Pennsylvania Department of Health
MOUNTAIN CITY NURSING & REHAB CTR
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MOUNTAIN CITY NURSING & REHAB CTR - 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 29, 2024, at Mountain City Nursing & Rehab Ctr, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: BLUE 01 - Component: 01 - Tag: 0000

Facility ID# 085602
Component 01
Blue Building

Based on a Medicare/Medicaid Recertification Survey completed on April 29, 2024, it was determined that Mountain City Nursing & Rehab Ctr 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 four story, Type II (222), fire resistive building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

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.

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: BLUE 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in four locations, affecting one of four floors.

Findings include:

1. Observation on April 29, 2024, between 10:22 a.m., and 10:44 a.m., revealed the following:

a. 10:22 a.m., damaged ceiling tiles within the ground floor, Maintenance Department.
b. 10:27 a.m., damaged ceiling tiles within the ground floor, Soiled Linen Room.
c. 10:37 a.m., a structural column located within the ground floor, Soiled Linen Room, was not properly protected above the suspended ceiling assembly.
d. 10:44 a.m., a structural steel column, located within the ground floor, Rehab Department, was not properly protected above the suspended ceiling assembly.

Exit interview with the Facilities Manager on April 29, 2024, at 12:10 p.m., confirmed the building construction deficiencies.

Plan of Correction - To be completed: 05/14/2024

1. Ceiling Tiles in Maintenance shop and soiled linen were replaced. Colum's in therapy and soiled linen room were repaired and properly protected
2. Building audit was completed for damaged ceiling tiles and unprotected Colum's. Repairs were
made as necessary
3. Education will be completed by the NHA to the maintenance director related to the importance of maintaining ceiling tiles and structural columns as required
4. Weekly Audits will be completed weekly by maintenance director or designee for 3 months and findings be reported during monthly QPI meeting

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: BLUE 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain two corridor openings, affecting two of four floors.

Findings include:

1. Observation on April 29, 2024, between 10:18 a.m., and 11:01 a.m., revealed the following:

a, 10:18 a.m., the ground floor, Copy Room door was not smoke-tight.
b. 11:01 a.m., the first floor, Clean Linen Room door required adjustment to fully latch within the door frame.

Exit interview with the Facilities Manager on April 29, 2024, at 12:10 p.m., confirmed the corridor opening deficiencies.

Plan of Correction - To be completed: 05/14/2024

1. Copy Room Door and 1st Clean Linen Room Doors were adjusted to Latch and be smoke tights
2. All Doors were audited for positive latching and smoke tightness.
3. Education will be completed by the NHA to the maintenance director related to the importance of maintaining corridor openings
4. Maintenance director or designee will audit all doors for 3 monthly and then quarterly. All findings will be reported at Monthly QPI meeting

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: BLUE 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier separation doors in one location, affecting one of four floor.

Findings include:

1. Observation on April 29, 2024, at 10:33 a.m., revealed the ground floor, east, smoke barrier separation doors required adjustment to fully latch.

Exit interview with the Facilities Manager on April 29, 2024, at 12:10 p.m., confirmed the smoke barrier door deficiency.

Plan of Correction - To be completed: 05/14/2024

1. Lobby East Wing Smoke Door was adjusted to fully latch.
2. All Smoke Doors were audited and repairs made, as necessary
3. Education will be completed by the NHA to the maintenance director related to the importance of ensuring smoke doors fully latch.
4. Maintenance director or designee will audit Smoke barrier doors for 3 monthly and then quarterly. All findings will be reported at Monthly QPI meeting

Initial comments:Name: WHITE 02 - Component: 02 - Tag: 0000

Facility ID# 085602
Component 02
White Building

Based on a Medicare/Medicaid Recertification Survey completed on April 29, 2024, at Mountain City Nursing & Rehab Ctr, it was determined there were no deficiencies identified under the 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 three story, Type II (222), fire resistive building, that is fully sprinklered.

Plan of Correction:

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