Pennsylvania Department of Health
GARDENS AT CAMP HILL, THE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDENS AT CAMP HILL, THE
Inspection Results For:

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GARDENS AT CAMP HILL, THE - 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 August 25, 2026, it was determined that The Gardens at Camp Hill was not in compliance with 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 a current emergency preparedness plan, which has been reviewed and updated for the current staff, which serves the entire component. Findings include: 1. Review of documentation on August 25, 2026, between 8:45 AM and 11:00 AM, confirmed the facility lacked a review and signature sheet for staff. Interview at the time of the exit conference with the Administrator, Director of Nursing and Maintenance Director on August 25, 2026, at 2:00 PM, confirmed the Emergency Preparedness Plan review and signature update sheet was not available.
 Plan of Correction - To be completed: 10/06/2026

1. A staff review and signature sheet for the Emergency Preparedness Plan was completed by current staff.
2. The Emergency Preparedness Plan was reviewed in full to confirm no other required annual elements were missing.
3. NHA or assigned designee given an Inservice on the annual staff review and signature requirement for the Emergency Preparedness Plan.
4. NHA or assigned designee will complete audits annually to ensure the review and signature sheet remains current, with results reported to QAPI.

403.748(a)(1)-(2), 416.54(a)(1)-(2), 418.113(a)(1)-(2), 441.184(a)(1)-(2), 482.15(a)(1)-(2), 483.475(a)(1)-(2), 483.73(a)(1)-(2), 484.102(a)(1)-(2), 485.542(a)(1)-(2), 485.625(a)(1)-(2), 485.68(a)(1)-(2), 485.727(a)(1)-(2), 485.920(a)(1)-(2), 486.360(a)(1)-(2), 491.12(a)(1)-(2), 494.62(a)(1)-(2) STANDARD Plan Based on All Hazards Risk Assessment: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.
§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)

[(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 the following:]

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*

(2) Include strategies for addressing emergency events identified by the risk assessment.

* [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

*[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. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.

*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.
Observations:
Name: - Component: -- - Tag: 0006 Based on observation and interview, it was determined the facility did not include a documented facility-based and community-based risk assessment, which affects the entire component. Findings include: 1. Observation on August 25, 2026, between 8:45 AM and 11:00 AM, revealed the facility did not have a risk assessment included in the Emergency Preparedness Plan. Interview at the time of the exit conference with the Administrator, Director of Nursing and Maintenance Director on August 25, 2026, at 2:00 PM, confirmed the facility failed to provide a risk assessment.
 Plan of Correction - To be completed: 10/06/2026

1. A documented facility-based and community-based risk assessment, using an all-hazards approach, was completed and added to the Emergency Preparedness Plan.
2. The completed risk assessment was reviewed with department heads to identify strategies for addressing each emergency event identified.
3. NHA or assigned designee given an Inservice on the annual risk assessment review requirement.
4. NHA or assigned designee will complete audits annually to ensure the risk assessment remains current, with results reported to QAPI.

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000
Facility ID #030502Component 01Main Building Based on a Medicare/Medicaid Recertification Survey completed on August 25, 2026, it was determined that The Gardens at Camp Hill 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 V (000), unprotected wood frame structure, with a basement, which is fully sprinklered. 
 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
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, observation and interview, it was determined the facility failed to 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 on August 25, 2026, between 8:45 AM and 11:00 AM, revealed the facility lacked portable legible and accurate life safety drawings of the facility with an active FSES. Floor plans lacked compartment labeling, resident room capacities, door swings, fire wall boundaries, smoke wall boundaries, hazardous areas, length and width of zones and travel distance. Interview at the time of the exit conference with the Administrator, Director of Nursing and Maintenance Director on August 25, 2026, at 2:00 PM, confirmed the lack of portable, legible and accurate life safety drawings of the facility. 2. Review of documentation, observation and interview on August 25, 2026, between 8:45 AM and 11:00 AM, revealed the facility lacked documentation verifying the 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 at the time of the exit conference with the Administrator, Director of Nursing and Maintenance Director on August 25, 2026, at 2:00 PM, confirmed the facility lacked manufacturer's operating/inspections instructions, for the individual detectors installed. 3. Observation and interview on August 25, 2026, between 8:45 AM and 11:00 AM, revealed the facility could not verify Carbon Monoxide Alarms could be heard by staff, on duty, in accordance with the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act. Interview at the time of the exit conference with the Administrator, Director of Nursing and Maintenance Director on August 25, 2026, at 2:00 PM, confirmed the facility could not verify Carbon Monoxide Alarms could be heard by staff, on duty. 4. Review of documentation, observation and interview on August 25, 2026, between 8:45 AM and 11:00 AM, revealed the facility could not verify Carbon Monoxide Alarms were installed in proximity, but less than fifteen feet, from a fossil-burning device, in accordance with the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act. Interview at the time of the exit conference with the Administrator, Director of Nursing and Maintenance Director on August 25, 2026, at 2:00 PM, confirmed the facility lacked documentation verifying alarms were installed in proximity, but at least fifteen feet, of a fossil-burning device. 5. Review of documentation and interview on August 25, 2026, between 8:45 AM and 11:00 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 at the time of the exit conference with the Administrator, Director of Nursing and Maintenance Director on August 25, 2026, at 2:00 PM, confirmed facility lacked documentation of evacuation and alarm protocols.
 Plan of Correction - To be completed: 10/06/2026

1. Portable, legible life safety drawings, including compartment labeling, resident room capacities, door swings, fire and smoke wall boundaries, hazardous areas, and zone travel distances, were completed and placed in the Life Safety book. Documentation was completed and provided verifying manufacturer testing and inspection of the Carbon Monoxide alarms, audibility at each staffed location, and placement within fifteen feet of fossil-burning devices.
2. Evacuation and alarm protocols for Carbon Monoxide alarms were documented and added to the Emergency Preparedness Plan.
3. Maintenance Director given an Inservice on maintaining accurate life safety drawings and Carbon Monoxide alarm documentation.
4. Maintenance Director or assigned designee will complete audits of the life safety drawings and Carbon Monoxide alarm documentation weekly x4, monthly x2, with results placed in the Life Safety book and reported to QAPI.

NFPA 101 STANDARD Building Construction Type and Height:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

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

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

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

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0161 Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire component. Findings include: 1. Observation on August 25, 2026, at 9:00 AM, revealed this is a two-story, Type V (000), unprotected wood frame structure, with a basement, which is fully sprinklered. This type of construction is not permitted under the 2012 Edition of the Life Safety Code for an existing health care occupancy. Interview at the time of the exit conference with the Administrator, Director of Nursing and Maintenance Director on August 25, 2026, at 2:00 PM, confirmed the facility exceeds the maximum allowable story height, for this type of construction.
 Plan of Correction - To be completed: 10/06/2026

DOH Life Safety Unit is requested to complete FSES assessment.
NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
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 - Component: 01 - Tag: 0225 Based on observation and interview, it was determined the facility failed to maintain the fire rated stairtower integrity and egress door, within the stairtower, to open, on one of three stairtowers within the component. Findings include: 1. Observation on August 25, 2026, at 12:40 PM revealed exit discharge doors, in the basement, south, required a force of more than 30 pounds to set the doors in motion. Interview at the time of the exit conference with the Administrator, Director of Nursing and Maintenance Director on August 25, 2026, at 2:00 PM, confirmed the doors did not begin to swing with an applied force of 30 pounds. 2. Observation on August 25, 2026, at 1:05 PM, revealed 2nd floor, middle stairtower, horizontal fire-rated hatch was removed. Interview at the time of the exit conference with the Administrator, Director of Nursing and Maintenance Director on August 25, 2026, at 2:00 PM, confirmed the horizontal fire-rated hatch was removed.
 Plan of Correction - To be completed: 10/06/2026

1. The exit discharge doors, basement south, were adjusted to open with a force not exceeding thirty pounds.
2. The Facility is requested a time limited waiver to for the horizontal fire-rated hatch in the second floor middle stairtower until February 25, 2027.
3. Maintenance Director given an Inservice on maintaining exit door operating force and stairtower fire-rated components.
4. Maintenance Director or assigned designee will complete audits of exit door operation and stairtower integrity weekly x4, monthly x2, with results reported to QAPI. Maintenance Director or assigned designee will complete audits of the stairtower hatch on an ongoing basis,2x monthly, with results reported to QAPI. Once Repaired audits of the rated hatch to be completed for function semi-annually

NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
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 - Component: 01 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintain hazardous area doors to be within the allowed gap margins, and to self-close, affecting one of three floors within the component. Findings include: 1. Observation on August 25, 2026, between 10:30 AM and 10:45 AM, revealed rated doors had gaps exceeding the allowed gap margins, at the following locations: a. 10:30 AM, Boiler Room, double doors had a gap, exceeding 3/16 inch; b. 10:35 AM, soiled side of the Laundry had a gap, exceeding 3/16 inch; c. 10:45 AM, Dietary Storage Room had a gap, exceeding 1/8 inch. Interview at the time of the exit conference with the Administrator, Director of Nursing and Maintenance Director on August 25, 2026, at 2:00 PM, confirmed the rated doors exceeded the allowed gap margins
 Plan of Correction - To be completed: 10/06/2026

1. The Boiler Room doors, soiled side Laundry door, and Dietary Storage Room door were repaired to be within the allowed gap margins and ensure positive latching within the door frame.
2. A facility-wide check of hazardous area doors was completed to identify any additional doors exceeding allowed gap margins.
3. Maintenance Director given an Inservice on ensuring appropriate door gap margins and latching.
4. Maintenance Director and NHA to complete audits to ensure appropriate latching weekly x4, monthly x2, for the duration of 12 months, with results reported to QAPI.

NFPA 101 STANDARD Cooking Facilities: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.
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 perform owner's checks, semi-annual hood cleanings and semi-annual testing of the fixed chemical fire suppression system, in one of one Kitchen within the component. Findings include: 1. Review of documentation on August 25, 2026, between 8:45 AM and 11:00 AM, revealed the facility failed to perform owner's quick check, of the fixed chemical fire suppression system, for one full year. Interview at the time of the exit conference with the Administrator, Director of Nursing and Maintenance Director on August 25, 2026, at 2:00 PM, confirmed the facility failed to conduct the owner's quick checks on the Kitchen's fixed chemical fire suppression system, for one full year. 2. Review of documentation on August 25, 2026, between 8:45 AM and 11:00 AM, revealed the facility failed to perform one full year of the Kitchen's exhaust ductwork, on a semi-annual basis. Interview at the time of the exit conference with the Administrator, Director of Nursing and Maintenance Director on August 25, 2026, at 2:00 PM, confirmed the facility failed to perform Kitchen ductwork, on a semi-annual basis.
 Plan of Correction - To be completed: 10/06/2026

1. Unable to correct past occurrences
2. Documentation will be provided verifying the Kitchen's fixed chemical fire suppression system owner's quick check and the semi-annual exhaust ductwork cleaning and testing was completed and documented in the Life Safety book.
3. Maintenance Director educated on verifying the suppression system owner's quick check and ductwork cleaning and testing schedule.
4. Maintenance Director or assigned designee will complete audits to verify suppression system and ductwork documentation weekly x4, monthly x2, with results placed in the Life Safety book and reported to QAPI.

NFPA 101 STANDARD Corridor - Doors:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
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 cross-corridor self-closing doors to close in the frame, affecting one of one elevator lobby within the component. Findings include: 1. Observation on August 25, 2026, at 1:20 PM, revealed the 1stfloor, cross corridor self-closing double doors, by elevator, left leaf failed to close, due to rubbing on right leaf. Interview at the time of the exit conference with the Administrator, Director of Nursing and Maintenance Director on August 25, 2026, at 2:00 PM, confirmed the door did not fully close in frame.
 Plan of Correction - To be completed: 10/06/2026

1. The cross-corridor self-closing doors near the elevator were adjusted to correct the rubbing so both leaves close fully within the frame.
2. A whole house audit of all corridor doors was completed to identify any additional doors not closing or latching properly.
3. Maintenance Director educated on positive latching of all doors within the frame and how a door is supposed to function when completely closing, latching, not drifting, and staying latched under pressure.
4. Maintenance Director or assigned designee will complete audits weekly, then monthly, to ensure proper closing and latching, with results reviewed by the QAPI team for further action planning as necessary.

NFPA 101 STANDARD Fire Drills: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.
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 conduct and perform fire drills (one per shift, per quarter), which affects the entire component. Findings include: 1. Review of documentation on August 25, 2026, between 8:45 AM and 11:00 AM, revealed the facility did not perform fire drills, during the following: a. 3rd quarter 2025, 1st, 2ndand 3rd shift; b. 4th quarter 2025, 1st, 2ndand 3rd shift. Interview at the time of the exit conference with the Administrator, Director of Nursing and Maintenance Director on August 25, 2026, at 2:00 PM, confirmed the lack of documentation, verifying fire drills were performed.
 Plan of Correction - To be completed: 10/06/2026

1. Unable to correct past occurrences.
2. Documentation will be provided verifying quarterly fire drills are completed for employees on each shift going forward.
3. Maintenance Director educated on appropriate documentation of fire drills and the requirement of one drill per shift, per quarter.
4. Maintenance Director or assigned designee will complete audits quarterly to ensure completion of fire drill documentation, as well as plans for fire drills in the upcoming quarter, with results reported to QAPI.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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 for the emergency generator deficiencies repairs and updated fuel sample quality test, which serves the entire component. Findings include: 1. Review of documentation on August 25, 2026, between 9:45 AM and 9:47 AM, revealed the facility lacked documentation for the following reported deficiencies, documented on the annual generator report, dated 4/21/2026: a. 9:45 AM, replace lift pump; b. 9:46 AM, insulate muffler; c. 9:47 AM, fuel polish. Interview at the time of the exit conference with the Administrator, Director of Nursing and Maintenance Director on August 25, 2026, at 2:00 PM, confirmed the lack of documentation, verifying the generator repairs had been made. 2. Review of documentation on August 25, 2026, between 8:45 AM and 10:30 AM, revealed the facility failed to polish the emergency fuel reserve and retest after the annual generator report, dated 4/21/2026, listed the deficiency and the annual fuel deficiency report, on 4/1/2026. Interview at the time of the exit conference with the Administrator, Director of Nursing and Maintenance Director on August 25, 2026, at 2:00 PM, confirmed the failure to polish fuel reserve and retest.
 Plan of Correction - To be completed: 10/06/2026

1. Documentation of the lift pump replacement, muffler insulation, and fuel polish identified on the annual generator report dated 4/21/2026 was obtained from the servicing vendor and filed in the Life Safety book.
2. The emergency fuel reserve was polished and retested.
3. Maintenance Director educated on verifying generator repair documentation and fuel testing requirements are completed and filed.
4. Maintenance Director or assigned designee will complete audits of generator service and fuel testing documentation with each service visit and the annual generator report, with results reported to QAPI.


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