Pennsylvania Department of Health
SUMMIT AT BLUE MOUNTAIN NURSING AND REHABILITATION CENTER, T
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SUMMIT AT BLUE MOUNTAIN NURSING AND REHABILITATION CENTER, T
Inspection Results For:

There are  36 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
SUMMIT AT BLUE MOUNTAIN NURSING AND REHABILITATION CENTER, T - 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 29, 2024, at The Summit at Blue Mountain 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: SKIILED NURSING - Component: 01 - Tag: 0000


Facility ID# 070502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 29, 2024, it was determined that The Summit at Blue Mountain Nursing and Rehabilitation 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 two story, Type II (000), unprotected noncombustible building that is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type: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.
Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: SKIILED NURSING - Component: 01 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain the required fire resistance rating with the adjacent occupancy type.

Findings include;

1. Observation on January 29, 2024, at 12:00 pm, revealed the double doors at the ground level two hour separation, with the adjacent occupancy had a gap between the door leafs in excess of the allowable tolerance.

Interview at the time of the exit conference with the administrator and maintenance supervisor on January 29, 2024, at 12:00 pm, confirmed the gap in the fire rated door leafs.





 Plan of Correction - To be completed: 02/14/2024

Adjusted doors. The gaps will be in allowable tolerance to comply with the Life Safety Code. Provide education to staff to observe fire doors and report any gaps that appear beyond the allowable tolerance or damage. Any in question will be investigated and fixed immediately. Monthly Audits x 3 Months pending no deficiencies of all fire doors to ensure the ongoing compliance is maintained. Findings will be reported to QAPI.
NFPA 101 STANDARD Alcohol Based Hand Rub Dispenser (ABHR):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.
Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Observations:
Name: SKIILED NURSING - Component: 01 - Tag: 0325

Based on observation and interview, the facility failed to properly install Alcohol Based Hand Rub (ABHR) dispensers in one of five smoke compartments.

Findings include:

Observation on January 29, 2024, at 11:28 am, revealed that an ABHR dispenser was installed over a light switch in room 215, 2nd floor.

Interview at the time of the exit conference with the administrator and maintenance supervisor on January 29, 2024, at 12:00 pm, confirmed the ABHR was too close to an ignition source.





 Plan of Correction - To be completed: 02/14/2024

The Hand sanitizer was removed and repositioned to comply with the standard. Provide education to staff to make aware that hand sanitizers are an alcohol base and cannot be within 1" laterally or over an electrical outlet or light switch as it is an ignition source. Any hand sanitizer that is observed to be in violation will be reported to facilities for immediate correction. A Full Audit of all Hand sanitizers and their location will be initiated. Monthly Audits x 3 months will be conducted to ensure the ongoing compliance. Findings to be reported to QAPI.

NFPA 101 STANDARD Corridor - Doors: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.
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: SKIILED NURSING - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors in one of five smoke compartments.

Findings include;

1. Observation on January 29, 2024, between 11:25 am and 11:27 am, revealed the following doors failed to latch in their frame when tested.

a. At 11:25 am, room 219, 2nd floor.
b. At 11:27 am, room 215, 2nd floor.

Interview at the time of the exit conference with the administrator and maintenance supervisor on January 29, 2024, at 12:00 pm, confirmed the doors lacked positive latching.





 Plan of Correction - To be completed: 02/14/2024


Adjustments to the door latch and seals were made for the door to operate properly and to comply with the Life Safety Code. Provide education to staff to make aware that all resident doors are to positive latch. Any that are not working properly be reported to facility designee to be fixed to comply with the Life Safety Code. A Full Audit will be done on the doors of the facility to check for positive latching. Monthly Audits x 3 Months will be conducted to ensure the ongoing compliance. Findings to be reported to QAPI.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port