Pennsylvania Department of Health
MOUNTAIN TOP REHABILITATION & HEALTHCARE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MOUNTAIN TOP REHABILITATION & HEALTHCARE 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 April 30, 2025, at Mountain Top Rehabilitation and Health Care 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 - Component: 01 - Tag: 0000

Facility ID# 040802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 30, 2025, it was determined that Mountain Top Rehabilitation and Health Care Center was not in compliance with the following requirements of the Life Safety Code for an existing 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 one story, Type V (111), protected, wood frame building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Doors with Self-Closing Devices:

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.

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain two doors with self-closing devices, affecting one of six smoke compartments.

Findings include:

1. Observation on April 30, 2025, between 10:14 am and 10:21 am, revealed the following doors failed to positive latch into frame.

a. At 10:14 am, Nurse's Station 2 door.
b. At 10:21 am, Resident Room 62 door that's tied into the fire alarm system.

Exit interview with the Facility Administrator and the Facilities Manager on April 30, 2025, at 11:00 am, confirmed the door failed to positive latch when tested.

Plan of Correction - To be completed: 05/28/2025

The Nurse's Station 2 door and Resident Room 62 door assembly was adjusted to provide positive latching by facility maintenance department.
The Maintenance Director/designee will conduct a facility wide audit to identify doors requiring adjustment to fully latch and coordinate repairs as identified.
The Nursing home Administrator will provide re-education to the Maintenance Director on proper door latching requirement.
The Maintenance Director will conduct audits on latching doors to verify compliance weekly x 4 weeks, then monthly x 2 months. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for compliance.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on document review observations and interview, it was determined the facility failed to maintain the sprinkler system in one location, affecting one of two floors.

Findings include:

1. Observation on April 30, 2025, at 9:55 am, revealed (3) sprinkler heads within Basement Laundry were loaded with lint.

Exit interview with the Facility Administrator and the Facilities Manager on April 30, 2025, at 11:00 am, confirmed the loaded sprinkler heads.

Plan of Correction - To be completed: 05/28/2025

The 3 basement laundry sprinkler heads were thoroughly cleaned of lint.
The Maintenance Director will conduct an audit of sprinkler heads within the basement laundry to verify that the sprinklers are lint free.
The Nursing Home Administrator/designee will provide re-education to the Maintenance Director for the requirements for sprinkler heads being free from lint.
The Maintenance Director/designee will conduct audits of random sprinklers heads to confirm that they are free of lint and verify compliance weekly audits x 4 weeks, then monthly x 2 months. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for compliance.

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 maintain one corridor opening, affecting one of two floors.

Findings include:

1. Observation on April 30, 2025, at 10:46 am, revealed the Main dining room, right set of double doors, failed to positive latch into frame.

Exit interview with the Facility Administrator and the Facilities Manager on April 30, 2025, at 11:00 am, confirmed the door failed to positive latch.

Plan of Correction - To be completed: 05/28/2025

The main dining room right set of double doors' door assembly was adjusted to provide positive latching by facility maintenance department
The Maintenance Director/designee will conduct a facility wide audit of double doors to identify doors requiring adjustment to fully latch and coordinate repairs as identified.
The Nursing home Administrator will provide re-education to the Maintenance Director on proper door latching requirement.
The Maintenance Director will conduct audits on latching doors to verify compliance weekly x 4 weeks, then monthly x 2 months. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for compliance

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