.m., the annual automatic sprinkler system report, dated 9/20/2024, reflected the following deficiencies (there was not further documentation to support that these deficiencies were corrected).
e1- "the electric bell did not function properly and shall be replaced ASAP."
e2- "the inspector's test valve has a leak and that cannot be located due to the drywall. This shall be investigated and repaired ASAP."
e3- "(2) Identifier signs are missing and shall be installed ASAP."
e4-"there is no record of a FDC Hydrotest. One should be performed ASAP."
e5-"there is a dry drop that is out of date and shall be replaced ASAP. Measurements shall be taken. It is recommended that the other dry drop be replaced to keep on the same cycle."
e6- "A separate quote is needed for Standpipe Inspection."

Exit interview with the Facility Administrator, Facilities Manager, and Facilities Director on March 25, 2025, between 1:15 p.m., and 1:30 p.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 05/24/2025

The BX wiring atop branch sprinkler piping within the Administration Suite was removed.
The ceiling tiles in the chapel were replaced.

The Administrator met with Tustin Fire Solutions on 4/10/2025 to arrange for the following work to be completed.
sprinkler heads "loaded" with lint, located within the first floor, Linen Chute will be cleaned / replaced as needed.
The facility has arranged for full test and inspection of the sprinkler system.
"the electric bell did not function properly and shall be replaced ASAP."
"the inspector's test valve was carefully inspected and no leak was detected.
Identifier signs will be replaced.
Hydro test documentation was located and testing was performed
dry drop that is out of date and will be replaced ASAP.
Standpipe inspection will be performed.
Staff were educated on importance scheduled tests of the sprinkler and associated systems..
The inspection schedule has been updated in TELS, the facility preventive maintenance program.
The administrator or designee will monitor compliance and report any issues to the facility QAPI.

NFPA 101 STANDARD Corridor - Doors:

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

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

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain one corridor opening, affecting one of three floors.

Findings include:

1. Observation on March 25, 2025, at 11:22 a.m., revealed the second floor Medication/Treatment Room door required adjustment to fully latch.

Exit interview with the Facility Administrator, Facilities Manager, and Facilities Director on March 25, 2025, between 1:15 p.m., and 1:30 p.m., confirmed the corridor opening deficiency.

Plan of Correction - To be completed: 05/24/2025

The second floor medication treatment room door was adjusted to ensure proper latching.
The inspection schedule has been updated in TELS, the facility preventive maintenance program.
The administrator or designee will monitor proper latching / compliance annually and report any issues to the facility QAPI

NFPA 101 STANDARD HVAC:

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

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on documentation review and interview, it was determined the facility failed to maintain fire dampers in multiple locations, affecting three of three floors.

Findings include:

1. Observation on March 25, 2025, at 12:50 p.m., revealed the facility lacked documentation to support four-year, fire damper maintenance.

Exit interview with the Facility Administrator, Facilities Manager, and Facilities Director on March 25, 2025, between 1:15 p.m., and 1:30 p.m., confirmed the fire damper deficiencies.

Plan of Correction - To be completed: 05/24/2025

The facility located the fire damper inspections and has identified dampers now due for inspection.
The inspection schedule has been updated in TELS, the facility preventive maintenance program.
The administrator or designee will monitor fire damper test completion and report any issues to the facility QAPI.

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

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

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain one linen chute, affecting one of three floors.

Findings include:

1. Observation on March 25, 2025, at 11:18 a.m., revealed the second floor linen chute door required adjustment to fully close, latch, and lock.

Exit interview with the Facility Administrator, Facilities Manager, and Facilities Director on March 25, 2025, between 1:15 p.m., and 1:30 p.m., confirmed the linen chute deficiency.

Plan of Correction - To be completed: 05/24/2025

On 4/3/2025 the 2nd floor linen chute door was cleaned and adjusted to ensure that it fully closes, latches and locks. The inspection schedule has been updated in TELS, the facility preventive maintenance program.
The administrator or designee will monitor proper latching / compliance annually and report any issues to the facility QAPI.

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 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to conduct and maintain fire drills in two instances, affecting three of three floors.

Findings include:

1. Observation on March 25, 2025, at 12:45 p.m., revealed the facility lacked data to support two of twelve fire drills within the past twelve month period (second shift, second quarter of 2024 and second shift, fourth quarter of 2024).

Exit interview with the Facility Administrator, Facilities Manager, and Facilities Director on March 25, 2025, between 1:15 p.m., and 1:30 p.m., confirmed the fire drill deficiencies.

Plan of Correction - To be completed: 05/24/2025

The facility cannot recreate past fire drills.
Staff were educated on the importance and requirements of timely fire drills. The administrator or designee will ensure that subsequent fire drills are conducted timely. The inspection schedule has been updated in TELS, the facility preventive maintenance program.
The administrator or designee will monitor compliance monthly and report any issues to the facility QAPI.

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 - Component: 01 - Tag: 0761

Based on documentation review and interview, it was determined the facility failed to maintain fire doors, affecting three of three floors.

Findings include:

1. Observation on March 25, 2025, at 12:53 p.m., revealed the facility lacked documentation to support yearly fire door functional/visual testing data.

Exit interview with the Facility Administrator, Facilities Manager, and Facilities Director on March 25, 2025, between 1:15 p.m., and 1:30 p.m., confirmed the fire door deficiencies.

Plan of Correction - To be completed: 05/24/2025

All fire doors were inspected on 4/9/2025 and 4/10/2025 and all units were found to be in compliance.
The inspection schedule has been updated in TELS, the facility preventive maintenance program.
The administrator or designee will monitor proper latching / compliance and report any issues to the facility QAPI.

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 01 - Component: 01 - Tag: 0914

Based on documentation review and interview, it was determined the facility failed to maintain electrical systems in multiple locations, affecting three of three floors.

Findings include:

1. Observation on March 25, 2025, at 1:12 p.m., revealed the facility lacked documentation to support annual receptacle testing data.

Exit interview with the Facility Administrator, Facilities Manager, and Facilities Director on March 25, 2025, between 1:15 p.m., and 1:30 p.m., confirmed the electrical systems deficiency.

Plan of Correction - To be completed: 05/24/2025

All receptacles were inspected on 4/9/2025 and 4/10/2025 and all receptacles were found to be in compliance.
The inspection schedule has been updated in TELS, the facility preventive maintenance program.
The administrator or designee will monitor proper inspection annually and report any issues to the facility QAPI.

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 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the generator set in one instance, affecting three of three floors.

Findings include:

1. Observation on March 25, 2025, between 1:00 p.m., and 1:04 p.m., revealed the facility lacked ninety-minute, annual load bank testing data.

Exit interview with the Facility Administrator, Facilities Manager, and Facilities Director on March 25, 2025, between 1:15 p.m., and 1:30 p.m., confirmed the generator set deficiency.

Plan of Correction - To be completed: 05/24/2025

4 hour load bank testing was completed on Friday, April 11th, 2025. No issues were noted during the inspection.
The inspection schedule has been updated in TELS, the facility preventive maintenance program.
The administrator or designee will monitor proper inspection annually and report any issues to the facility QAPI.

NFPA 101 STANDARD Electrical Equipment - Other:

Electrical Equipment - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, 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 10 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0919

Based on observation and interview, it was determined the facility failed to maintain electrical systems in one location, affecting one of three floors.

Findings include:

1. Observation on March 25, 2025, at 12:02 p.m., revealed a junction box, located above the suspended ceiling assembly, within Main Dining, that exhibited an errant wire protruding from the junction box.

Exit interview with the Facility Administrator, Facilities Manager, and Facilities Director on March 25, 2025, between 1:15 p.m., and 1:30 p.m., confirmed the electrical systems deficiency.

Plan of Correction - To be completed: 05/24/2025

On 4/2/2025 the errant wire was removed from the junction box.
Staff were educated on errant wires remaining in drop ceiling assemblies.
Other areas were inspected and no other errant wires were located.
The administrator or designee will monitor annually and report any issues to the facility QAPI.

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