Non-Compliance with Life Safety Code at Kadima Rehabilitation & Nursing
Summary
Kadima Rehabilitation & Nursing at Pottstown was found to be non-compliant with the Life Safety Code requirements during a revisit to a Medicare/Medicaid Recertification Survey. The facility failed to maintain a documented program for testing, cleaning, and replacing batteries in the carbon monoxide alarms. This deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged that the carbon monoxide detection system was not being maintained as required. Additionally, the facility lacked an evacuation and alarm protocol policy for the carbon monoxide detection system. This was also confirmed by the Director of Maintenance, who admitted that the facility could not provide an alarm protocol and evacuation plan for carbon monoxide. Furthermore, the exterior doors to the Main Mechanical Room, which houses critical utilities such as the domestic water main, main electrical panel, and generator, were not secured from unauthorized access, leaving these utilities vulnerable. These issues were observed and confirmed during the survey, and subsequent observations determined that the deficiencies related to the carbon monoxide alarms and protocols were not corrected.
Plan Of Correction
1. The facility is unable to retroactively document testing, cleaning, and battery replacement program of the carbon monoxide alarms. 2. Facility-wide audit of carbon monoxide detectors conducted. Carbon monoxide detectors will be installed in places where fossil fuel appliances are in use. 3. Audits will be conducted monthly for twelve months and annually thereafter. Results of the audits will be presented to our QAPI committee for review and analysis of need for ongoing monitoring. 4. An evacuation and alarm protocol policy will be written and enacted. Education will be provided to staff regarding policy. 5. Exterior doors to the Main Mechanical Room have been secured and will remain secured at all times. 6. Audits will be conducted monthly for 12 months. 7. Results of the audits will be presented to our QAPI committee for review and analysis of need for ongoing monitoring.
Penalty
The facility failed to maintain and provide an accurate, portable Life Safety Code (LSC) floor plan during surveyor review. Surveyors requested the on-site LSC floor plan and found it was unavailable, and an interview with the administrator confirmed that the plan could not be produced. The required floor plan was to clearly indicate smoke barrier walls, 2-hour fire barrier walls, horizontal exits, rated rooms (including storage rooms, soiled utility rooms, and designated medical gas rooms), required exits, and shaft walls.
The facility did not obtain required approvals for converting resident rooms to storage on one floor and failed to provide accurate, portable Life Safety Code floor plans that included all required rated partitions and exits. These deficiencies were confirmed by facility leadership and repeated from a prior survey.
The facility did not notify the Department of Health before making changes to its HVAC systems, including installing window AC units and modifying electrical cords after P-Tec HVAC failures. This deficiency was confirmed through observation and staff interviews, and the issue remained unaddressed at the time of a follow-up visit.
Surveyors found that the facility did not provide updated life safety floor plans, lacked documentation of annual carbon monoxide alarm inspections per manufacturer instructions, and could not verify evacuation and alarm protocols as required by state law. Facility leadership confirmed these documentation deficiencies during interviews.
A deficiency was cited for failing to address certain general requirements under LSC Sections 18.1 and 19.1 that were not covered by the existing K-tags. The report does not specify the exact actions or omissions involved.
The facility did not notify the Department of Health before starting major renovations, failed to obtain required plan approvals, and lacked up-to-date Life Safety Code floor plans and a carbon monoxide alarm evacuation policy with staff in-service, as confirmed by facility leadership.
Failure to Maintain Required Portable Life Safety Code Floor Plans
Penalty
Summary
The facility failed to maintain and provide accurate, portable Life Safety Code (LSC) floor plans as required by the Division of Safety Inspection, affecting the entire facility. During document review on April 30, 2026, at 12:54 p.m., surveyors requested the facility’s portable LSC floor plan and found it was unavailable at the time of the survey. The required LSC floor plan was to include clearly identified smoke barrier walls extending from outside wall to outside wall, 2-hour fire barrier walls, horizontal exits, rated rooms such as storage rooms, soiled utility rooms, and designated medical gas rooms, as well as required exits and shaft walls. Interview with the administrator at the exit conference on the same date and time confirmed that the facility’s LSC floor plan was not available for surveyor use.
Plan Of Correction
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Indiana Skilled Nursing INC dba Beacon Ridge agrees with the allegations and citations listed on the statement of deficiencies. Indiana Skilled Nursing INC dba Beacon Ridge maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Indiana Skilled Nursing INC dba Beacon Ridge written credible allegation of compliance. By submitting this plan of correction, Indiana Skilled Nursing INC dba Beacon Ridge does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Indiana Completion Date: 05/29/2026 Status: APPROVED Date: 05/20/2026 Skilled Nursing INC dba Beacon Ridge reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. Maintenance department was educated on the need for the floor plan to include the designated items required on the Life Safety Code Floor Plan. Random audits will be completed by the Administrator and/or designee monthly for 2 months to assure that the floor plan is compliant. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Obtain Required Approvals and Maintain Accurate Life Safety Floor Plans
Penalty
Summary
The facility failed to maintain compliance with general requirements of the Life Safety Code (LSC) on one of its six building levels. Specifically, the facility did not obtain the required approval from the Department of Health State Plan Review or a granted occupancy from the Life Safety Division for converting resident rooms to storage rooms on the fifth floor. This deficiency was observed during a site visit and is a repeat finding from the previous year's survey. Additionally, the facility was unable to provide accurate floor plans that identified the fifth floor rooms as storage locations, and both the administrator and maintenance director confirmed that the necessary paperwork had not been submitted. Further deficiencies were identified regarding the facility's failure to maintain and provide accurate, portable floor plans that outlined designated rated partitions throughout the building. During document review and interviews, it was found that the facility did not have a Life Safety Code Floor Plan on-site that included required elements such as smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits, and shaft walls. The maintenance supervisor confirmed that the floor plan provided during the survey did not accurately contain these required items.
Plan Of Correction
The systematic change will be to get a copy of portable floor plans for the facility. A copy will be kept in the Administrator's office and the Director of Maintenance's office. The Administrator will review annually portable copies with the Director of Maintenance to assure there's a complete set for use. Monthly Quality Assurance meetings will review floor plans.
Failure to Notify Department of Health of HVAC Modifications
Penalty
Summary
The facility failed to notify the Pennsylvania Department of Health prior to making modifications and changes to its heating, ventilating, and air conditioning (HVAC) systems. Specifically, when Packaged Terminal Air Conditioners (P-Tec HVAC) failed, the facility installed window air conditioning units and altered their electrical cords without first obtaining Department-approved plans or notifying the Department as required. This action was observed during a site visit, and the deficiency was confirmed through interviews with the Administrator, Regional and local Maintenance Director, and the VP of Building Operations. A subsequent onsite revisit determined that the facility had still not notified the Department of Health regarding the HVAC modifications. This ongoing failure to communicate planned changes affecting the facility's environment was confirmed in an exit interview with the Maintenance Director. The deficiency affected the entire facility, as it pertained to the systems responsible for maintaining safe and efficient environmental conditions for all residents.
Failure to Maintain Life Safety Documentation and Carbon Monoxide Alarm Protocols
Penalty
Summary
Surveyors identified several deficiencies related to the facility's compliance with general requirements for life safety and state regulations. The facility failed to provide updated and accurate life safety floor plans when requested during the survey. Both the Director of Nursing and the Director of Maintenance confirmed at the exit conference that the facility could not produce these required documents. Additionally, the facility did not have documentation verifying that annual testing and inspection of installed carbon monoxide alarms had been performed according to the manufacturer's instructions, as required by the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act. A Nighthawk battery-operated carbon monoxide detector was observed at the main desk, but no supporting documentation was available. Further, the facility lacked documentation verifying the existence and implementation of evacuation and alarm protocols related to carbon monoxide alarms, also in accordance with the 2016 Act 48. This was confirmed during interviews with facility leadership, who acknowledged the absence of required documentation for both annual inspections and evacuation/alarm protocols. No information about specific residents or their conditions was included in the report.
Plan Of Correction
1. Life Safety floor plan drawings have been updated and are available for review. Carbon monoxide alarms throughout the facility will receive their annual testing per the manufacturer's instructions. Evacuation and alarm protocols are available for review. 2. The facility has updated its floor plan drawings and made available its evacuation and alarm protocols. These items are posted in the Emergency Preparedness Manual. 3. The Environmental Services Director was re-educated on the requirements of K0100. The carbon monoxide alarms will be tested annually in July. The Emergency Preparedness Manual will be reviewed quarterly and PRN for accuracy. 4. The NHA or designee completed a one-time audit of the Emergency Preparedness Manual to ensure that floor plan drawings and evacuation/alarm protocols were available. The NHA or designee will complete an annual audit of the Carbon Monoxide alarm testing in July x 2 years. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Unaddressed General Life Safety Code Requirements
Penalty
Summary
A deficiency was identified regarding general requirements under Life Safety Code (LSC) Sections 18.1 and 19.1 that were not addressed by the provided K-tags. The report notes that there are unmet general requirements, but does not specify the exact actions or omissions that led to the deficiency. No specific details about residents, staff, or events are provided in the report.
Failure to Notify Department and Maintain Required Safety Documentation
Penalty
Summary
The facility failed to notify the Pennsylvania Department of Health prior to initiating external window renovations throughout the building and additional interior renovations to a shut down wing on the ground floor following water damage. This action was taken without obtaining Department-approved plans, as confirmed by the Maintenance Supervisor and Director of Safety/Security during the exit interview. The lack of notification and approval was determined through observation, document review, and staff interviews. Additionally, the facility did not provide portable Life Safety Code Floor Plans that included required information such as smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits, and shaft walls. During the survey, it was also found that the facility lacked a carbon monoxide alarm evacuation policy plan and had not conducted associated staff in-service training, as required by the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act. These deficiencies affected the entire facility and were confirmed by facility leadership during the exit interview.
Plan Of Correction
Approval for window renovation received from DSI on 5/15/25. Facility will ensure that approval is obtained prior to beginning any future renovations. Facility will ensure that floor plans are readily available for future surveys. Carbon monoxide policy in place. Staff will be educated on carbon monoxide policy.
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