Pennsylvania Department of Health
INDEPENDENCE REHAB AND NURSING
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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INDEPENDENCE REHAB AND NURSING - 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 September 22, 2025, it was determined that Cheltenham Nursing And Rehabilitation Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 (WEST BUILDING) - Component: 01 - Tag: 0000
Facility ID 032202

Component 01

West Building

Based on a Medicare/Medicaid Recertification Survey completed on September 22, 2025, it was determined that Cheltenham Nursing And Rehabilitation Center - West Building was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (000) unprotected wood frame building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

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

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

Observations:
Name: MAIN BUILDING 01 (WEST BUILDING) - Component: 01 - Tag: 0211 Based on observation and interview, it was determined the facility failed to maintain means of egress free of obstruction, affecting one of two levels. Findings include: 1. Observation on September 22, 2025, at 11:15 a.m., revealed an exit door that required excessive force to open when tested, first floor C-Side near room 117. Exit Interview with the Administrator and Maintenance Director on September 22, 2025, at 1:15 p.m., confirmed the door required excessive force to open.

Plan of Correction - To be completed: 12/29/2025

Preparation and/or execution of this plan of correction does not constitute admission or agreement by this provider of the facts alleged, or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and/or state law. The plan of correction constitutes our credible allegation of compliance.

1.The maintenance team adjusted the C-side exit door near room 117. The door opens without the use of excessive force.

2. On 10/2/2025 the maintenance team inspected all emergency exit doors to verify that there were no obstructions to egress.

3. On 10/2/2025 the NHA educated the maintenance team on maintaining that the means of egress are free of obstructions.

4. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify the proper functionality of all emergency exit doors in accordance with NFPA 101 requirements. Results of the audits will be reviewed at the QAPI meeting held monthly.

NFPA 101 STANDARD Doors with Self-Closing Devices:

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: MAIN BUILDING 01 (WEST BUILDING) - Component: 01 - Tag: 0223 Based on observation and interview, it was determined the facility failed to ensure that doors to hazardous area enclosures are maintained and positively latching, affecting one of two levels. Findings include: 1. Observation made on September 22, 2025, at 10:35 a.m., revealed a rated door that had a broken mag-lock assembly and failed to positively latch when tested, first floor Laundry Folding Room. Exit Interview with the Administrator and Maintenance Director on September 22, 2025, at 1:15 p.m., confirmed the door deficiencies.

Plan of Correction - To be completed: 12/29/2025

1. On 10/2/2025 the Maintenance Director repaired the magnetic housing device in the first-floor laundry folding room. The Maintenance Director also adjusted the hardware on the door to achieve positive latching.

2. On 10/2/2025 the Maintenance Director inspected all doors with a mag lock assembly to verify proper functionality and positive latching.

3. On 10/2/2025 the NHA educated the maintenance team on maintaining doors to hazardous areas enclosures are maintained and doors positively latch in accordance with NFPA 101 requirements.

4. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify that enclosures are maintained, and doors positively latch per NFPA 101 requirements. Results of the audits will be reviewed at the QAPI meeting held monthly.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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 (WEST BUILDING) - Component: 01 - Tag: 0353 Based on observation and interview facility failed to ensure sprinkler system would activate in a timely manner in two of two levels within the component. Findings include: 1. Observation on September 22, 2025, between 10:30 a.m., and 12:45 p.m., revealed in the following areas. a) Basement Central Supply Storage room was missing large portions of the drywalled ceiling which could delay the activation of the sprinkler system. b) First floor Service Corridor had an eggcrate in place of a missing smoke/fire rated ceiling tile, which creates a plenum, and could delay the activation of the sprinkler system. Exit Interview with the Administrator and Maintenance Director on September 22, 2025, at 1:15 p.m., confirmed the missing ceilings.

Plan of Correction - To be completed: 12/29/2025

1. On 10/9/2025, the Maintenance Director team repaired the drywalled ceiling in the basement central supply room. (B) On 9/22/2025 the Maintenance Director replaced the egg crate ceiling tile with a solid ceiling tile.

2. The maintenance team conducted an audit of all ceiling tiles and ceiling assemblies. Repairs were made where necessary to maintain a smoke resistant ceiling in accordance with NFPA requirements.

3. On 10/2/2025 The Maintenance Director was educated by the NHA on maintaining a smoke resistant ceiling.

4. The Maintenance Director and/or designee will conduct ceiling tile audits weekly for 4 weeks. Results of the audits will be reviewed at the monthly QAPI meeting.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 (WEST BUILDING) - Component: 01 - Tag: 0355 Based upon observation and interview, it was determined the facility failed to ensure that portable fire extinguishers were inspected on one of two levels within this component. Findings Include: 1. Observations made on September 22, 2025, between 10:30 a.m., and 12:45 p.m., revealed fire extinguishers missing monthly quick checks in the following locations: a) Elevator room fire extinguisher was missing all quick checks since May 2025. b) Kitchen fire extinguisher was missing all quick checks since May 2025. Exit Interview with the Administrator and Maintenance Director on September 22, 2025, at 1:15 p.m., confirmed the extinguishers were missing monthly quick checks in the above-named locations.

Plan of Correction - To be completed: 12/29/2025

1. On 9/22/2025 the Maintenance assistant inspected the fire extinguishers in the elevator room and in the kitchen.

2. On 9/22/2025 the maintenance team conducted an audit of all fire extinguishers to verify that monthly inspection documentation was present.

3. On 10/2/2025 The NHA educated the Maintenance Director on fire extinguishers being properly installed, maintained, and inspected per code.

4. The Maintenance Director will conduct monthly inspections on fire extinguishers. Results of the inspections will be reviewed at the monthly QAPI meeting.

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 (WEST BUILDING) - Component: 01 - Tag: 0363 Based on observation and interview, it was determined the facility failed to ensure that corridor doors positively latched into the door frame and remained closed in the frame, affecting two of over forty doors within the component. Findings include: 1. Observations made on September 22, 2025, between 10:30 a.m. and 10:40 a.m., revealed corridor doors that failed to latch in the following locations: a. 10:30 a.m., on the first floor, Service Hallway Kitchen door 1. b. 10:40 a.m., on the first floor, Service Hallway Kitchen door 2. Exit Interview with the Administrator and Maintenance Director on September 22, 2025, at 1:15 p.m., confirmed the doors failed to latch in the above-named locations. 2. Observations made on September 22, 2025, between 10:30 a.m. and 12:45 p.m., revealed corridor doors that failed to latch in the following locations: a. Resident room 111 failed to latch. Exit Interview with the Administrator and Maintenance Director on September 22, 2025, at 1:15 p.m., confirmed the doors failed to latch in the above-named locations.

Plan of Correction - To be completed: 12/29/2025

1. The Maintenance Director has engaged a vendor to repair Service Hallway doors 1 and 2. (2) On 9/23/2025 The Maintenance Director replaced the door hardware in room 111 with positive latching hardware.

2. On 9/23/2025 the Maintenance Director/Designee audited corridor doors to verify corridor doors latch to their frame.

3. On 10/2/2025 the Administrator educated the Maintenance department Director on ensuring corridor doors latch to their frame.

4. The Administrator/Designee will conduct audits of corridor doors weekly for 4 weeks to ensure corridor doors latch to their frame. The results of the audits will be reviewed at the QAPI meeting held monthly.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: MAIN BUILDING 01 (WEST BUILDING) - Component: 01 - Tag: 0372 Based on observation and interview it was determined that the facility failed to ensure that smoke barrier walls were complete and maintained free of unsealed penetrations on one of one story within this component. 1. Observations made on September 22, 2025, between 10:30 a.m., and 12:45 p.m., revealed unsealed penetrations of smoke barrier walls in the following locations: a) Unsealed electrical conduit penetration, above smoke barrier doors outside of the Copy / Admin area. Exit Interview with the Administrator and Maintenance Director on September 22, 2025, at 1:15 p.m.,confirmed the unsealed penetrations of the smoke barrier walls in the above location.

Plan of Correction - To be completed: 12/29/2025

1. On 9/23/2025 The Maintenance Assistant sealed the electrical conduit penetration above the smoke barrier doors outside of the copy/admin area using an UL approved stop gap penetration system.

2. The Maintenance team inspected all smoke barrier walls for penetration. Repairs were made as needed.

3. On 10/2/2025 the NHA educated the maintenance team on maintaining the integrity of smoke barrier walls.

4. The Maintenance Director and/designee will conduct audits of smoke barrier walls to check for penetrations weekly for 4 weeks. Results of the audits will be reviewed at the QAPI meeting held monthly.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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

Observations:
Name: MAIN BUILDING 01 (WEST BUILDING) - Component: 01 - Tag: 0374 Based on observation and interview, it was determined the facility failed to maintain smoke doors affecting one of two levels. Findings include: 1. Observation on September 22, 2025, at 10:55 a.m., revealed the double corridor, smoke doors would not close smoke tight, first floor service corridor that leads to the West Wing. Exit Interview with the Administrator and Maintenance Director on September 22, 2025, at 1:15 p.m., confirmed the doors failed to close smoke tight.

Plan of Correction - To be completed: 12/29/2025

1. On 9/22/2025 the Maintenance Director adjusted the double corridor doors leading to the West Wing to ensure the doors close properly and resist the passage of smoke.

2. On 9/22/2025 the Maintenance Director inspected all smoke doors to verify that they closed smoke tight.

3. On 9/22/2025 the NHA educated the maintenance team on maintaining smoke barrier doors in accordance with NFPA 101 requirements.

4. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify that smoke barrier doors are in accordance with NFPA 101 requirements. Results of the audits will be reviewed at the QAPI meeting held monthly.

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 (WEST BUILDING) - Component: 01 - Tag: 0521 Based on document review and interview, it was determined the facility failed to maintain and inspect HVAC systems, affecting the entire facility. Findings include: 1. Document review on September 22, 2025, at 8:45 a.m., revealed that the facility could not provide documentation that the fire/smoke dampers inspection was performed within the past 4 years. Exit Interview with the Administrator and Maintenance Director on September 22, 2025, at 1:15 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 12/29/2025

1. The Maintenance Director has contacted a vendor to conduct a Smoke/Fire Damper inspection. Documentation will be available upon completion of the inspection.

2. On 9/22/2025 the Maintenance Director reviewed documentation to verify that all other inspections for the HVAC system were current.

3. On 10/2/2025the NHA educated the maintenance team on maintaining and inspecting the HVAC system.

4. The Maintenance Director and/or designee will conduct audits weekly for 4 weeks of HVAC systems inspections and documentation are current. Results of the audits will be reviewed at the QAPI meeting held monthly.

NFPA 101 STANDARD Electrical Systems - Other:

Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 (WEST BUILDING) - Component: 01 - Tag: 0911 Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, affecting one of two levels. Findings include: 1. Observation on September 22, 2025, at 11:25 a.m., revealed two electrical elevator panels were missing their protective cover plates, on the first floor, Elevator Room near Business Office. Exit Interview with the Administrator and Maintenance Director on September 22, 2025, at 1:15 p.m., confirmed the missing cover plates. Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, affecting one of two levels within the component. Findings include: 2. Observation on September 22, 2025, at 10:50 a.m., revealed a surface mounted quad box receptacle, unsecured from wall mounting within the laundry folding room. Exit Interview with the Administrator and Maintenance Director on September 22, 2025, at 1:15 p.m., confirmed the unsecured surface mounted box.

Plan of Correction - To be completed: 12/29/2025

1. On 9/22/2025 the Maintenance Supervisor installed the protective cover plates on the two electrical panels in the elevator room. On 9/22/2025 the Maintenance Director mounted the quad box receptacle in the laundry folding room.

2. On 9/22/2025 the maintenance team inspected all electrical panels and quad box receptacles to verify proper mounting.

3. On 9/22/2025 the Administrator educated the Maintenance Department on K-tag 911 regarding maintaining the protection of electrical wiring.

4. The Maintenance Director/Designee will conduct audits weekly for 4 weeks to ensure no exposed wiring or cover plates for electrical panels are missing. Audits will be reviewed at the QAPI meeting held monthly.

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 (WEST BUILDING) - Component: 01 - Tag: 0918 Based on document review and interview, it was determined the facility failed to maintain and test the generator, affecting one of nine emergency generator reports. Findings include: 1. Document review on September 22, at 8:45 a.m., revealed the facility could not produce documentation of the Annual Fuel Quality Test. Exit Interview with the Administrator and Maintenance Director on September 22, 2025, at 1:15 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 12/29/2025

1. On 10/10/2025 the Annual Fuel Quality Test was conducted for the emergency generator.

2. The Maintenance Director verified that the Annual Fuel Quality Test was added to TELS (preventative maintenance system).

3. On 10/2/2025 the NHA educated the maintenance team on maintaining the testing/inspections requirements for the emergency generator.

4. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify testing/inspection documentation is present for the emergency generator. Results of the audits will be reviewed at the QAPI meeting held monthly.

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 01 (WEST BUILDING) - Component: 01 - Tag: 0923 Based on observation and interview, it was determined the facility failed to ensure medical gas cylinders were properly stored one of two levels within this component. Findings include: 1. Observations made on September 22, 2025 between 10:30 a.m., and 12:45 p.m., revealed (2) freestanding unsecured oxygen cylinders in the Medicine Room, West Wing C. Exit Interview with the Administrator and Maintenance Director on September 22, 2025, at 1:15 p.m., confirmed the unsecured oxygen cylinders.

Plan of Correction - To be completed: 12/29/2025

1. On 9/22/2025 the Maintenance Director immediately secured the free-standing oxygen cylinder located in the West Wing C side medication room.

2. On 9/22/2025 the maintenance team inspected all medication rooms to verify that all oxygen cylinders were properly secured.

3. On 9/22/25 the NHA educated the all staff team on proper storage and transportation of oxygen cylinders.

4. The Maintenance Director and/or designee will conduct audits weekly for 4 weeks to verify oxygen cylinders are stored properly. Results of the audits will be reviewed at the QAPI meeting held monthly.

Initial comments:Name: BUILDING 02 (EAST & SOUTH ADDITION) - Component: 02 - Tag: 0000
Facility ID 032202

Component 02

East &; South Addition

Based on a Medicare/Medicaid Recertification Survey completed on September 22, 2025, it was determined that Cheltenham Nursing And Rehabilitation Center - East &; South Addition was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a four-story, Type II (000), unprotected non-combustible building, that is fully sprinklered.

Plan of Correction:

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: BUILDING 02 (EAST & SOUTH ADDITION) - Component: 02 - Tag: 0161 Based on document review and interview, it was determined the facility failed to maintain the building construction requirements, affecting the entire building. Findings include: Documentation review on September 22, 2025, at 8:45 a.m., revealed the facility has been classified as a four story, Type II (000), unprotected non-combustible construction, which is fully sprinklered. The building story height exceeds the maximum allowance for unprotected non-combustible construction by two stories. Exit Interview with the Administrator and Maintenance Director on September 22, 2025, at 1:15 p.m., confirmed the construction type and building height.

Plan of Correction - To be completed: 12/29/2025

The facility will be engaging a certified external auditor to conduct a comprehensive Fire Safety Evaluation System (FSES) audit. This audit will evaluate the facility's fire safety measures across all designated zones, ensuring that each area meets or exceeds the rigorous standards set forth by the FSES. A passing score for each zone is a critical requirement, as it will demonstrate the facility's commitment to maintaining a safe environment for all residents, staff, and visitors.
Upon successfully achieving a passing score in all zones, the facility will become eligible for the Centers for Medicare & Medicaid Services (CMS) approved time-limited waiver. This waiver will grant the facility an extension to comply with any remaining fire safety requirements that may need additional time or adjustments, while ensuring that essential safety measures are already in place to safeguard occupants in the interim.

The FSES audit will cover a range of critical fire safety aspects, including but not limited to: fire detection and alarm systems, emergency evacuation plans, fire suppression systems, staff training and preparedness, and overall compliance with both local fire codes and CMS regulations. Each zone will be meticulously assessed to identify potential vulnerabilities and areas for improvement, and the results will be used to implement necessary corrective actions.

Achieving a passing score not only ensures eligibility for the CMS time-limited waiver but also reflects the facility's proactive approach to maintaining a high standard of fire safety, protecting both the health and safety of all those within the facility and mitigating the risk of fire-related incidents.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Observations:
Name: BUILDING 02 (EAST & SOUTH ADDITION) - Component: 02 - Tag: 0353 Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system, affecting one of four levels. Findings include: 1. Observation on September 22, 2025, from 11:40 a.m. to 12:05 p.m., revealed the following sprinkler deficiencies: a. missing escutcheon, fourth floor East Side Lounge. b. escutcheon not properly mounted, second floor East Side Lounge. Exit Interview with the Administrator and Maintenance Director on September 22, 2025, at 1:15 p.m., confirmed the sprinkler deficiencies.

Plan of Correction - To be completed: 12/29/2025

1. On 9/23/2025 the Maintenance Director replaced the missing escutcheon in the fourth floor East side lounge and properly mounted the escutcheon in the second-floor East side lounge.

2. The maintenance team inspected all sprinkler heads throughout the facility to verify that all escutcheons were present and properly mounted. Repairs or replacements were made as necessary.

3. The NHA educated the maintenance team on maintaining the automatic sprinkler system per NFPA requirements.

4. The Maintenance Director and/or designee will conduct audits of the sprinkler system weekly for 4 weeks to verify that escutcheons are present and properly mounted. The results of the audits will be reviewed at the QAPI meeting held monthly.

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: BUILDING 02 (EAST & SOUTH ADDITION) - Component: 02 - Tag: 0541 Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of chutes, affecting two of four levels. Findings include: 1. Observation on September 22, 2025, from 11:40 a.m. to 12:05 p.m., revealed the following linen chute doors failed to self-close and latch when tested from the fully open position: a. 11:40 a.m., third floor South Wing. b. 12:05 p.m., second floor South Wing. Exit Interview with the Administrator and Maintenance Director on September 22, 2025, at 1:15 p.m., confirmed the chutes failed to self-close and latch.

Plan of Correction - To be completed: 12/29/2025

1. The Maintenance team replaced the latching hardware on the 2nd and 3rd floor South Wing linen chutes to ensure proper functioning.

2. The Maintenance Director inspected the linen chutes on other units and verified the proper functionality.

3. On 10/2/2025 the NHA educated the maintenance team on maintaining the fire resistance rating of the linen chutes in accordance with NFPA 101 requirements.

4. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify positive latching and the proper functionality of the linen chute doors. Results of the audits will be reviewed at the QAPI meeting held monthly.

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