Pennsylvania Department of Health
EMERALD NURSING AND REHABILITATION
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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EMERALD NURSING AND REHABILITATION - 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 April 9, 2026, it was determined that Emerald Nursing and Rehabilitation 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 provide documentation verifying the emergency preparedness plan had been reviewed within the previous twelve months, affecting the entire component. Findings include: 1. Review of documentation on April 9, 2026, at 9:30 AM, revealed the facility failed to provide documentation verifying the emergency preparedness plan had been reviewed within the previous twelve months. Interview with the Environmental Services Director on April 9, 2026, at 9:30 AM, confirmed the lack of documentation verifying the emergency preparedness plan had been reviewed within the previous twelve months.

Plan of Correction - To be completed: 04/27/2026

This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection
1. Facility is unable to retroactively correct lack of reviewing facility emergency preparedness plan within previous 12 months.
2. Maintenance Director/Designee and NHA will review facility emergency preparedness plan by 4/24/26. Annual review sign off sheet will be placed at front of emergency preparedness plan binder.
3. NHA/Designee will educate Maintenance Director on requirement of reviewing facility emergency preparedness plan annually.
4. NHA/Designee will schedule annual review of emergency preparedness plan within 1 year. Results will be reviewed by QAPI Committee during QAPI meetings.

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000
Facility ID #023202 Component 01Building 01Based on a Medicare/Medicaid Recertification Survey completed on April 9, 2026, it was determined that Emerald Nursing and Rehabilitation 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 two-story, Type II (000), unprotected noncombustible structure, with a basement, which is fully sprinklered.

Plan of Correction:

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 - Component: 01 - Tag: 0291 Based on document review and interview, it was determined the facility failed the provide documentation verifying monthly and annual testing of battery back-up emergency lighting fixtures, affecting the entire component. Findings include: 1. Review of documentation on April 9, 2026, at 10:00 AM, revealed the facility lacked documentation verifying monthly 30-second testing of the emergency battery back-up lighting fixtures had occurred since 10/3/2025. Interview with the Environmental Services Director on April 9, 2026, at 10:00 AM, confirmed the lack of documentation verifying monthly testing of the emergency battery back-up lighting fixtures had occurred within the previous twelve months. 2. Review of documentation on April 9, 2026, at 10:01 AM, revealed the facility lacked documentation verifying an annual 90-minute test of the emergency battery back-up lighting fixtures had occurred within the previous twelve months. Interview with the Environmental Services Director on April 9, 2026, at 10:01 AM, confirmed the lack of documentation verifying annual testing of the emergency battery back-up lighting fixtures had occurred within the previous twelve months.

Plan of Correction - To be completed: 04/27/2026

1. Facility is unable to retroactively correct lack of monthly testing of emergency battery backup light fixtures.
2. Maintenance Director/designee will conduct annual 90 minute testing of facility emergency battery backup light fixtures by 4/24/26. Monthly 30 minute will begin in May 2026
3. NHA/Designee will educate Maintenance Director on monthly requirement of testing and documentation of emergency battery backup light fixtures.
4. NHA/Designee will audit monthly testing and documentation of emergency battery back up light fixtures quarterly for 1 year. Results of audits will be reviewed by QAPI Committee during QAPI meetings.

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 signage had been subjected to monthly inspections within the previous twelve months, affecting the entire component. Findings include: 1. Review of documentation on April 9, 2026, at 10:10 AM, revealed the facility failed to provide documentation verifying exit signs had been inspected monthly within the previous twelve months, with the exception of 5/9/2025 and 8/31/2025. Interview with the Environmental Services Director on April 9, 2026, at 10:10 AM, confirmed the lack of documentation verifying monthly exit sign inspections had occurred within the previous twelve months.

Plan of Correction - To be completed: 04/27/2026

1. Facility is unable to retroactively correct lack of monthly exit sign inspections.
2. Maintenance Director/Designee will conduct inspection of facility exit signs by 4/17/26
3. NHA/Designee will educate Maintenance Director on monthly requirement of inspecting exit signs.
4. NHA/Designee will audit monthly testing and documentation of inspections of exit signs monthly for 12 months. Results of audits will be reviewed by QAPI Committee during QAPI meetings.

NFPA 101 STANDARD Cooking Facilities:

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

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

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0324 Based on document review and interview, it was determined the facility failed to provide documentation verifying the Kitchen suppression system had been inspected on a semi-annual basis, within the previous twelve months, affecting one of six smoke compartments within the component. Findings include: 1. Review of documentation on April 9, 2026, at 9:45 AM, revealed the facility lacked documentation verifying the Kitchen suppression system had been inspected since 3/4/2025. Interview with the Environmental Services Director on April 9, 2026, at 9:45 AM, confirmed the lack of documentation verifying the Kitchen suppression system had been inspected within the previous twelve months.

Plan of Correction - To be completed: 04/27/2026

1. Facility is unable to retroactively correct lack of kitchen suppression system inspection.
2. Kitchen suppression system was inspected on 4/14/26.
3. NHA/Designee will educate Maintenance Director on requirement of semi-annual inspections of kitchen suppression system.
4. NHA/Designee will audit kitchen suppression inspections every 6 months for 1 year to ensure inspection is being completed semi-annually. Results of audits will be reviewed by QAPI Committee during QAPI meetings.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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 observation and interview, it was determined the facility failed to maintain the automatic sprinkler protection system to be free from extraneous weight, affecting one of six smoke compartments within the component. Findings include: 1. Observation on April 9, 2026, at 12:40 PM, revealed a white wire, zip-tied in three locations, to sprinkler piping within the 1st floor Elevator Machine Room. Interview with the Environmental Services Director on April 9, 2026, at 12:40 PM, confirmed the wire was supported by the sprinkler system.

Plan of Correction - To be completed: 04/27/2026

Maintenance Director removed zip ties from sprinkler on 4/16/26.

Maintenance Director/Designee will audit facility sprinklers to ensure no other wires were zip tied to sprinkler system by 4/17/26.

NHA/Designee will educate Maintenance Director on need to maintain the automatic sprinkler protection system to be free from extraneous weight.

NHA/Designee will audit 5 sprinkler piping and the ceiling work above piping monthly for 12 months to ensure there are no wires tied to sprinkler piping. Results of audits will be reviewed by QAPI Committee during QAPI meetings.

NFPA 101 STANDARD Portable Fire Extinguishers:

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.

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, observation and interview, it was determined the facility failed to provide documentation verifying portable fire extinguishers had been subjected to an annual inspection within the previous twelve months, and to maintain the illumination of indicator lights, in six of six smoke zones within the component. Findings include: 1. Review of documentation on April 6, 2026, at 9:56 AM, revealed the facility lacked documentation verifying portable fire extinguishers had been subjected to an annual inspection, since 3/4/2025. Interview with the Environmental Services Director on April 9, 2026, at 9:56 AM, confirmed the lack of documentation verifying portable fire extinguishers had been subjected to an annual inspection within the previous twelve months. 2. Observation on April 9, 2026, at 11:00 AM, revealed portable fire extinguisher lights, throughout the facility, were not illuminated, as evidenced on the 3rd floor, across from Resident Room 340. Interview with the Environmental Services Director on April 9, 2026, at 11:00 AM, confirmed the indicator light was not illuminated.

Plan of Correction - To be completed: 04/27/2026

Facility is unable to retroactively correct lack of fire extinguisher annual inspection. Maintenance Director will correct the illumination of the portable fire extinguisher lighting by 4/24/26

Fire Extinguisher annual inspection was completed on 4/14/26. Maintenance Director/Designee audited facility portable fire extinguisher lighting to ensure no others are illuminating improperly on 4/21/26.

NHA/Designee will educate Maintenance Director on need to maintain fire extinguisher inspection annually. NHA/Designee will educate Maintenance Director on need for proper illumination of portable fire extinguisher lighting.

NHA/Designee will audit annual fire extinguisher inspections semiannually to ensure the inspection has been scheduled and to confirm receipt of the report. Report will be filed in the life safety book. NHA/Designee will conduct quarterly audits of fire extinguisher signage/lighting checks to ensure they are being completed and any issues have been reported and corrected. Results of audits will be reviewed by QAPI Committee during QAPI meetings.

NFPA 101 STANDARD Corridors - Construction of Walls:

Corridors - Construction of Walls
2012 EXISTING
Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code.
Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames.
If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area.
19.3.6.2, 19.3.6.2.7

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0362 Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of corridor walls, affecting one of six smoke compartments within the component. Findings include: 1. Observation on April 9, 2026, at 11:25 AM, revealed an unprotected penetration of 2nd floor corridor wall, located between Resident Room 220 and Resident Room 222. Interview with the Environmental Services Director on April 9, 2026, at 11:25 AM, confirmed the corridor wall did not resist the passage of smoke.

Plan of Correction - To be completed: 04/27/2026

1 Maintenance Director will correct the unprotected penetration on 2nd floor corridor by 4/17/26
2. Maintenance Director/Designee will conduct audit of facility to ensure there were no other unprotected penetrations in facility corridors by 4/17/26
3. NHA/Designee will educate Maintenance Director on need to maintain smoke resistance of corridor walls.
4. NHA/Designee will audit facility corridors monthly for 12 months to ensure there are no other unprotected penetrations. Results of audits will be reviewed by QAPI Committee during QAPI meetings.

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 - Component: 01 - Tag: 0363 Based on observation and interview, it was determined the facility failed to maintain the positive latching of corridor doors, affecting one of six smoke compartments within the component. Findings include: 1. Observation on April 9, 2026, at 11:34 AM, revealed the door to the 2nd floor Linen Room, across from Resident Room 228, lacked positive latching hardware. Interview with the Environmental Services Director on April 9, 2026, at 11:34 AM, confirmed the corridor door lacked positive latching hardware.

Plan of Correction - To be completed: 04/27/2026

1. Maintenance Director will replace latching hardware of the 2nd floor linen room door by 4/24/26
2. Maintenance Director/Designee will audit of facility to ensure there were no other doors without positive latching hardware by 4/17/26.
3. NHA/Designee will educate Maintenance Director on need to ensure there is positive latching hardware on doors.
4. NHA/Designee will facility doors monthly for 12 months to ensure there is positive latching hardware. Results of audits will be reviewed by QAPI Committee during QAPI meetings.

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 documentation verifying weekly inspections, monthly exercises, and annual fuel testing of the emergency generator, affecting the entire component. Findings include: 1. Review of documentation on April 9, 2026, at 9:51 AM, revealed the facility lacked documentation verifying weekly inspections and monthly exercises of the emergency generator had occurred, since 10/31/2025. Interview with the Environmental Services Director on April 9, 2026, at 9:51 AM, confirmed the lack of documentation verifying weekly inspections and monthly exercises of the emergency generator had occurred within the previous twelve months. 2. Review of documentation on April 9, 2026, at 10:20 AM, revealed the facility lacked documentation verifying the quality of the diesel fuel servicing the emergency generator had been tested within the previous twelve months. Interview with the Environmental Services Director on April 9, 2026, at 10:20 AM, confirmed the lack of documentation verifying the quality of the diesel fuel servicing the emergency generator had been tested within the previous twelve months.

Plan of Correction - To be completed: 04/27/2026

Facility is unable to retroactively correct lack of weekly inspections and monthly exercises for emergency generator.

Maintenance Director/Designee will conduct weekly inspection and monthly exercise of emergency generator by 4/24/26. Date of last load bank testing was June 3, 2025. 30 min load bank monthly testing was completed on 4/23/26. 90 min Load bank will be completed by May 5th.

NHA/Designee will educate Maintenance Director on need to conduct weekly inspections and monthly exercises for emergency generator

NHA/Designee will audit monthly for 12 months to ensure that required inspections and exercises are being conducted. Results of audits will be reviewed by QAPI Committee during QAPI meetings.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

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

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0920 Based on observation and interview, it was determined the facility failed to monitor the use of extension cords and surge protectors, affecting one of six smoke compartments within the component. Findings include: 1. Observation on April 9, 2026, at 10:30 AM, revealed an extension cord, powering a surge suppressor, within the 1st floor Maintenance Shop. Interview with the Environmental Services Director on April 9, 2026, at 10:30 AM, confirmed the use of an extension cord to supply electrical power to a surge suppressor.

Plan of Correction - To be completed: 04/27/2026

1. Maintenance Director immediately removed the extension cord powering a surge suppressor in the 1st floor Maintenance Shop. .
2. Maintenance Director/Designee will audit facility for any other extension cords being improperly used by 4/17/26.
3. NHA/Designee will educate Maintenance Director proper usage of extension cords.
4. NHA/Designee will audit 5 rooms/offices monthly for 3 months to ensure that there are no extension cords being used improperly. Results of audits will be reviewed by QAPI Committee during QAPI meetings.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

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

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0923 Based on observation and interview, it was determined the facility failed to provide a way to secure oxygen storage rooms from unauthorized entry, and to limit the amount of oxygen stored open to the corridor, affecting two of six smoke compartments within the component. Findings include: 1. Observation on April 9, 2026, at 11:07 AM, revealed the 3rd floor Oxygen Storage Room was unlocked and incapable of being secured against unauthorized access. Interview with the Environmental Services Director on April 9, 2026, at 11:07 AM, confirmed the Oxygen Storage Room was incapable of being secured against unauthorized access. 2. Observation on April 9, 2026, at 11:30 AM, revealed 15 "E" size portable oxygen storage cylinders located behind the 2nd floor Nurses' Station. Interview with the Environmental Services Director on April 9, 2026, at 11:30 AM, confirmed the capacity for the storage of oxygen, open to the corridor, exceeded 300 cubic feet.

Plan of Correction - To be completed: 04/27/2026

1. Maintenance Director will install lock to secure the 3rd floor Oxygen storage room by 4/24/26. Maintenance Director removed 3 of the E sized oxygen storage containers to ensure it did not exceed 300 cubic feet.
2. Maintenance Director/Designee will audit facility to ensure any other oxygen storage areas are secured and do not exceed 300 cubic feet.
3. NHA/Designee will educate Maintenance Director to ensure oxygen storage areas are secured and do not exceed 300 cubic feet.
4. NHA/Designee will audit oxygen storage areas monthly for 12 months to ensure that they are secure and do not exceed 300 cubic feet. Results of audits will be reviewed by QAPI Committee during QAPI meetings.

NFPA 101 STANDARD Gas Equipment - Precautions for Handling Oxyg:

Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds
Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99)
11.6.2 (NFPA 99)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0929 Based on observation and interview, it was determined the facility failed to maintain portable oxygen cylinders as secured at all times, affecting one of six smoke compartments within the component. Findings include: 1. Observation on April 9, 2026, at 11:08 AM, revealed an unsecured portable oxygen "E" tank within the 3rd floor Med Prep Room. Interview with the Environmental Services Director on April 9, 2026, at 11:08 AM, confirmed the unsecured portable oxygen tank.

Plan of Correction - To be completed: 04/27/2026

1. Maintenance Director immediately removed the unsecured portable oxygen E tank from the 3rd floor Med Prep room.
2. Maintenance Director/Designee will audit facility to ensure there are no other unsecured portable oxygen E tanks by 4/17/26.
3. NHA/Designee will educate Maintenance Director and licensed nurses that portable oxygen E tanks cannot be left unsecured.
4. NHA/Designee will audit med prep rooms monthly for 12 months to ensure that there are no unsecured portable oxygen E tanks. Results of audits will be reviewed by QAPI Committee during QAPI meetings.

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