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

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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 May 22, 2025, at Montgomery Subacute And Respiratory Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

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 May 22, 2025, 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 building, with a basement and unused attic, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.

Observations:
Name: MAIN BUILDING 01 (MANSION) - Component: 01 - Tag: 0100

Based on document review and interview, it was determined the facility failed to provide accurate, portable floor plans as required, affecting the entire facility.

Findings include:

1. Document review on May 22, 2025, at 8:15 a.m., revealed the facility failed to provide portable Life Safety Code Floor Plans that included the following information:

a. Smoke Barrier Walls (outside wall to outside wall)
b. Fire Barrier Walls (2-hour walls)
c. Horizontal Exits
d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan;
e. Required Exits should be clearly noted; and
f. Shafts Walls

Exit interview with the Administrator and the Director of Maintenance on May 22, 2025, at 11:00 a.m., confirmed the facility was unable to provide portable floor plans with the required information.

Plan of Correction - To be completed: 06/23/2025

Facility will work with an outside vendor to produce portable Life Safety Code Floor plans to include the following information – Smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits and shaft walls.

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:

Observation and document review on May 22, 2025, between 8:00 a.m., and 11:00 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.

Exit interview with the Administrator and the Director of Maintenance on May 22, 2025, at 11:00 a.m., confirmed the improper building height.

Plan of Correction - To be completed: 06/23/2025

The facility has submitted a Time Limited Waiver (TLW) to the Director of the Division of Safety Inspection, Department of Health as a part of our Plan of Correction. This TLW will in no way create any adverse effects on the safety of our residents, given the multitude of backup safety measures provided in the facility.

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 two of three smoke compartments within this component.

Findings include:

1. Observation and documentation reviewed on May 22, 2025, at 10:35 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.

Exit interview with the Administrator and the Director of Maintenance on May 22, 2025, at 11:00 a.m., confirmed the cross-corridor door frame/archway did not meet the requirements.

2. Observation on May 22, 2025, at 10:55 a.m., revealed inside the Kitchen, in the basement, the stairwell exit hardware was able to be locked/unlocked from one side of door, utilizing a hardware locking feature which could prevent egress upstairs through the door.

Exit interview with the Administrator and the Director of Maintenance on May 22, 2025, at 11:00 a.m., confirmed that the door could be locked, preventive degrees out of basement.

Plan of Correction - To be completed: 06/23/2025

The building failed to maintain clearance of less than 7 feet 6 inches. The 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.

1. The stairwell exit hardware on the door in the basement leading up to the Kitchen was changed to hardware which would allow egress upstairs through the door.
2. Maintenance Director/Designee will complete an initial and thereafter monthly audit X2 months to ensure that exits are readily accessible.
3. NHA/Designee will educate the Maintenance Department on the requirement for exits to be readily accessible.
4. Results of the audit will be brought to the Monthly QAPI meeting for review and recommendations.

NFPA 101 STANDARD Aisle, Corridor, or Ramp Width:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

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:

Observation on May 22, 2025, between 10:15 a.m., and 10:30 a.m., revealed, on the second floor, the corridors were less than four feet in width in several areas.

Exit interview with the Administrator and the Director of Maintenance on May 22, 2025, at 11:00 a.m., confirmed the second-floor corridor width was not within the four-foot tolerance.

Plan of Correction - To be completed: 06/23/2025

The building failed to have corridors that were at least 4 feet. 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 May 22, 2025, at 10:45 a.m., revealed one of the exits required travels up to the First Floor, Mansion Basement East Wing.

Exit interview with the Administrator and the Director of Maintenance on May 22, 2025, at 11:00 am, confirmed the exit did not lead directly outside.

2. Observation on May 22, 2025, at 10:45 a.m., revealed, one of the West wing in the basement, the exits required travel through an intervening room, Mansion Basement South/Stenton Wing.

Exit interview with the Administrator and the Director of Maintenance on May 22, 2025, at 11:00 am, confirmed the exit did not lead directly outside.

3. Observation on May 22, 2025, at 10:45 a.m., revealed one of the West wing smoke compartments exits through the lounge/dining area West Hall, Mansion on the First Floor.

Exit interview with the Administrator and the Director of Maintenance on May 22, 2025, at 11:00 am, confirmed the exit passes through an intervening room.

Plan of Correction - To be completed: 06/23/2025

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 Emergency Lighting:

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

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

Observations:
Name: MAIN BUILDING 01 (MANSION) - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to maintain battery back up lighting within the facility.
Findings include:
Document review on May 22, 2025, between 8:30 a.m. and 11:00 a.m., revealed the facility annual subcontracted inspection report listen 6 battery packs in need of replacement. Evidence of corrective actions was not available during the time of the survey.
Exit interview with the Administrator and the Director of Maintenance on May 22, 2025, at 11:00 a.m., confirmed the corrective actions were not completed.

Plan of Correction - To be completed: 06/23/2025

1. Facility contracted with outside vendor to have 6 battery packs identified on the annual inspection report replaced.
2. Maintenance Director/Designee will complete an initial and thereafter monthly audit X2 months of the annual inspection reports to ensure recommendations are completed.
3. NHA/Designee will educate the Maintenance Department on the requirement to review inspection reports and complete recommendations.
4. Results of the audit will be brought to the Monthly QAPI meeting for review and recommendations

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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: MAIN BUILDING 01 (MANSION) - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous areas with proper separation, affecting one of three floors.
Findings include:
Observation on May 22, 2025, at 10:30 a.m., revealed an unoccupied area on the first floor mansion (Room #400 units) were used for storage. The rooms were not designed as storage areas and lacked the requirements for hazardous area separations.
Exit interview with the Administrator and the Director of Maintenance on May 22, 2025, at 11:00 a.m., confirmed hazardous areas were not maintained.

Plan of Correction - To be completed: 06/23/2025

1. The contents of the room identified on the 400 unit were removed.
2. The Maintenance Director/Designee will complete an initial and thereafter monthly audit X3 months of unoccupied areas to ensure they are not being used for storage.
3. NHA/Designee will educate staff on the requirement that unoccupied areas are not to be used for storage unless they meet the requirements for hazardous area separations.
4. Results of the audit will be brought to the Monthly QAPI meeting for review and recommendations

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 (MANSION) - Component: 01 - Tag: 0911

Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting one of three levels.

Findings include:

Observations on May 22, 2025, at 10:45 a.m. revealed in basement laundry room that there was a frayed Romex wire, protruding from wall, wrapped around the outside corner of wall, towards adjacent bathroom.

Exit interview with the Administrator and the Director of Maintenance on May 22, 2025, at 11:00 a.m., confirmed the exposed wiring.

Refer to NFPA 70, National Electric Code, 99, 6.3.2.1.

Plan of Correction - To be completed: 06/23/2025

1. The Romex wire found in the basement laundry room was repaired.
2. The Maintenance Director/designee will complete an initial and thereafter monthly audit X3 months to ensure electrical wiring is maintained and not exposed.
3. NHA/Designee will educate the Maintenance Department to ensure that electrical wiring is maintained and not exposed.
4. Results of the audit will be brought to the Monthly QAPI meeting for review and recommendations.

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 May 22, 2025, 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 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: BLDG 02 (WANAMAKER & MCCRACKEN) - Component: 02 - Tag: 0293

Based on observation and interview, it was determined that the facility failed to ensure exit signs were continuously illuminated in one of two levels.

Findings include:
Observations on May 22, 2025, between 8:45 a.m., and 11:00 a.m., revealed two exit signs not illuminated in the following locations.
a) McCracken: Bottom of exit stairwell, exiting to generator area.
b) Wanamaker: Bottom of exit stairwell, exiting to path.

Exit interview with the Administrator and the Director of Maintenance on May 22, 2025, at 11:00 a.m., confirmed unilluminated exit signs.

Plan of Correction - To be completed: 06/23/2025

1. The Maintenance Director repaired the exit sign at the bottom of the exit stairwell, exiting to generator on McCracken and the exit sign at the bottom of exit stairwell, exiting to path on Wanamaker to continuously illuminate.
2. The Maintenance Director/Designee will complete an initial and thereafter weekly audit X4 weeks of all exit signs to ensure they are continuously illuminated.
3. NHA/Designee will educate the Maintenance Department on the regulation related to exit signs to be continuously illuminated.
4. Results of the audit will be brought to the Monthly QAPI meeting for review and recommendations.

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: 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 at least fifteen doors in compartment.

Findings include:

Observation on May 22, 2025, at 9:00 a.m., revealed inside basement, the door to unused storage room 1, was not closing flush into frame to latch.

Exit interview with the Administrator and the Director of Maintenance on May 22, 2025, at 11:00 a.m., confirmed door can not latch.

Plan of Correction - To be completed: 06/23/2025

1. Door to the unused storage room 1 was repaired so that it is flush to the frame and has a positive latch.
2. Maintenance Director/Designee will conduct an initial and thereafter weekly audit X4 weeks of corridor doors to ensure they close flush and positive latch.
3. NHA/Designee will educate the Maintenance Department on the regulation to ensure that corridor doors close flush and have a positive latch.
4. Results of the audit will be brought to the Monthly QAPI meeting for review and recommendations.

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 two of two floors.

Findings include:

Observation on May 22, 2025, between 8:45 a.m., and 11:00 a.m., revealed:

a) Wanamaker, on the first floor, at nurses station: More than 12 portable oxygen cylinders stored without signage of separation of full or empty.

b) McCracken, on the second floor, at nurses station: More than 12 portable oxygen cylinders stored without signage of separation of full or empty

Exit interview with the Administrator and the Director of Maintenance on May 22, 2025, at 11:00 a.m., confirmed more than 12 cylinders were stored and separation signage was missing.

Plan of Correction - To be completed: 06/23/2025

1. The Maintenance Director installed "Full" and "Empty" signs at the oxygen storage locations on Wanamaker and McCraken and separated the oxygen cylinders that were empty and full.
2. The Maintenance Director will complete an initial and thereafter weekly audit X4 weeks of all oxygen storage areas to ensure that oxygen cylinders are stored in separate racks by empty and full.
3. The Maintenance Director/Designee will educate staff that oxygen cylinders are to be stored separately by "Empty" and "Full".
4. Results of the audit will be brought to the Monthly QAPI meeting for review and recommendations.

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