Pennsylvania Department of Health
CARING HEART REHABILITATION AND NURSING CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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CARING HEART REHABILITATION AND NURSING 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 June 3, 2026, it was determined that Caring Heart Rehabilitation and Nursing Center 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 documentation review and interview, it was determined the facility failed to ensure Emergency Preparedness Plan policies and procedures were reviewed and updated at least annually, affecting the entire facility. Findings include: 1. Document review on June 3, 2026, at 9:00 a.m., revealed the Facility's Emergency Preparedness Plan had not been properly reviewed and updated within the annual review cycle per 42 CFR interview with the Regional Manager, Administrator, and Maintenance Manager on June 3, 2026, at 1:30 p.m., confirmed the EPP documentation was not updated.

Plan of Correction - To be completed: 07/20/2026

- The facility's Emergency Preparedness Plan (EPP) was reviewed, updated, and finalized for the current annual cycle.
- The Maintenance Director was re-educated on the requirement to review and update the EPP annually.
- The Administrator or designee will audit EPP updates. Monthly audits times 3 will continue with results reported to the QA Committee.

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 documentation review and interview, it was determined the facility failed to ensure the Emergency Preparedness Plan was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach and including strategies for addressing emergency events identified by risk assessments. Findings include: 1. Document review on June 3, 2026, at 9:00 a.m., revealed the Facility's Emergency Preparedness Plan did not include an updated documented community-based risk assessment and facility-based HVA resulting in the inability to utilize an all-hazards approach for developing strategies for addressing emergency events identified by the risk assessments performed as per 42 CFR Exit interview with the Regional Manager, Administrator, and Maintenance Manager on June 3, 2026, at 1:30 p.m., confirmed the outdated Hazard Vulnerability Assessments.

Plan of Correction - To be completed: 07/20/2026

- A documented community-based and facility-based Hazard Vulnerability Assessment (HVA) was completed and integrated into the emergency plan.
- The Maintenance Director was re-educated on utilizing the updated HVA to drive facility emergency strategies.
- The Director of Maintenance or designee will audit risk assessment data monthly. Monthly audits times 3 will continue with results reported to the QA Committee.

403.748(a)(3), 416.54(a)(3), 418.113(a)(3), 441.184(a)(3), 482.15(a)(3), 483.475(a)(3), 483.73(a)(3), 484.102(a)(3), 485.542(a)(3), 485.625(a)(3), 485.68(a)(3), 485.727(a)(3), 485.920(a)(3), 491.12(a)(3), 494.62(a)(3) STANDARD EP Program Patient Population:

§403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3).

[(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:]

(3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.**

*[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 all of the following:
(3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.

*NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.]

Observations:
Name: - Component: -- - Tag: 0007 Based on document review and interview, it was determined the facility failed to ensure policies and procedures were in place addressing patient population, including, but not limited to, persons at-risk; the type of services the facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans, affecting the entire facility. Findings include: 1. Document review on June 3, 2026, at 9:00 a.m., revealed Facility's Emergency Preparedness Plan failed to include policies and procedures addressing patient population, including, but not limited to, persons at-risk; the type of services the facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. Exit interview with the Regional Manager, Administrator, and Maintenance Manager on June 3, 2026, at 1:30 p.m., confirmed the missing patient population vulnerability assessment.

Plan of Correction - To be completed: 07/20/2026

- Policies addressing the vulnerable resident population, available emergency services and delegations of authority, were added to the EPP.
- The Maintenance Director was re-educated on the updated resident population vulnerability protocols and chain of command.
- The Administrator or designee will audit emergency staffing and succession logs monthly. Monthly audits times 3 will continue with results reported to the QA Committee.

403.748(a)(4), 416.54(a)(4), 418.113(a)(4), 441.184(a)(4), 482.15(a)(4), 483.475(a)(4), 483.73(a)(4), 484.102(a)(4), 485.542(a)(4), 485.625(a)(4), 485.68(a)(4), 485.727(a)(5), 485.920(a)(4), 486.360(a)(4), 491.12(a)(4), 494.62(a)(4) STANDARD Local, State, Tribal Collaboration Process:

§403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4)

[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:]

(4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. *

* [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.

Observations:
Name: - Component: -- - Tag: 0009 Based on document review and interview, it was determined the facility failed to develop and maintain an emergency preparedness plan that included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts, affecting the entire facility. Findings include: 1. Document review on June 3, 2026, at 9:00 a.m., revealed the facility failed to develop and maintain an emergency preparedness communication plan that included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts. Exit interview with the Regional Manager, Administrator, and Maintenance Manager on June 3, 2026, at 1:30 p.m., confirmed the missing external agency collaboration processes.

Plan of Correction - To be completed: 07/20/2026

- Facility reached out The OEM of Philadelphia to establish a collaborative connection.
- The Maintenance Director was re-educated on requirements to initiate and document annual contact with local emergency management agencies.
- The Maintenance Director or designee will audit external agency contact logs monthly. Monthly audits times 3 will continue with results reported to the QA Committee.

403.748(b), 416.54(b), 418.113(b), 441.184(b), 482.15(b), 483.475(b), 483.73(b), 484.102(b), 485.542(b), 485.625(b), 485.68(b), 485.727(b), 485.920(b), 486.360(b), 491.12(b), 494.62(b) STANDARD Development of EP Policies and Procedures:

§403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b).

(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years.

*[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.

*Additional Requirements for PACE and ESRD Facilities:

*[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years.

*[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area.

Observations:
Name: - Component: -- - Tag: 0013 Based on documentation review and interview, it was determined the facility failed to ensure emergency preparedness policies and procedures, based on the emergency plan, risk assessment and communication plan, were updated at least annually, affecting the entire component. Findings include: 1. Document review on June 3, 2026, at 9:00 a.m., revealed the facility could not provide an emergency preparedness plan facility-based/community-based risk assessment which is one of the components required to update the emergency preparedness policies and procedures annually. Exit interview with the Regional Manager, Administrator, and Maintenance Manager on June 3, 2026, at 1:30 p.m., confirmed the missing external agency collaboration processes.

Plan of Correction - To be completed: 07/20/2026

- Emergency preparedness policies and procedures were updated to align with the newly revised facility and community risk assessments.
- The Maintenance Director was re-educated on anchoring emergency policy updates to active risk assessments annually.
- The Administrator or designee will audit emergency policies monthly. Monthly audits times 3 will continue with results reported to the QA Committee

483.475(c)(8), 483.73(c)(8) STANDARD LTC and ICF/IID Sharing Plan with Patients:

§483.73(c)(8); §483.475(c)(8)

*[For LTC Facilities at §483.73(c):]
[(c) The LTC facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually. The communication plan must include all of the following:]

*[For ICF/IIDs at §483.475(c):]
[(c) The ICF/IID must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years. The communication plan must include all of the following:]

(8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.

Observations:
Name: - Component: -- - Tag: 0035 Based on document review and interview, it was determined the facility failed to maintain and update an emergency preparedness communication plan that includes a method for sharing information from the emergency plan, that the facility has determined appropriate, with residents and their families or representatives. Findings include: 1. Document review and interview on June 3, 2026, at 9:00 a.m., revealed the emergency communications plan did not include a method of sharing information from the emergency plan with residents and their families or representatives, affecting the entire facility. Exit interview with the Regional Manager, Administrator, and Maintenance Manager on June 3, 2026, at 1:30 p.m., confirmed the missing communication processes.

Plan of Correction - To be completed: 07/20/2026

- A communication template for sharing appropriate emergency plan information with residents and families was implemented.
- The Maintenance Director was re-educated on the mandate to maintain a method for sharing EPP summaries with residents and representatives.
- The Director of Social Services or designee will audit family notification logs monthly. Monthly audits times 3 will continue with results reported to the QA Committee.

Initial comments:Name: MAIN BUILDING 01 (CLIVEDEN) - Component: 01 - Tag: 0000
Facility ID# 191802

Component 01

Main (Cliveden) Building

Based on a Medicare/Medicaid Recertification Survey completed on June 3, 2026, it was determined that Caring Heart Rehabilitation And Nursing Center - Main Cliveden 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 five-story, Type II (222), fire resistive building, with a penthouse, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies - Construction Type:

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.

Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3

Observations:
Name: MAIN BUILDING 01 (CLIVEDEN) - Component: 01 - Tag: 0133 Based on observation and interview, it was determined the facility failed to maintain the fire resistance of fire barriers, affecting one six floors. Findings include: 1. Observation on June 3, 2026, at 11:50 a.m., revealed a penetration surrounding a data line, on the first floor, above double fire doors near the front lobby. Exit interview with the Regional Manager, Administrator and Maintenance Manageron June 3, 2026, at 1:30 p.m.,confirmed the fire wall penetration.

Plan of Correction - To be completed: 07/20/2026

- The open penetration surrounding the data line above the first-floor front lobby fire doors was sealed with fire-rated material.
- The Maintenance Director was re-educated on maintaining fire barriers and properly sealing data line penetrations.
- The Director of Maintenance or designee will audit fire barriers weekly x 4. Monthly audits times 3 will continue with results reported to the QA Committee.

NFPA 101 STANDARD Means of Egress - General:

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 (CLIVEDEN) - Component: 01 - Tag: 0211 Based on observation and interview, it was determined the facility failed to maintain means of egress free of obstructions, affecting one of six floors. Findings include: 1. Observation on June 3, 2026, at 11:30 a.m., revealed the door required excessive force to open, on the first floor, Emergency Exit door near Laundry Storage Room. Exit interview with the Regional Manager, Administrator and Maintenance Manager, on June 3, 2026, at 1:30 p.m., confirmed the deficient emergency door. 2. Observation on June 3, 2026, at 12:05 p.m., revealed the double doors leading to an enclosed courtyard could be mistaken for an exit and lacked signage indicating "Not an Exit", on the first floor, near Mr. Airy entrance doors. Exit interview with the Regional Manager, Administrator and Maintenance Manager on June 3, 2026, at 1:30 p.m.,confirmed the missing signage.

Plan of Correction - To be completed: 07/20/2026

- The first-floor exit door near Laundry Storage was repaired to open smoothly, and a "Not an Exit" sign was installed on the courtyard double doors near the Mt. Airy entrance.
- The Maintenance Director was re-educated on maintaining unobstructed egress routes, proper door operation, and required cautionary signage.
- The Director of Maintenance or designee will inspect exit doors and signage weekly. Monthly audits times 3 will continue with results reported to the QA Committee.

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 01 (CLIVEDEN) - Component: 01 - Tag: 0293 Based on observation and interview, it was determined the facility failed to ensure exit signs were maintained, affecting one of six floors. Findings Include: 1. Observation made on June 3, 2026, at 11:15 a.m., revealed an exit sign being held together with black duct tape and missing its front cover, on the first floor, near double corridor doors that lead to Laundry Room. Exit interview with the Regional Manager, Administrator and Maintenance Manager on June 3, 2026, at 1:30 p.m., confirmed the deficient exit sign.

Plan of Correction - To be completed: 07/20/2026

- The damaged exit sign near the first-floor Laundry Room corridor doors was replaced with a new cover assembly.
- The Maintenance Director was re-educated on replacing broken directional signage immediately instead of using temporary tape fixes.
- The Director of Maintenance or designee will audit exit signs weekly x4. Monthly audits times 3 will continue with results reported to the QA Committee.

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 (CLIVEDEN) - Component: 01 - Tag: 0324 Based on document review and interview, it was determined the facility failed to maintain and inspect the kitchen exhaust hood suppression system, affecting one of two suppression reports. Findings include: 1. Document review on June 3, 2026, at 9:00 a.m., revealed the semi-annual inspection report dated December 8, 2025, listed a deficiency that stated, "Class K is due for a hydrotest." Evidence of corrective action was not available at time of survey. Exit interview with the Regional Manager, Administrator and Maintenance Manager on June 3, 2026, at 1:30 p.m.,confirmed the missing documentation.

Plan of Correction - To be completed: 07/20/2026

- A certified hydrostatic test was conducted and documented for the Class K kitchen hood suppression cylinder.
- The Maintenance Director was re-educated on tracking hood suppression reports and resolving listed deficiencies immediately.
- The Director of Maintenance or designee will review vendor compliance schedules monthly. Monthly audits times 3 will continue with results reported to the QA Committee.

NFPA 101 STANDARD Fire Alarm - Control Functions:

Fire Alarm - Control Functions
The fire alarm automatically activates required control functions and is provided with an alternative power supply in accordance with NFPA 72.
18.3.4.4, 19.3.4.4, 9.6.1, 9.6.5, NFPA 72

Observations:
Name: MAIN BUILDING 01 (CLIVEDEN) - Component: 01 - Tag: 0344 Based on observation and interview, the facility failed to ensure fire alarm control functions were maintained on one of six floors. Findings include: 1. Observation on June 3, 2026, at 11:20 a.m., revealed the magnetically held fire door failed to close and latch due to a broken self-closer, on the first floor, Laundry Room. Exit interview with the Regional Manager, Administrator and Maintenance Manager on June 3, 2026, at 1:30 p.m., confirmed the broken self-closer.

Plan of Correction - To be completed: 07/20/2026

- A new self-closer mechanism was installed on the first-floor Laundry Room magnetic fire door to ensure automatic positive-latching upon alarm.
- The Maintenance Director was re-educated on inspecting automatic door-closing hardware and maintaining positive latching functions.
- The Director of Maintenance or designee will audit magnetic door release functions weekly x4. Monthly audits times 3 will continue with results reported to the QA Committee.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 (CLIVEDEN) - Component: 01 - Tag: 0353 Based on document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire facility. Findings include: 1. Document review on June 3, 2026, at 9:00 a.m., revealed the annual sprinkler report dated May 6, 2026, listed the following deficiencies: a. The water supply during the main drain testing is significantly lower (44.85 PSI) than the hydraulic calculations (08/22/18 05/06/26). This needs to be investigated. (This is being remedied by fire pump installation that is currently taking place 08/14/25). b. Tampers in Riser Room are not tied in and need to be ASAP (11/14/25 05/06/26). c. The data on the hydraulic nameplate appears to be incorrect and needs to be investigated. d. The control valve above ceiling in riser room reports to the panel as trouble and need to be reprogrammed as supervisory. e. The control valve in the Cliveden 1FL Stairwell C reports to the panel as trouble and needs to be reprogrammed as supervisory. f. The waterflow above the ceiling in the sprinkler room reports as main waterflow and no other waterflow switch was located during the time of inspection. g. Fire pump project was still ongoing at time of quarterly inspection. Certain tampers were disconnected until project is finished. Valves were locked and chained 08/14/25. Evidence of corrective action was not available at time of survey. Exit interview with the Regional Manager, Administrator and Maintenance Manager on June 3, 2026, at 1:30 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 07/20/2026

The concerns regarding the fire pump will be addressed once the project is complete. We are now under a TLW due to the fact that we are waiting for the electrical plans to be approved and then installed. I will send our latest TLW along with the letter from our Fire Pump vendor regarding the timeline, to Gwendolyn.

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 (CLIVEDEN) - Component: 01 - Tag: 0363 Based on observation and interview, it was determined the facility failed to ensure corridor doors were maintained to resist the passage of smoke, affecting one of six floors. Findings include: 1. Observation on June 3, 2026, at 11:15 a.m., revealed the door was missing from the hinges and frame, on the first floor Utility Room near the Soiled Laundry Room. Exit interview with the Regional Manager, Administrator and Maintenance Manager on June 3, 2026, at 1:30 p.m.,confirmed the missing door.

Plan of Correction - To be completed: 07/20/2026

- A replacement 1 3/4 inch solid-bonded core wood door was rehung on its hinges at the first-floor Utility Room near Soiled Laundry.
- The Maintenance Director was re-educated on the mandate requiring all corridor smoke doors to be maintained in place.
- The Director of Maintenance or designee will audit corridor doors weekly x4. Monthly audits times 3 will continue with results reported to the QA Committee

NFPA 101 STANDARD Operating Features - Other:

Operating Features - Other
List in the REMARKS section any LSC Section 18.7 and 19.7 Operating Features 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 in Form CMS-2567.

Observations:
Name: MAIN BUILDING 01 (CLIVEDEN) - Component: 01 - Tag: 0700 Based on document review and interview, it was determined the facility failed to institute policies ensuring the proper operation of the facility, affecting the entire facility. Findings include: 1. Document review on June 3, 2026, at 9:00 a.m., revealed the water supply during the main drain testing is significantly lower (44.85 PSI) than the hydraulic calculations. The facility failed to conduct and document the Fire Watch on multiple shifts as required per NFPA 101, (sections 9.6.1.6 and 9.7.6.) until the installation of a new fire pump and retest were completed. Exit interview with the Regional Manager, Administrator and Maintenance Manager on June 3, 2026, at 1:30 p.m., confirmed the missing fire watch shifts.

Plan of Correction - To be completed: 07/20/2026

- Action Taken: A continuous Fire Watch was implemented.
- Staff In-Servicing/Re-education: The Maintenance Director was re-educated on Fire Watch protocols, round timing, and documentation mandates during system impairment.
- QA Monitoring: The Administrator or designee will audit Fire Watch logs monthly until the system is fully compliant, with results reviewed by the QA Committee.

NFPA 101 STANDARD Fire Drills:

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 01 (CLIVEDEN) - Component: 01 - Tag: 0712 Based on document review and interview, it was determined the facility failed to perform one of twelve required fire drills. Findings include: 1. Document review on June 3, 2026, at 9:00 a.m., revealed the facility could not provide documentation that a fire drill was conducted for the first quarter, first shift, 2026. Exit interview with the Regional Manager, Administrator and Maintenance Manager on June 3, 2026, at 1:30 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 07/20/2026

- The facility was in a state of non-compliance for the fire drill for the first shift in the first quarter
- The Maintenance Director was re-educated on the mandate to conduct fire drills quarterly on each shift under varying conditions.
- The Director of Maintenance or designee will audit fire drill charts monthly. Monthly audits times 3 will continue with results reported to the QA Committee.

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 (CLIVEDEN) - Component: 01 - Tag: 0918 Based on document review, observation and interview, it was determined the facility failed to maintain and test the generator, affecting the entire facility. Findings include: 1. Document review on June 3, 2026, at 9:00 a.m., revealed the following deficiencies: a. Inspection/service report dated March 13, 2026, listed a deficiency that stated, "Block heater is not working and needs replaced. b. Inspection/service report dated October 21, 2025, listed deficiencies that stated, "Recommend replacement of oil cooler due to leak. Recommend replacement of valve covers due to leak. Recommend replacement of block heater." Evidence of corrective action was not available at time of survey. Exit interview with the Regional Manager, Administrator and Maintenance Manager on June 3, 2026, confirmed the missing documentation. 2. Observation on June 3, 2026, at 11:55 a.m., revealed the emergency generator annunciator panel was in trouble mode, Front Desk. Exit interview with the Regional Manager, Administrator and Maintenance Managerat on June 3, 2026, 1:30 p.m., confirmed the annunciator panel was in trouble mode.

Plan of Correction - To be completed: 07/20/2026

- The emergency generator block heater, oil cooler, and valve covers were repaired/replaced, and the front desk annunciator panel trouble mode was cleared.
- The Maintenance Director was re-educated on tracking generator service report deficiencies and monitoring annunciator errors.
- The Director of Maintenance or designee will inspect the annunciator panel daily and verify logs weekly. Monthly audits times 3 will continue with results reported to the QA Committee.

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 (CLIVEDEN) - Component: 01 - Tag: 0923 Based on observation and interview, it was determined the facility failed to ensure medical gas cylinders were properly stored, affecting one of six floors. Findings include: 1. Observation on June 3, 2021, at 11:35 a.m., revealed the door failed to close and latch when tested, on the first floor, Oxygen Storage Room near the Sprinkler Riser Room. Exit interview with the Regional Manager, Administrator and Maintenance Manager on June 3, 2026, at 1:30 p.m., confirmed the door failed to close and latch.

Plan of Correction - To be completed: 07/20/2026

The door to the first-floor Oxygen Storage Room was adjusted to fully close and positive-latch upon testing.
- The Maintenance Director was re-educated on testing medical gas storage room enclosures for positive latching compliance.
- The Director of Maintenance or designee will audit the oxygen storage room door mechanism weekly. Monthly audits times 3 will continue with results reported to the QA Committee.

Initial comments:Name: BUILDING A CONVERSION (MT AIRY BLDG A) - Component: 02 - Tag: 0000
Facility ID# 191802

Component 02

Mt. Airy Building A

Based on a Medicare/Medicaid Recertification Survey completed on June 3, 2026, it was determined that Caring Heart Rehabilitation And Nursing Center - Mt. Airy Building A 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 five-story, Type II (222), fire resistive building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

Observations:
Name: BUILDING A CONVERSION (MT AIRY BLDG A) - Component: 02 - Tag: 0211 Based on observation and interview, it was determined the facility failed to maintain means of egress free of obstructions, affecting one of five floors. Findings include: 1. Observation on June 3, 2026, at 1:05 p.m., revealed the door leading to an enclosed courtyard could be mistaken for an exit and lacked signage indicating "Not an Exit", on the second floor, near elevator. Exit interview with the Regional Manager, Administrator and Maintenance Manager on June 3, 2026, at 1:30 p.m., confirmed the missing signage.

Plan of Correction - To be completed: 07/20/2026

A "Not an Exit" sign was installed on the second-floor double doors leading to the enclosed courtyard near the elevator.
- The Maintenance Director was re-educated on egress identification standards and labeling doors that could be mistaken for exit routes.
- The Director of Maintenance or designee will audit courtyard doors weekly X 4. Monthly audits times 3 will continue with results reported to the QA Committee.

NFPA 101 STANDARD Corridor - Doors:

Observations:
Name: BUILDING A CONVERSION (MT AIRY BLDG A) - Component: 02 - Tag: 0363 Based on observation and interview, it was determined the facility failed to ensure that corridor doors were maintained to resist the passage of smoke and positively latch when tested, affecting one of five floors. Findings include: 1. Observation on June 3, 2026, at 1:25 p.m., revealed door failed to close and latch when tested, on the first floor, Break Room. Exit interview with the Regional Manager, Administrator and Maintenance Manager on June 3, 2026, at 1:30 p.m., confirmed the door failed to close and latch.

Plan of Correction - To be completed: 07/20/2026

- The first-floor Break Room corridor door hardware was adjusted to ensure automatic closing and positive latching.
- The Maintenance Director was re-educated on repairing door alignment and hardware to maintain smoke resistance barriers.
- The Director of Maintenance or designee will audit break room door latching weekly x 4. Monthly audits times 3 will continue with results reported to the QA Committee.

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: BUILDING A CONVERSION (MT AIRY BLDG A) - Component: 02 - Tag: 0911 Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting one of five floors. Findings include: 1. Observations on June 3, 2026, revealed 2 ceiling junction boxes missing protective cover plates, on the second floor Dining Room. Refer to NFPA 70, National Electric Code, and NFPA 99, 6.3.2.1. Exit interview with the Regional Manager, Administrator and Maintenance Manager on June 3, 2026, at 1:30 p.m., confirmed the missing cover plates.

Plan of Correction - To be completed: 07/20/2026

- Approved protective cover plates were installed on the two open ceiling junction boxes in the second-floor Dining Room.
- The Maintenance Director was re-educated on National Electric Code requirements regarding enclosing open electrical wiring.
- The Director of Maintenance or designee will inspect dining area ceilings weekly x 4. Monthly audits times 3 will continue with results reported to the QA Committee.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Observations:
Name: BUILDING A CONVERSION (MT AIRY BLDG A) - Component: 02 - Tag: 0923 Based on observation and interview, it was determined the facility failed to maintain oxygen storage requirements, affecting two of three of five floors. Findings include: 1. Observations on June 3, 2026, between 12:55 p,m., and 1:10 p.m., revealed the following deficiencies. a. 12:50 p.m., Missing self-closer, on the fourth floor, Oxygen Storage Room. b. 1:00 p.m. Missing cautionary signage on door, on the third floor, Oxygen Storage Room. c. 1:05 p.m., Door failed to close and latch when tested due to dragging on the floor, on the third floor, Oxygen Storage Room. d. 1:15 p.m., Missing cautionary signage on door and full/empty signs that separate oxygen cylinders, on the second floor, Oxygen Storage Room near Nurses Station. Exit interview with the Regional Manager, Administrator and Maintenance Manager on June 3, 2026, at 1:30 p.m., confirmed the oxygen storage deficiencies.

Plan of Correction - To be completed: 07/20/2026

A new self-closer was installed on the fourth-floor oxygen door, "No Smoking Oxygen In Use" signs were posted on the third and second-floor doors, the third-floor dragging door was planed to latch, and full/empty markers were placed in the second-floor room.
- The Maintenance Director was re-educated on medical gas storage parameters, signage mandates, self-closing setups, and cylinder segregation.
- The Director of Maintenance or designee will audit all oxygen storage rooms weekly x 4. Monthly audits times 3 will continue with results reported to the QA Committee.

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