Pennsylvania Department of Health
LUTHER WOODS NURSING AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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LUTHER WOODS NURSING AND REHABILITATION 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 19, 2025, it was determined that Luther Woods Nursing and Rehabilitation Center have deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(d)(1), 416.54(d)(1), 418.113(d)(1), 441.184(d)(1), 482.15(d)(1), 483.475(d)(1), 483.73(d)(1), 484.102(d)(1), 485.542(d)(1), 485.625(d)(1), 485.68(d)(1), 485.727(d)(1), 485.920(d)(1), 486.360(d)(1), 491.12(d)(1) STANDARD EP Training Program:

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(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:]
(1) Training program. The [facility] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures.

*[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least every 2 years.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.
(v) Maintain documentation of all emergency preparedness training.
(vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and
procedures.

*[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures.

*[For PACE at §460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures.

*[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.

*[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.
(v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures.

*[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures.

*[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.

Observations:
Name: - Component: -- - Tag: 0037 Based on document review and interview, it was determined the facility failed to maintain a training program that is based on the facility's emergency preparedness plan, affecting the entire facility. Findings include: 1. Review of documentation on November 19, 2025, at 9:00 a.m., revealed the facility failed to perform training to the emergency preparedness plan that included the following: a. Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. b. Provide emergency preparedness training at least annually. c. Maintain documentation of the training. d. Demonstrate staff knowledge of emergency procedures. Exit interview with the Administrator and the Maintenance Director on November 19, 2025, at 1:00 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 12/17/2025

a. All expected staff have gone thru initial training for emergency preparedness.
b. Annual emergency preparedness drills are/ training is completed twice each year.
c. The Director of Maintenance will maintain documentation of all drills/training
d. Our Staff Educator will ensure we have a test which will allow staff to demonstrate their knowledge of emergency procedures.

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 Emergency Plan's required annual-full scale exercise or accepted substitution and the required additional exercise or accepted substitution, affecting the entire facility. Findings include: 1. Review of documentation on November 19, 2025, at 9:00 a.m., revealed the facility failed to conduct an annual full-scale exercise or accepted substitution and an additional exercise or accepted substitution within the previous 12 months. Exit interview with the Administrator and the Maintenance Director on November 19, 2025, at 1:00 p.m., confirmed the missing documentation.

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

We have reached out to Montgomery County several times regarding a community-based Emergency Round Table with no response. We have been participating in a RISE backed program- HAP Evolve which offers a group based emergency round table quarterly. Today we contacted a local company called Life Safety training. They will help us set up a community program which should be in place by 1/15/2026.
We had an actual disaster take place on 11/5/25 with a community transformer hit by lightning which resulted in a power surge in the building which knocked out our transformer. The Fire Department responded. I have submitted an Event Report and we have an After-Action Report in place. We will ensure all attempts to communicate with Montgomery County regarding Community Emergency Preparedness drills are documented in the future.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 640302
Component 01
Main Building
on a Medicare/Medicaid Recertification Survey completed on November 19, 2025, it was determined that Luther Woods Nursing And Rehabilitation 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).
is a one-story, Type III (200), unprotected ordinary building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

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

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

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211 Based on observation and interview, it was determined the facility failed to ensure there were no obstructions to egress, affecting one of two levels. Findings include: 1. Observation on November 19, 2025, at 12:40 p.m. to 12:45 p.m., revealed doors leading to an enclosed courtyard could be mistaken for an exit and lacked signage indicating "Not an Exit " at the following locations: a. 12:40 p.m., 2 sets of sliding doors, near the DON Office. b. 12:45 p.m., 2 sets of sliding doors, across from the dining room. Exit interview with the Administrator and the Maintenance Director on November 19, 2025, at 1:00 p.m., confirmed the missing signage.

Plan of Correction - To be completed: 12/11/2025

Maintenance has ordered proper signage for all sliding doors. We will complete installation by December 15, 2025. All maintenance team members will inspect doors weekly for a month following up w quarterly checks to ensure signage remains in place.

NFPA 101 STANDARD Emergency Lighting:

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 01 - Component: 01 - Tag: 0291 Based on observation and interview, it was determined the facility failed to ensure battery back-up lighting was maintained, affecting one of two levels. Findings include: 1. Observation on November 19, 2025, at 11:35 a.m., revealed a battery back-up light that failed to illuminate when tested, A-Wing Nurses Station. Exit interview with the Administrator and the Maintenance Director on November 19, 2025, at 1:00 p.m., confirmed the deficient battery back-up light.

Plan of Correction - To be completed: 12/11/2025

Maintenance ordered batteries for the Emergency Lights. They arrived and have been installed. All lights are working. Maintenance team will inspect all emergency lights weekly x 4 and then monthly after that.

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 maintain fire alarm initiating devices, affecting one of two levels. Findings include: 1. Observation on November 19, 2025, at 11:25 am, revealed a smoke detector with an excessive buildup of dust and dirt, Main Level Laundry Room. Exit interview with the Administrator and the Maintenance Director on November 19, 2025, at 1:00 p.m., confirmed the deficient smoke detector.

Plan of Correction - To be completed: 12/11/2025

Maintenance has cleaned the affected sprinkler heads and began inspection of sprinklers throughout the building. We will inspect sprinklers weekly x 2 months and then monthly

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345 Based on document review and interview, it was determined the facility failed to ensure the fire alarm system was maintained, affecting one of two fire alarm reports. Findings include: 1. Document review on November 19, 2025, at 9:00 a.m., revealed the fire alarm inspection report dated December 16, 2024, listed a "Functional Failure" for the C-Wing Activities Room Pull Station. Evidence of corrective action and retest was not available at time of survey. Exit interview with the Administrator and the Maintenance Director on November 19, 2025, at 1:00 p.m., confirmed the missing documentation.

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

Maintenance has contacted Johnson Controls to provide us with paperwork for C Wing. Expected completion date is 12/29/25

NFPA 101 STANDARD Smoke Detection:

Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0347 Based on observation and interview, it was determined the facility failed to maintain smoke detectors in a smoke resistive ceiling assembly, affecting two of four smoke compartments. Findings include: 1. Observation on November 19, 2025, between 11:10 a.m. and 11:55 a.m., revealed missing ceiling tiles, at the following locations: a. 11:10 a.m., Basement Storage Room 1 (next to boiler room). b. 11:15 a.m., Basement Storage Room 2. c. 11:20 a.m., Basement Boiler Room. d. 11:25 a.m., Basement Medical Storage Room. d. 11:55 a.m., Main Level Mini-Lounge closet. Exit interview with the Administrator and the Maintenance Director on November 19, 2025, at 1:00 p.m., confirmed the missing ceiling tiles.

Plan of Correction - To be completed: 12/15/2025

Maintenance has received the ceiling tiles and has begun installing them. This project will be completed by 12/15/25. We will then begin inspecting the ceiling tiles throughout the building weekly x 4 then quarterly.

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, observation, and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire facility. Findings include: 1. Document review on November 19, 2025, at 9:00 a.m., revealed the February 20, 2025, sprinkler inspection report listed a deficiency that stated, "Antifreeze in both loops failed testing, antifreeze should be replaced and expansion tank should be installed". Evidence of corrective action and retest was not available at time of survey. Exit interview with the Administrator and the Maintenance Director on November 19, 2025, at 1:00 p.m., confirmed the missing documentation. 2. Observation on November 19, 2025, from 11:20 a.m. to 12:20 p.m., revealed the following sprinkler deficiencies: a. 11:20 a.m., multiple sprinklers with excessive build-up of dust and dirt, Main Level Laundry Room (covered the bulb). b. 12:05 p.m., missing escutcheon, Beauty Salon. c. 12:20 p.m., buildup of fire caulk on multiple sprinkler escutcheons, near C-Wing Nurses Station and Room 303. Exit interview with the Administrator and the Maintenance Director on November 19, 2025, at 1:00 p.m., confirmed the sprinkler deficiencies.

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

Maintenance contacted Keystone Fire Protection to provide us with the proper documentation of the antifreeze test that was retested. We expect the report by 12/29/25.

NFPA 101 STANDARD Portable Fire Extinguishers:

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

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355 Based on document review, it was determined the facility failed to ensure that fire extinguisher inspectors were certified, affecting one of three fire extinguisher documents. Findings include: 1. Document review on November 19, 2025, at 9:00 a.m., revealed the facility could not provide certification documentation for the inspector that performed the facility's annual portable fire extinguisher inspection in December 2024. Exit interview with the Administrator and the Maintenance Director on November 19, 2025, at 1:00 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 12/23/2025

Director of Maintenance has contacted Winchester Fire Protection to provide us with Inspector's certification number. The report is expected by 12/23/25. Maintenance will ensure all certificates for all new Inspectors are attained and kept on file.

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 - Component: 01 - 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 three of four smoke compartments. Findings include: 1. Observation on November 19, 2025, from 11:15 a.m., revealed doors that failed to close and latch at the following locations: a. 11:15 a.m., Basement Storage Room #2 b. 11:20 a.m., Main Level Laundry Room. c. 11:40 a.m., Main Level A-Wing Ice Room. d. 11:55 a.m., Main Level B-Wing Medication Room (at nurses' station) e. 12:25 p.m., Main Level C-Wing Clean Linen Room (at nurses' station) Exit interview with the Administrator and the Maintenance Director on November 19, 2025, at 1:00 p.m., confirmed the door deficiencies.

Plan of Correction - To be completed: 01/05/2026

Maintenance has ordered all necessary parts to repair the doors. We expect to have the repairs completed by 1/5/2026. Maintenance team will then inspect the doors weekly x 4, then monthly.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:

Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0371 Based on document review and interview, it was determined the facility failed to provide smoke compartments not greater than 22,500 square feet, with a travel distance not to exceed 200 feet, affecting one of four smoke compartments. Findings include: 1. Observation and document review on November 19, 2025, at 9:00 a.m., revealed smoke compartments, front and back hallways, exceed 22,500 square feet in length. Exit interview with the Administrator and the Maintenance Director on November 19, 2025, at 1:00 p.m., confirmed the B Wing smoke compartment exceeded 22,500 square feet.

Plan of Correction - To be completed: 01/05/2026

Ken Walters, Director of Maintenance, will contact the Department of Health to request a FSES

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521 Based on document review, observation, and interview, it was determined the facility failed to maintain the Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting the entire facility. Findings include: 1. Document review on November 19, 2025, at 9:00 am., revealed the facility could not provide a damper inspection report for the previous 12 months. Exit interview with the Administrator and the Maintenance Director on November 19, 2025, at 1:00 p.m., confirmed the missing documentation. 2. Observation on November 19, 2025, at 12:15 p.m., revealed ductwork that was dislodged from the smoke wall, above double doors near the ARMAC Office, C-Wing. Exit interview with the Administrator and the Maintenance Director on November 19, 2025, at 1:00 p.m., confirmed the open ductwork.

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

1. Maintenance called outside vendor to perform the damper inspection and provide us with documentation that inspection was competed. Completion date: 12/15/25
2. Maintenance will repair dislodged smoke wall by the RNAC Office- this will be completed by 12/30/25.

NFPA 101 STANDARD Electrical Systems - Other:

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

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911 Based on observation and interview, it was determined the facility failed to maintain electrical wiring in one instance, affecting three of four smoke compartments. Installation shall be in accordance with NFPA 99 Section 6.3.2.1. Findings include: 1. Observation on November 19, 2025, from 11:10 a.m. to 11:50 a.m., revealed the following electrical deficiencies. a. 11:10 a.m., unsecured junction box above ceiling, Basement Storage Room #1 back wall. b. 11:35 a.m., junction box missing its cover plate, above corridor ceiling (next to room 111). c. 11:45 a.m., MC cable not ending in a junction box above double doors leading to Piano Room, A-Wing. d. 11:45 a.m., unsecured junction box above double doors leading to Piano Room, A-Wing. e. 11:50 a.m., unsecured junction box above double doors leading to Piano Room, B-Wing. Exit interview with the Administrator and the Maintenance Director on November 19, 2025, at 1:00 p.m., confirmed the above electrical deficiencies.

Plan of Correction - To be completed: 12/17/2025

Maintenance has contacted Charles Keller Inc. to make all electrical repairs. The expected completion date is 12/17/25. Maintenance will do a building inspection weekly x 4, then monthly.

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 outlet multipliers, affecting one of two levels. Findings include: 1. Observation on November 19, 2025, from 11:35 a.m., to 12:10 p.m., revealed the use of outlet multipliers at the following locations: a. 11:35 a.m., Main Level A-Wing Ice Room. b. 12:10 p.m., Main Level Beauty Salon. Exit interview with the Administrator and the Maintenance Director on November 19, 2025, at 1:00 p.m., confirmed the unauthorized use of outlet multipliers.

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

Maintenance will remove all outlet multipliers and install proper outlets. Expected completion date will be 12/19/25. Maintenance team will do a weekly inspection looking for outlet multipliers x 4, then monthly.

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