Pennsylvania Department of Health
MONTGOMERY SUBACUTE AND RESPIRATORY CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 41 surveys for this facility. Please select a date to view the survey results.

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MONTGOMERY SUBACUTE AND RESPIRATORY 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 July 30, 2024, it was determined that Montgomery Subacute And Respiratory Center, had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

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

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

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

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.

Observations:
Name: - Component: -- - Tag: 0004

Based on document review and interview, it was determined the facility failed to maintian the emergency preparedness plan.

1. Document review and interview on July 30, 2024, between 9:30 a.m., and 11:15 a.m., revealed the EP plan was not updated as needed or reviewed in the past twelve months.

Interview at the time of the exit conference with the administrator and facility maintenance representative on July 30, 2024, at 1:30 p.m., confirmed the plan had not been reviewed or updated.

Plan of Correction - To be completed: 09/13/2024

A. The Emergency Plan signature page was updated on July 11, 2024 with signatures from Medical Director, DON, Maintenance Director and LNHA.
B. LNHA and Maintenance Director will ensure that it is updated yearly.

Initial comments:Name: MAIN BUILDING 01 (MANSION) - Component: 01 - Tag: 0000

Facility ID# 036302
Component 01
Mansion Building

Based on a Medicare/Medicaid Recertification Survey completed on July 30, 2024, it was determined that Montgomery Subacute And Respiratory Care- Mansion 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 three-story, Type V (000), unprotected wood frame construction, with a basement and unused attic, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: MAIN BUILDING 01 (MANSION) - Component: 01 - Tag: 0161

Based on observation, document review, and interview, it was determined the facility failed to maintain construction requirements, affecting the entire component.

Findings include:

1. Observation and document review on, between 9:30 a.m., and 11:15 a.m., revealed the facility's building construction has been classified as a three story, Type V (000), unprotected wood frame construction, with a basement and unused attic. The building story height exceeds the maximum allowance for unprotected wood frame construction by two stories.

Interview at the time of the exit conference with the administrator and facility maintenance representatives on July 30, 2024, at 1:30 p.m., confirmed the building construction type.

Plan of Correction - To be completed: 09/13/2024

A. Related to building story height exceeding the maximum allowance for unprotected wood frame construction by 2 stories. Center is requesting the use of previous Fire Safety Evacuation System on file. Center is requesting Department of Health to come to the Center to perform the Fire Safety Evacuation System evaluation.

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 (MANSION) - Component: 01 - Tag: 0211

Based on observation, document review, and interview, it was determined the facility failed to ensure exits were readily accessible, affecting one of three smoke compartments within this component.

Findings include:

1. Observation and documentation reviewed on July 30, 2024, at 11:35 a.m., revealed at the entrance to the west wing exit corridor, the archway for the cross corridor double doors had headroom clearance of less than the required height of six feet eight inches. The archway was located near the south wing nurse station.

Interview at the time of the exit conference with the administrator and facility maintenance representatives on July 30, 2024, at 1:30 p.m., confirmed the cross-corridor door frame/archway did not meet the requirements.

Plan of Correction - To be completed: 09/13/2024

A. Archway for the cross corridor double doors had headroom clearance of less than the required height of six feet eight inches. Center is requesting the use of previous Fire Safety Evacuation System on file. Center is requesting Department of Health to come to the Center to perform the Fire Safety Evacuation System evaluation.

NFPA 101 STANDARD Aisle, Corridor, or Ramp Width:

Aisle, Corridor or Ramp Width
2012 EXISTING
The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5.
19.2.3.4, 19.2.3.5

Observations:
Name: MAIN BUILDING 01 (MANSION) - Component: 01 - Tag: 0232

Based on observation and interview, it was determined the facility failed to maintain at least a four-foot corridor width of aisles or corridors serving as exit access, affecting one of three smoke compartments.

Findings include:

1. Observation on July 30, 2024, between 11:15 a.m., and 11:30 a.m., revealed the second-floor corridors were less than four feet in width in several areas.

Interview at the time of the exit conference with the administrator and facility maintenance representatives on July 30, 2024, at 1:30 p.m., confirmed the second-floor corridor width was not within the four-foot tolerance.

Plan of Correction - To be completed: 09/13/2024

Second floor corridors were less than four feet in width in several areas. Center is requesting the use of previous Fire Safety Evacuation System on file. Center is requesting Department of Health to come to the Center to perform the Fire Safety Evacuation System evaluation.

NFPA 101 STANDARD Number of Exits - Corridors:

Number of Exits - Corridors
Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies.
18.2.5.4, 19.2.5.4

Observations:
Name: MAIN BUILDING 01 (MANSION) - Component: 01 - Tag: 0252

Based on observation and interview, it was determined the facility failed to provide two approved exits located remotely from each other for every corridor, affecting two of three smoke compartments.

Findings Include:

1. Observation on July 30, 2024, at 11:45 a.m., revealed one of the exits required travels up to the First Floor, Mansion Basement East Wing.

Interview at the time of the exit conference with the administrator and facility maintenance representatives on July 30, 2024, at 1:30 p.m., confirmed the exit did not lead directly outside.

2. Observation on July 30, 2024, at 11:50 a.m., revealed one of the West wing basement exits required travel through an intervening room, Mansion Basement South/Stenton Wing.

Interview at the time of the exit conference with the administrator and facility maintenance representatives on July 30, 2024, at 1:30 p.m., confirmed the exit did not lead directly outside.

3. Observation on July 30, 2024, at 11:58 a.m., revealed one of the West wing smoke compartments exits through the lounge/dining area West Hall, Mansion First Floor.

Interview at the time of the exit conference with the administrator and facility maintenance representatives on July 30, 2024, at 1:30 p.m., confirmed the exit passes through an intervening room.

Plan of Correction - To be completed: 09/13/2024

A. Two approved exits located remotely from each other for every corridor on mansion basement east wing exit does not lead directly outside. Mansion basement south/Stenton wing exits do not lead outside. West wing smoke compartments exit through the lounge/dining area west hall, mansion first floor. Center is requesting the use of previous Fire Safety Evacuation System on file. Center is requesting Department of Health to come to the Center to perform the Fire Safety Evacuation System evaluation.

NFPA 101 STANDARD Gas and Vacuum Piped Systems - Inspection and:

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.

Gas and Vacuum Piped Systems - Inspection and Testing Operations
The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required.
5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 (MANSION) - Component: 01 - Tag: 0908

Based on document review and interview, it was determined the facility failed to maintian the medical gas system on two of two floors.

Findings include:

1. Document review and interview on July 30, 2024, between 9:15 a.m., and 12:00 p.m., revealed the piped in medical gas system had not been inspected since October 2022.

Interview at the time of the exit conference with the administrator and facility maintenance representatives on July 30, 2024, at 1:30 p.m., confirmed documentation of an medical inspection including all elements could not be produced at the time of the survey and the most recent inspection found was dated 2022.

Plan of Correction - To be completed: 09/13/2024

A. Piped medical gas system medical inspection of oxygen flow meters proposal will be completed
B. Maintenance Director and LNHA will ensure that this is completed yearly for the facility
C. Linde Gas will do the inspection and it will be done The first week of September.

Initial comments:Name: BLDG 02 (WANAMAKER & MCCRACKEN) - Component: 02 - Tag: 0000

Facility ID# 036302
Building 02
Wanamaker First Floor
McCracken Second Floor

Based on a Medicare/Medicaid Recertification Survey completed on July 30, 2024, it was determined that Montgomery Subacute And Respiratory Center- Wanamaker and McCracken Buildings were 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 483.70(a).

This is a two-story, Type II (000), unprotected noncombustible construction, with a partial basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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

Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: BLDG 02 (WANAMAKER & MCCRACKEN) - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintian hazardous areas on two of two floors.

Findings include:

1. Observation on July 30, 2024, between 11:45 a.m., and 12:03 p.m., revealed the following;

a. At 11:45 a.m., 2nd floor McCracken wing soiled utility room failed to latch in the frame.
b. At 12:03 p.m., 1st floor Wanamaker Wing bio-hazard room had an open 3 inch hole in the wall below the ceiling, behind the door.

Interview at the time of the exit conference with the administrator and facility maintenance representatives on July 30, 2024, at 1:30 p.m., confirmed the hazardous area deficiencies.

Plan of Correction - To be completed: 09/13/2024

A. The soiled utility room latch was fixed and a 3-inch hole in the wall below the ceiling was fixed.
B. Maintenance Director/Designated person will walkthrough to note all issues via the ceiling and doors in the facility.
C. The maintenance director will do rando audit the units weekly x 4 weeks for holes in the ceiling and all door latches are working properly.

NFPA 101 STANDARD Corridor - Doors:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

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: BLDG 02 (WANAMAKER & MCCRACKEN) - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors on one of two floors.

Findings include:

1. Observation on July 30, 2024, at 12:02 p.m., revealed the door to room 105, Wanamaker wing was not smoke tight when latched in the frame.

Interview at the time of the exit conference with the administrator and facility maintenance representatives on July 30, 2024, at 1:30 p.m., confirmed the door lacked smoke tight integrity.

Plan of Correction - To be completed: 09/13/2024

A. Room 105 door was corrected and can latch in the frame
B. Maintenance Director/ Designated person will walk through the facility to check all doors to ensure they latch
C. Random Audits will be done weekly x 4 weeks to audit all doors to ensure they latch

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: BLDG 02 (WANAMAKER & MCCRACKEN) - Component: 02 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintian smoke barriers affecting two of three smoke barriers.

Findings include:

1. Observation on July 30, 2024, at 11:59 a.m., revealed the smoke barrier doors on the 1st floor Wanamaker wing had broken hardware and could not close smoke tight.

Interview at the time of the exit conference with the administrator and facility maintenance representatives on July 30, 2024, at 1:30 p.m., confirmed the smoke barrier doors did not close smoke tight.

Plan of Correction - To be completed: 09/13/2024

A. Smoke barrier doors on Wanamaker wing was fixed and corrected.
B. Maintenance Director/Designated person will walkthrough facility to ensure all smoke barrier doors are able to close tight.
C. Random Audits will be done weekly x 4 weeks to ensure all smoke barrier doors can close tight

NFPA 101 STANDARD Gas and Vacuum Piped Systems - Inspection and:

Observations:
Name: BLDG 02 (WANAMAKER & MCCRACKEN) - Component: 02 - Tag: 0908

Based on document review and interview, it was determined the facility failed to maintian the medical gas system on two of two floors.

Findings include:

1. Document review and interview on July 30, 2024, between 9:15 a.m., and 12:00 p.m., revealed the piped in medical gas system had not been inspected since October 2022.

Interview at the time of the exit conference with the administrator and facility maintenance representatives on July 30, 2024, at 1:30 p.m., confirmed documentation of an medical inspection including all elements could not be produced at the time of the survey and the most recent inspection found was dated 2022.

Plan of Correction - To be completed: 09/13/2024

A. Piped medical gas system proposal for the outside is being completed now from Linde Gas company
B. Facility will ensure that the medical gas system inspection is completed annually.
C. LNHA, Maintenance Director and RT Director educated on annual gas system inspection

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: BLDG 02 (WANAMAKER & MCCRACKEN) - Component: 02 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain portable oxygen cylinders on one of two floors.

Findings include:

1. Observation on July 30, 2024, at 11:47 a.m., revealed two portable oxygen cylinders sitting unprotected on the floor in the supervisors office on the 2nd floor McCracken wing.

Interview at the time of the exit conference with the administrator and facility maintenance representatives on July 30, 2024, at 1:30 p.m., confirmed the cylinders were not secured in any way from falling over.

Plan of Correction - To be completed: 09/13/2024

A. The two portable oxygen cylinders were put back the oxygen tank area.
B. RT Director and Maintenance Director will provide education to staff about loose portable oxygen tanks
C. RT Director will complete audits daily x 3 days for 2 weeks. Audit 1 day for 1 week x 2 weeks.

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