Pennsylvania Department of Health
ANN'S CHOICE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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ANN'S CHOICE - 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 May 12, 2026, at Ann's Choice, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000
Facility ID# 18860201

Component 01

Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 12, 2026, it was determined that Ann's Choice 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 (222), fire resistive building, with basement and unused attic spaces, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Emergency Lighting:

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.

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0291 Based on document review, and interview, it was determined the facility failed to maintain its emergency lighting, affecting one of four levels. Findings include: 1. Document review on May 12, 2026, at 9:00 am, revealed the facility lacked documentation of the following required tests of the battery back-up lighting: a. monthly 30-second testing. b. annual 90-minute test. Exit interview with Assistant Administrator and Maintenance Director on May 12, 2026, at 12:00 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 06/18/2026

1. The emergency lighting was confirmed operational on the May audit completed 5/11/26.
2. A review of documentation indicated a 3-month gap in auditing from August 2025-December 2025. Audits resumed in January 2026 and were completed through May 2026.
3. NHA or designee will educate the Maintenance Director on the requirement to maintain documentation of the following required tests of the battery back-up lighting: monthly 30-second testing and annual 90-minute test.
4. NHA or designee will audit monthly for 3 months to ensure documentation of the battery back-up lighting test is completed.
5. Results of audits will be presented at the monthly Quality Assurance/Performance Improvement (QAPI) meeting. Additional audits may be determined based on review of findings.

NFPA 101 STANDARD Exit Signage:

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0293 Based on document review and interview, it was determined the facility failed to ensure that exit signs were maintained, affecting five of twelve required inspections. Findings include: 1. Document review on May 12, 2026, at 9:30 a.m., revealed the facility could not produce documentation showing monthly exit sign inspections that were conducted August - December, 2025. Exit interview with Assistant Administrator and Maintenance Director on May 12, 2026, at 12:00 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 06/18/2026

1. The exit signs were confirmed operational on the May audit completed 5/11/26.
2. A review of documentation indicated a 3-month gap in auditing from August 2025-December 2025. Audits resumed in January 2026 and were completed through May 2026.
3. NHA or designee will educate the Maintenance Director on the requirement to maintain documentation showing that monthly exit sign inspections were conducted.
4. NHA or designee will audit monthly for 3 months to ensure documentation is completed showing that monthly exit sign inspections were conducted.
5. Results of audits will be presented at the monthly Quality Assurance/Performance Improvement (QAPI) meeting. Additional audits may be determined based on review of findings.

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 - Component: 01 - Tag: 0521 Based on document review and interview, it was determined the facility failed to maintain Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting one of four levels. Findings include: 1. Document review on May 12, 2026, at 9:30 am, revealed the February 2026 fire damper inspection report listed 3- failed dampers and 10- as inaccessible. Documentation of subsequent repairs was not available at time of survey. Exit interview with Assistant Administrator and Maintenance Director on May 12, 2026, at 12:00 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 06/18/2026

1. Repair of the 3 failed dampers was completed 6/3/2026 and inspection of the 10 inaccessible dampers is scheduled for 6/9/ 2026.
2. NHA or designee will educate the Maintenance Director on the requirement to maintain Heating, Ventilating and Air Conditioning (HVAC) equipment, including maintaining documentation of fire damper inspections and subsequent repairs.
3. NHA or designee will audit the fire damper inspection report to ensure all dampers are inspected and documentation of subsequent repairs is completed.
4. Results of audits will be presented at the monthly Quality Assurance/Performance Improvement (QAPI) meeting. Additional audits may be determined based on review of findings.

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