Pennsylvania Department of Health
NORRITON SQUARE 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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NORRITON SQUARE 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 January 30, 2026, at Norriton Square Nursing and Rehabilitation 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# 068202Component 01Based on a Medicare/Medicaid Recertification Survey completed on January 30, 2026, it was determined that Norriton Square 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).This is a three-story, Type II (111), protected noncombustible building, 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 maintain paths of egress free from all impediments, affecting one of three levels in the facility. Findings include: Observations on January 30, 2026, between 10:28 am and 10:34 am, revealed the following deficiencies:10:28 am, 1st floor, exterior door near Physical Therapy requires "NOT AN EXIT" signage;10:31 am, 1st floor, exterior door in Physical Therapy requires "NOT AN EXIT" signage;10:34 am, discharge from exit door from stairwell near Physical Therapy was blocked due to snow.Exit interview with the Maintenance Director and Administrator on January 30, 2026, at 10:45 am, confirmed the above deficiencies.

Plan of Correction - To be completed: 03/08/2026

NHA and maintenance director added a "not an exit" sign near the therapy gym on the 1st floor, and removed snow from outside of the exit stairwell near the gym. Random weekly audits x 12 weeks of egress doors will be completed by the NHA or designee to ensure there is no snow.
The results will be reviewed monthly at the QAPI meeting x3 to ensure compliance.

NFPA 101 STANDARD Electrical Systems - 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.

Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914 Based on document review and interview, it was determined the facility failed to maintain and inspect electrical receptacles, affecting the entire facility. Findings include: Document review on January 30, 2026, at 8:15 am, revealed the facility failed to provide documentation that electrical receptacle testing had been performed within the last year.Exit interview with the Maintenance Director and Administrator on January 30, 2026, at 10:45 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 03/08/2026

Maintenance director or designee will complete annual testing of electrical receptacles. NHA or designee will re-educate the maintenance director on completion of electrical receptacle testing. Quarterly audit of the receptacle testing will be completed by NHA or designee x 2. The results will be reviewed at the QAPI meeting x2 to ensure compliance.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918 Based on observation and interview, it was determined the facility failed to maintain the emergency generator, affecting the entire facility. Findings include: Observation on January 30, 2026, at 10:10 am, revealed the emergency generator remote annunciator panel was showing a low temperature alarm.Exit interview with the Maintenance Director and Administrator on January 30, 2026, at 10:45 am, confirmed the low temperature alarm.

Plan of Correction - To be completed: 03/08/2026

The emergency generator is at the correct temperature and is functioning. The facility Maintenance Director was educated on the requirements for monitoring the emergency generator temperature. The Maintenance Director will complete a weekly audit x 12 weeks of the following emergency generator temperature checks. Emergency Generator temperature results will be reviewed monthly at the QAPI meeting x3 to ensure compliance.

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