Pennsylvania Department of Health
IVORY WELLNESS CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 46 surveys for this facility. Please select a date to view the survey results.

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


IVORY WELLNESS CENTER - 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 November 24, 2025, it was determined that Ivory Wellness Center, 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 observation and interview, it was determined the facility failed to review and update the emergency preparedness plan that was developed for the complete facility. Findings include: 1. Documentation review of the EP plan on November 24, 2025, at 9:30 am, revealed the EP plan did not reflect the present name of the facility, did not list the current administrative staff and was signed off, but not updated in the last twelve months. Exit interview with the Administrator and Maintenance Director on November 24, 2025, at 1:45 p.m. confirmed the EP Plan was not updated.

Plan of Correction - To be completed: 12/30/2025

The disaster plan was re-signed, updated, and corrected to reflect the current facility name and administrative staff.

All residents may be affected by this deficient practice.

The administrator or designee will audit the disaster plan monthly x 3 months to ensure the information contained within, is current and correct.
Findings of these audits will be presented at the facility's QAPI meeting. It will be determined at that time if continued audits are necessary.

403.748(d)(2), 416.54(d)(2), 418.113(d)(2), 441.184(d)(2), 482.15(d)(2), 483.475(d)(2), 483.73(d)(2), 484.102(d)(2), 485.542(d)(2), 485.625(d)(2), 485.68(d)(2), 485.727(d)(2), 485.920(d)(2), 486.360(d)(2), 491.12(d)(2), 494.62(d)(2) STANDARD EP Testing Requirements:

§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).

*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:

(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:

(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.

*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.

(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.

*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.

*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.

*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.

*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.

*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.

*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.

*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.

Observations:
Name: - Component: -- - Tag: 0039 Based on document review and interview, it was determined the facility failed to conduct the required annual-full scale exercise and additional exercise to test the emergency preparedness plan, affecting the entire facility. Findings include: Document review on November 24, 2025, at 10:15 a.m., revealed the facility failed to conduct the required annual-full scale exercise and additional exercise to test the emergency preparedness plan within the previous 12 months. Exit interview with the Administrator and Maintenance Director on November 24, 2025 at 1:45 p.m. confirmed the lack of required exercises.

Plan of Correction - To be completed: 12/30/2025

The annual disaster drill was conducted on 5/23/2025, and the paperwork was obtained. An additional disaster drill was conducted on 11/29/2025 and the paperwork was obtained,

All residents may be affected by this deficient practice.

The maintenance director or designee will audit the facility required inspections monthly x 3 months to ensure inspections are done timely and the paperwork is available for viewing.

Findings of these audits will be presented at the facility's QAPI meeting. It will be determined at that time if continued audits are necessary.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000
Facility ID# 125102Component 01Main BuildingBased on a Medicare/Medicaid Recertification Survey completed on November 24, 2025, it was determined that Ivory Wellness Center 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 three-story, Type II (000), unprotected non-combustible construction, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

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 01 - Component: 01 - Tag: 0161 Based on observation, document review and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire facility. Findings include: Document review on November 24, 2025, between 8:30 a.m., and 11:00 a.m., revealed the facility has been classified as a three story, Type II (000), unprotected non-combustible construction, that is fully sprinklered. The story height exceeds the maximum allowance by two stories. Exit Interview with the Administrator and Maintenance Director on November 24, 2025, at 1:45 p.m., confirmed the building height exceeded the maximum allowed.

Plan of Correction - To be completed: 12/30/2025

Towne Manor East would like the Department of Health and Human Services Life Safety Divisions assistance with reapplying for another FSES for three-story type II (000), unprotected noncombustible construction, that is fully sprinklered. The story height exceeds the maximum allowance by two stories. The facility has submitted a TLW with the DOH on 12/29/2025 as part of this POC.
The Administrator or designee is responsible for monitoring this annually to ensure that the waiver is place and up to date.
All residents may be affected by this deficient practice.

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 01 - Component: 01 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintain a hazardous area enclosure in one of five smoke compartments of the facility. Findings include: 1.Observation on November 24, 2025 between 8:30 a.m. and 11:00 a.m., in basement conference/multi-purpose room, revealed a chair propping a door (with a closure) preventing the door to latch as multiple employees were observed propping the door and loading combustible materials into space. Conference/multi-purpose room is larger than 50 sq ft and doubles as a general storage location for multiple departments. Exit interview with the Administrator and Maintenance Director on November 24, 2025, at 1:45 p.m., confirmed that staff propped door open when loading items and left a chair within doorframe when unattended.

Plan of Correction - To be completed: 12/30/2025

The chair was removed to allow administrative conference room door to close freely. All residents may be affected by this deficient practice.
Administrative staff will be educated not to obstruct doorways with rooms containing combustible material.
Maintenance director or designee will randomly audit the facility weekly x 4 weeks to ensure that doors to areas containing combustible material close freely. Findings of these audits will be presented at the facility's QAPI meeting. It will be determined at that time if continued audits are necessary.

NFPA 101 STANDARD Cooking Facilities:

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

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324 Based on document review and interview, it was determined the facility failed to maintain and inspect the kitchen hood suppression system, affecting two of four inspections. Findings include: 1. Document review on November 24, 2025, at 10:15 a.m., revealed the facility could not produce documentation of a semi-annual kitchen hood suppression system inspection within 6 months of 3/3/2025. Exit interview with the Administrator and Maintenance Director on November 24, 2025, at 1:45 p.m. confirmed the lack of documentation. 2. Document review on November 24, 2025, at 10:20 a.m., revealed the facility could not produce documentation of a semi-annual kitchen hood cleaning within 6 months of 4/15/2025. Exit interview with the Administrator and Maintenance Director on November 24, 2025, at 1:45 p.m. confirmed the lack of documentation. 3. Document review on November 24, 2025 at 10:17 a.m., revealed the last semi- annual kitchen hood suppression report dated 3/3/2025 reported the following deficiencies and note: a) System Cylinder is due for hydrostatic testing or replacement. b) System Cartridge is due for replacement. c) Pipe Integrity is due. d) SVA (System Valve Actuator) due for replacement. e) Note* - The pull station is located by the dishwasher area and should be relocated due to the steam from the dishwasher. Exit interview with the Administrator and Maintenance Director on November 24, 2025, at 1:45 p.m. confirmed documentation of repairs was not available.

Plan of Correction - To be completed: 12/30/2025

On 12/9/2025 the hood cleaning company performed the semi-annual hood cleaning.
The mechanical company has performed the semi-annual inspection on the kitchen suppression system on 12/19/2025.
The facility has also signed the proposal to relocate the fire pull station in the dish room.
On 5/27/25 the mechanical company performed the repairs as stated:
a) System Cylinder that was due for hydrostatic testing or
replacement.
b) System Cartridge that was due for replacement
c) Pipe Integrity.
d) SVA (System Valve Actuator) replaced.
Paperwork was obtained indicating the aforementioned repairs.

All residents may be affected by this deficient practice.

The maintenance director or designee will audit the facility required inspections monthly x 3 months to ensure inspections and repairs are done timely and the paperwork is available for viewing.

Findings of these audits will be presented at the facility's QAPI meeting. It will be determined at that time if continued audits are necessary.

NFPA 101 STANDARD Fire Alarm System - Initiation:

Fire Alarm System - Initiation
Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200' travel distance is not exceeded.
18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0342 Based on observation and interview, it was determined the facility failed to ensure fire alarm notification devices were maintained, affecting two of three levels within in the facility. Findings include: Observation on November 24, 2025, between 11:00 a.m., and 1:30 p.m., revealed:a) The wall mounted manual pull station on First floor, outside the DON office and next to 1st South stairwell, was obstructed by a med cart. b) The wall mounted manual pull station on Ground floor, next to G South stairwell, was obstructed by a med cart. Exit interview with the Administrator and Maintenance Director on November 24, 2025, at 1:45 p.m., confirmed the obstructed pull stations.

Plan of Correction - To be completed: 12/30/2025

The cart was immediately removed from the areas obstructing the fire pull stations. A sign was placed on the wall in the affected areas that states "no equipment shall be placed in this area"

All residents may be affected by this deficient practice.

Nursing staff will be educated not to place equipment or carts in areas with a fire pull station.
Maintenance director or designee will perform random facility audits weekly, x 4 weeks to ensure that areas with fire pull stations are not obstructed.

Findings of these audits will be presented at the facility's QAPI meeting. It will be determined at that time if continued audits are necessary.

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 - Component: 01 - Tag: 0353 Based on document review and interview, it was determined the facility failed to maintain automatic sprinkler system components in operable condition, affecting the entire facility. Findings include: Document review on November 24, 2025, between 8:30 a.m., and 11:00 a.m., revealed the 5/5/2025, semi- annual sprinkler inspection report, noted the following deficiency:a) Dry side of piping on the main drain leaks at the threading when running water. Exit Interview with the Administrator and Maintenance Director on November 24, 2025, at 1:45 p.m., confirmed verification of repair was not available.

Plan of Correction - To be completed: 12/30/2025

On 5/21/25 the mechanical company replaced the 2" piping that was leaking at the threading. The paperwork was obtained.

All residents may be affected by this deficient practice.

The maintenance director or designee will audit the facility required inspections monthly x 3 months to ensure inspections and repairs are done timely and the paperwork is available for viewing

Findings of these audits will be presented at the facility's QAPI meeting. It will be determined at that time if continued audits are necessary.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918 Based on document review, observation, and interview, it was determined the facility failed to maintain required testing of emergency generator components, affecting one generator. Findings Include: 1. Document review on November 24, 2025, between 8:30 a.m., and 11:00 a.m., and observation of EES generator at 1:40 p.m., revealed the facility lacked testing and verifying documentation of repairs regarding reported deficiencies on the 5/28/2025 report by contractor "The Generator Guy". Upon survey exit, a newer report was provided by a different contractor dated 11/17/2025. New report did not state or include the previous deficiencies. Visual inspection of EES confirmed and verified the below listed deficiencies from the 5/28/25 report was not addressed at time of survey. EES installed battery is dated 12/2021. Coolant quality status is unknown. a) Testing- Annual 90-minute Load Bank Report (diesel only) if cannot meet 30% of nameplate was not available for review. b) 5/28/25 Deficiency - "Generator coolant is very poor, coolant system service needed" c) 5/28/25 Deficiency - "Battery life is poor and needs to be replaced - Still waiting on approval for both to be done" d) "No evidence of Wet Stacking" is not listed or indicated on annual reports that were available and reviewed. Exit interview with the Administrator and Maintenance Director on November 24, 2025, at 1:45 p.m., discussed that the recent 11/17/2025 report cannot be accepted as a clean report as we have verified together, that the prior reported deficiency issues remain at time of annual survey event.

Plan of Correction - To be completed: 12/30/2025

On 11/26/25 the generator company performed a two-hour building load test, installed new batteries, and performed additional coolant testing with new samples. Paperwork was obtained for these repairs, which also indicates "no wet stacking".

All residents may be affected by this deficient practice.

The maintenance director or designee will audit the facility required inspections monthly x 3 months to ensure inspections and repairs are done timely and the paperwork is available for viewing

Findings of these audits will be presented at the facility's QAPI meeting. It will be determined at that time if continued audits are necessary.

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 01 - Component: 01 - Tag: 0920 Based on observation and interview, it was determined the facility failed to prohibit the improper and unauthorized use of electrical devices, affecting one of three levels. Findings include: 1. Observation on November 24, 2025, at 12:25 p.m., on First floor, inside DON office, revealed an orange extension cord appearing to power a power strip, underneath the DON desk. Exit Interview with the Administrator and Maintenance Director on November 24, 2025, at 1:45 p.m., confirmed the unauthorized use of electrical devices.

Plan of Correction - To be completed: 12/30/2025

The extension cord was immediately removed from the DON office.

All residents may be affected by this deficient practice.

Administrative nursing staff will be educated on the use of power strips and extension cords.
Maintenance director or designee will randomly audit the facility weekly x 4 weeks to ensure that no extension cords are being used.

Findings of these audits will be presented at the facility's QAPI meeting. It will be determined at that time if continued audits are necessary.

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 - Component: 01 - Tag: 0923 Based on observation and interview, it was determined the facility failed to ensure oxygen cylinders stored within rooms, were distanced from combustible materials / ignition sources in one of three levels within this component. Findings include: 1. Observation made on November 24, 2025, between 11:00 a.m., and 1:30 p.m., revealed: a) Behind nurse's station First floor, oxygen cylinders were stored less than five feet from electrical receptacles, electrical equipment and electrical panel. b) Behind nurse's station Ground floor, oxygen cylinders were stored less than five feet from electrical receptacles, electrical equipment and electrical panel. Exit Interview with the Administrator and Maintenance Director on November 24, 2025, at 1:45 P.M., confirmed that the cylinders were stored less than five feet from combustible / ignition sources.

Plan of Correction - To be completed: 12/30/2025

The oxygen tanks on both nursing units were relocated away from the electric panel

All residents may be affected by this deficient practice.

Maintenance director or designee will randomly audit the facility weekly x 4 weeks to ensure that oxygen tanks are properly stored according to the regulation.

Findings of these audits will be presented at the facility's QAPI meeting. It will be determined at that time if continued audits are necessary.

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