Pennsylvania Department of Health
KING OF PRUSSIA SKILLED NUSING AND REHABILITATION CENTER
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


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 48 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.


KING OF PRUSSIA SKILLED NUSING 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 August 19, 2024, at King of Prussia Skilled 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: BUILDING 01 (MAIN & MEDBRIDGE BLDG) - Component: 01 - Tag: 0000

Facility ID# 125902
Building 01
Main & Medbridge Building

Based on a Medicare/Medicaid Recertification Survey completed on August 19, 2024, it was determined that King of Prussia Skilled Nursing and Rehabilitation Center - Main & Medbridge 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 483.90(a).

This is a two-story, Type II (000), unprotected non-combustible building, 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: BUILDING 01 (MAIN & MEDBRIDGE BLDG) - Component: 01 - Tag: 0100

Based on document review and interview, it was determined the facility failed to provide accurate floor plans affecting one floor plan.
Findings include:

Document review on August 19, 2024, between 8:30 a.m. and 12:45 p.m., revealed the facility failed to provide documentation of floor plans including:
1.Non specific component boundaries
2.Kitchen and other hazard areas not identified on plans
3.Building components not identified
4.Smoke walls not identified
5.Fire doors not identified
Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 10/10/2024

1. Administrator or designee will re-educate the Maintenance Director on the importance of producing accurate floor plans to ensure the safety of the facility.
2. The Maintenance Director will get an estimate from an architect to do an updated floor plan for the facility (this includes: fire doors, smoke walls, building components, kitchen and other hazardous areas, and non-specific component boundaries).
3. The Maintenance Director will audit monthly if any changes or additions are made to the facility and get an updated plan, as needed.
4. The Maintenance Director or Administrator will review outcome audits at QAPI Committee x 3 months.

NFPA 101 STANDARD Multiple Occupancies:

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 - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:
Name: BUILDING 01 (MAIN & MEDBRIDGE BLDG) - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of common walls, affecting one of two levels.

Findings include:

Observation on August 19, 2024, at 11:20 a.m., revealed the upper-level fire doors separating Main/Physical Therapy components failed to close and latch when tested.

Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the common wall door deficiency.

Plan of Correction - To be completed: 10/10/2024

1. Facility will maintain the fire resistance doors.
2. Administrator or designee will re-educate the Maintenance Director on the importance and urgency in maintaining the fire resistance doors and ensuring that it latches.
3. The Maintenance Director will conduct weekly audits of upper-level and lower-level fire doors separating. This includes the main/physical therapy components that failed to close and latch when tested. The Maintenance Director will verify that all doors latch to ensure safety.
4. The Maintenance Director or Administrator will review outcome audits at QAPI Committee x3 months.

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: BUILDING 01 (MAIN & MEDBRIDGE BLDG) - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to ensure means of egress are maintained free of all obstructions, affecting one of two levels in the component.

Findings include:

Observation on August 19, 2024, at 11:50 a.m., revealed, on the second floor, in the emergency stairway, the staff did not know the code to open the exit door.

Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the staff did not know the exit code.

Plan of Correction - To be completed: 10/10/2024

1. Facility will ensure means of egress are maintained: making sure that the facility has safe and efficient pathways and exits for evacuation during emergencies.
2. Administrator or designee will re-educate the Maintenance Director on the importance of ensuring efficient pathways and exits for evacuation during emergencies.
3. The Maintenance Director will conduct weekly audits by randomly asking various staff members to verify emergency codes in the facility in order to exit the facility safely. This includes discussing exits and pathways in incase of emergencies to verify efficient and safe evacuation.
4. The Maintenance Director or Administrator will review outcome audits at QAPI Committee x 3 months.

NFPA 101 STANDARD Emergency Lighting:

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.

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: BUILDING 01 (MAIN & MEDBRIDGE BLDG) - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to provide battery back up light testing, affecting the entire facility.
Findings include:
Document review on August 19, 2024, between 8:30 a.m. and 12:45 p.m., revealed the facility failed to provide documentation of the reports:
1.Battery back up lighting 30 second test
2.Battery back up lighting 90 minute test

Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 10/10/2024

1. Facility will provide battery back up light testing.
2. Administrator or designee will re-educate the Maintenance Director on the need to provide battery back up light testing, which affects the entire facility.
3. The Maintenance Director will conduct weekly audits testing the back up lighting 30/90 seconds and housing appropriate documentation as proof of ongoing testing.
4. The Maintenance Director or Administrator will review outcome audits at QAPI Committee x 3 months.

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: BUILDING 01 (MAIN & MEDBRIDGE BLDG) - Component: 01 - Tag: 0293

Based on document review and interview, it was determined the facility failed to provide exit sign inspection reports, affecting the entire facility.
Findings include:
Document review on August 19, 2024, between 8:30 a.m. and 12:45 p.m., revealed the facility failed to provide documentation of the reports:
1.Exit sign monthly inspection
Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 10/10/2024

1. The facility will provide exit sign inspection reports.
2. Administrator or designee will re-educate the Maintenance Director on the urgency to provide exit sign inspection reports, which affect the entire facility.
3. The Maintenance Director will conduct weekly audits confirming exit sign inspection complete and all signs are accounted for and placed in appropriate areas.
4. The Maintenance Director or Administrator will review outcome audits at QAPI Committee x 3 months.

NFPA 101 STANDARD Cooking Facilities:

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: BUILDING 01 (MAIN & MEDBRIDGE BLDG) - Component: 01 - Tag: 0324

Based on document review and interview, it was determined the facility failed to provide semi annual kitchen suppression test /maintenance reports and exhaust hood/duct cleaning reports, affecting one of two floors.
Findings include:

Document review on August 19, 2024, between 8:30 a.m. and 12:45 p.m., revealed the facility failed to provide documentation of the reports:
1.Semi annual kitchen suppression test/maintenance reports for the second half of the year 2023
2.Kitchen exhaust hood/duct cleaning semi annual report for the second half of the year of 2023

Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 10/10/2024

1. Facility will provide semi annual kitchen suppression test /maintenance reports and exhaust hood/duct cleaning reports. Cintas already completed tasks as of May 20, 2024 and is done 2x a year.
2. Administrator or designee will re-educate the Maintenance Director on the importance to provide semi annual kitchen suppression test /maintenance reports and exhaust hood/duct cleaning reports.
3. The Maintenance Director will conduct monthly audits for: kitchen suppression test/maintenance reports & Kitchen exhaust hood/duct cleaning to verify they are completed timely and all reports are accurate and in compliance.
4. The Maintenance Director or Administrator will review outcome audits at QAPI Committee x 3 months.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: BUILDING 01 (MAIN & MEDBRIDGE BLDG) - Component: 01 - Tag: 0345

Based on observation and interview, it was determined the facility failed to maintain the fire alarm system, affecting the entire facility.

Findings include:

1. Document review on August 19, 2024, at 9:00 a.m., revealed the facility could not produce documentation showing a semi-annual fire alarm visual inspection had been performed in 2024
Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the missing documentation.

2. Observation on August 19, 2024, at 10:25 a.m., revealed upper-level kitchen fire alarm pull station #2 was damaged and inoperable at time of survey.

Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the damaged pull station.

3. Observation on August 19, 2024, at 11:00 a.m., revealed the facility fire alarm panel remained in trouble mode during the survey.

Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the fire alarm panel trouble status.

Plan of Correction - To be completed: 10/10/2024

1. Facility will maintain the fire alarm system. Alarm system was corrected by Cintas and is fully functioning.
2. Administrator or designee will re-educate the Maintenance Director on the importance of maintaining the: fire alarm system, producing documentation showing a semi-annual fire alarm visual inspection had been performed, verifying all fire pull stations are safely operating, and fire alarm panel is not in trouble mode.
3. The Maintenance Director will conduct weekly audits to verify the fire alarm is inspected and in good working order along with the appropriate documentation. Also, all fire panels are accurately coded and not in trouble mode.
4. The Maintenance Director or Administrator will review outcome audits at QAPI Committee x 3 months.

NFPA 101 STANDARD Smoke Detection:

Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2

Observations:
Name: BUILDING 01 (MAIN & MEDBRIDGE BLDG) - Component: 01 - Tag: 0347

Based upon observation and interview, it was determined the facility failed to maintain smoke detectors, affecting one of two levels.

Findings include:

Observation on August 19, 2024, at 10:20 a.m., revealed, on the first floor, in Kitchen, a smoke detector detached from its housing.

Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the detached smoke detector.

Plan of Correction - To be completed: 10/10/2024

1. Facility maintains all smoke detectors and kitchen smoke detector was corrected, attached to its housing, and fully functioning.
2. Administrator or designee will re-educate the Maintenance Director on maintaining all smoke detectors to avoid safety of the facility.
3. The Maintenance Director will conduct weekly audits to verify all smoke detectors are maintained, accounted for, and attached to its housing.
4. The Maintenance Director or Administrator will review outcome audits at QAPI Committee x 3 months.

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: BUILDING 01 (MAIN & MEDBRIDGE BLDG) - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to provide quarterly sprinkler inspection reports, affecting the entire facility.

Findings include:
Document review on August 19, 2024, between 8:30 a.m. and 12:45 p.m., revealed the facility failed to provide documentation of the following tests and inspections:
a. Second and fourth quarter mechanical water flow alarm device
b. Control valves including PIV annual test
c. Dry system trip test annual
d. internal valve and pipe 5 year
e. multiple deficiencies noted on sprinkler inspection report from 1/17/2024 with no documentation of correction
Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 10/10/2024

1. Facility will provide quarterly sprinkler inspection reports.
2. Administrator or designee will re-educate the Maintenance Director on the importance of providing quarterly sprinkler inspection reports, which affects the entire facility.
3. The Maintenance Director will conduct monthly audits to ensure documentation of the appropriate tests and inspections: mechanical water flow alarm device, Control valves including PIV annual test, Dry system trip test annual, internal valve and pipe 5 year, multiple deficiencies that were noted on sprinkler inspection report from 1/17/2024 with no documentation of correction will no be corrected and have no errors moving forward.
4. The Maintenance Director or Administrator will review outcome audits at QAPI Committee x 3 months.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: BUILDING 01 (MAIN & MEDBRIDGE BLDG) - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain fire extinguisher inspections, affecting the entire facility.

Findings include:

1. Observation made on August 19, 2024, at 10:20 a.m., revealed, on the first floor, kitchen fire extinguisher tag was missing its monthly quick-check inspections.

Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the missing monthly quick checks.

2. Document review on August 19, 2024, between 8:30 a.m. and 12:45 p.m., revealed the facility failed to provide documentation for certification of individual(s) conducting annual maintenance of fire extinguishers.
Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 10/10/2024

1. Facility will maintain fire extinguisher inspections.
2. Administrator or designee will re-educate the Maintenance Director on the importance of maintaining fire extinguisher inspections to avoid affecting the entire facility and its safety.
3. The Maintenance Director will conduct monthly audits to verify all extinguishers have been inspected and in compliance with correct dates. This includes: tags on extinguishers for monthly quick check inspections, and provided documentation for certification of individual(s) conducting annual maintenance of fire extinguishers.
4. The Maintenance Director or Administrator will review outcome audits at QAPI Committee x 3 months.

NFPA 101 STANDARD Utilities - Gas and Electric:

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Observations:
Name: BUILDING 01 (MAIN & MEDBRIDGE BLDG) - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting one of two levels.

Findings include:

Observation on August 19, 2024, at 10:55 a.m., revealed, in upper-level Medbridge Salon, a- non-GFCI outlet located within 6 feet of a sink. Per NFPA 70 210.8(B)5, a GFCI outlet is required where receptacles are installed within 6 ft of the outside edge of the sink.

Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the unprotected outlet.

Plan of Correction - To be completed: 10/10/2024

1. Facility will comply with NFPA 70, National Electric Code, for electrical wiring and equipment.
2. Administrator or designee will re-educate the Maintenance Director on the urgency to comply with NFPA 70, National Electric Code, for electrical wiring and equipment.
3. The Maintenance Director will conduct monthly audits to ensure compliance with outlets located within 6 feet of a sink. Per NFPA 70 210.8(B)5, a GFCI outlet is required where receptacles are installed within 6 ft of the outside edge of the sink.
4. The Maintenance Director or Administrator will review outcome audits at QAPI Committee x 3 months.

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: BUILDING 01 (MAIN & MEDBRIDGE BLDG) - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility failed to maintain Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting two of two levels.

Findings include:

Document review on August 19, 2024, at 9:00 a.m., revealed the January 30, 2023, fire damper inspection report listed the numerous dampers deficient or inaccessible. Documentation of subsequent repairs was not available at time of survey.

Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 10/10/2024

1. Facility will maintain Heating, Ventilating and Air Conditioning (HVAC) equipment.
2. Administrator or designee will re-educate the Maintenance Director on the urgency in maintaining Heating Ventilating and Air Conditioning (HVAC) equipment.
3. The Maintenance Director will conduct weekly audits to ensure fire damper inspections are accurately conducted and any repairs needed are completed and appropriate documentation is produced and tracked.
4. The Maintenance Director or Administrator will review outcome audits at QAPI Committee x 3 months.

NFPA 101 STANDARD Fire Drills:

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: BUILDING 01 (MAIN & MEDBRIDGE BLDG) - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to provide quarterly fire drill reports, affecting 4 of 12 drills.
Findings include:
Document review on August 19, 2024, between 8:30 a.m. and 12:45 p.m., revealed the facility failed to provide documentation of the following drills:
1.Second quarter second shift
2.Third quarter first, second and third shift

Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 10/10/2024

1. Facility will provide quarterly fire drill reports.
2. Administrator or designee will re-educate the Maintenance Director on the importance of providing quarterly fire drill reports.
3. The Maintenance Director will conduct weekly audits to ensure all fire drill reports are accurate and up to date (this includes on all shifts).
4. The Maintenance Director or Administrator will review outcome audits at QAPI Committee x 3 months.

NFPA 101 STANDARD Smoking Regulations:

Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: BUILDING 01 (MAIN & MEDBRIDGE BLDG) - Component: 01 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain smoking areas outside the facility, affecting one of two levels.

Findings include:

Observation on August 19, 2024, at 9:00 a.m., revealed a staff member smoking directly outside the kitchen rear entrance. Facility smoking policy was not available for review at time of survey.

Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the employee smoking.

Plan of Correction - To be completed: 10/10/2024

1. Administrator or designee will re-educate the Maintenance Director on the importance of maintaining smoking areas outside the facility.
2. The Maintenance Director will also educate staff on smoke free facility and policies.
3. The Maintenance Director will conduct weekly audits to ensure all areas of the facility are smoke free and no smoking conducted on premises.
4. The Maintenance Director or Administrator will review outcome audits at QAPI Committee x 3 months.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: BUILDING 01 (MAIN & MEDBRIDGE BLDG) - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of electrical devices affecting one of two levels.

Findings include:

Observations on August 19, 2024, revealed the following electrical deficiencies:

a. 10:50 a.m.. upper-level kitchen- fridge plugged into extension cord.
b. 11:25 a.m., upper-level schedulers office- outlet multiplier in use.

Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the unauthorized electrical devices.

Plan of Correction - To be completed: 10/10/2024

1. Facility will prohibit the unauthorized use of electrical devices.
2. Administrator or designee will re-educate the Maintenance Director on the importance of prohibiting the unauthorized use of electrical devices.
3. The Maintenance Director will conduct weekly audits to ensure all areas are free of unauthorized devices. This includes: kitchen- fridge plugged into extension cord, outlet multiplier use.
4. The Maintenance Director or Administrator will review outcome audits at QAPI Committee x 3 months.

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: BUILDING 01 (MAIN & MEDBRIDGE BLDG) - Component: 01 - Tag: 0923

Based on observation and interview, it was determined that the facility failed to maintain oxygen storage requirements, affecting one of two levels.

Findings include:

Observation on August 19, 2024, at 11:40 a.m., revealed, upper level Medbridge Nurse Station oxygen storage room lacked required cautionary signage.

Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the missing signage.

Plan of Correction - To be completed: 10/10/2024

1. Facility will maintain oxygen storage requirements.
2. Administrator or designee will re-educate the Maintenance Director on the importance of maintaining oxygen storage requirements.
3. The Maintenance Director will conduct weekly audits to ensure the oxygen storage room is labeled with the required cautionary signage.
4. The Maintenance Director or Administrator will review outcome audits at QAPI Committee x 3 months.

Initial comments:Name: NORTHEAST ADDITION - Component: 03 - Tag: 0000

Facility ID# 125902
Building 03
Northeast Addition

Based on a Medicare/Medicaid Recertification Survey completed on August 19, 2024, it was determined that King of Prussia Skilled Nursing and Rehabilitation Center - Northeast Addition was not in compliance with the 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 two-story, Type II (111), protected non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress Requirements - Other:

Means of Egress Requirements - Other
List in the REMARKS section any LSC Section 18.2 and 19.2 Means of Egress 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.
18.2, 19.2

Observations:
Name: NORTHEAST ADDITION - Component: 03 - Tag: 0200

Based on observation and interview, it was determined the facility failed to ensure there were no obstructions to egress, affecting one of two levels.

Findings include:

Observation on August 19, 2024, at 12:00 p.m., revealed upper-level doors leading to an enclosed courtyard lacked signage indicating ' Not an Exit ' .

Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the missing signage.

Plan of Correction - To be completed: 10/10/2024

1. Facility will ensure there were no obstructions to egress.
2. Administrator or designee will re-educate the Maintenance Director on the importance of verifying there are no obstructions to egress, affecting one of two levels.
3. The Maintenance Director will conduct weekly audits x 12 weeks to ensure upper-level doors leading to an enclosed courtyard have appropriate signage indicating ' Not an Exit. '
4. The Maintenance Director or Administrator will review outcome audits at QAPI Committee x 3 months.

NFPA 101 STANDARD Egress Doors:

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

Observations:
Name: NORTHEAST ADDITION - Component: 03 - Tag: 0222

Based on observation and interview, it was determined that the facility failed to maintain egress doors with delayed egress locking systems, affecting one of two floors.

Findings include:

Observation on August 19, 2024, at 11:50 a.m., revealed, upper-level emergency exit delayed-egress door failed to release after 15 seconds when tested, and as indicated on the posted signage.

Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the delayed egress door failed to release when tested.

Plan of Correction - To be completed: 10/10/2024

1. Facility will maintain egress doors without a delayed egress locking system.
2. Administrator or designee will re-educate the Maintenance Director on the importance of maintaining the egress doors to avoid delayed egress locking systems, which ultimately affects one or two floors.
3. The Maintenance Director will conduct weekly audits to ensure that upper-level emergency exit delayed-egress doors no longer fail to release after 15 seconds when tested, and as indicated on the posted signage.
4. The Maintenance Director or Administrator will review outcome audits at QAPI Committee x 3 months.

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: NORTHEAST ADDITION - Component: 03 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous areas in sprinklered locations, affecting one of two levels.

Findings Include:

Observation on August 19, 2024, at 11:00 a.m., revealed lower-level Soiled Utility room door failed to latch when tested.

Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the door deficiency.

Plan of Correction - To be completed: 10/10/2024

1. Facility will maintain hazardous areas in sprinklered locations.
2. Administrator or designee will re-educate the Maintenance Director on the importance of maintaining hazardous areas in sprinklered locations.
3. The Maintenance Director will conduct weekly audits to verify all appropriate doors latch when tested.
4. The Maintenance Director or Administrator will review outcome audits at QAPI Committee x 3 months.

NFPA 101 STANDARD Smoke Detection:

Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2

Observations:
Name: NORTHEAST ADDITION - Component: 03 - Tag: 0347

Based upon observation and interview, it was determined the facility failed to maintain smoke detectors, affecting one of two levels.

Findings include:

Observation on August 19, 2024, at 10:20 a.m., revealed, in lower-level clean utility room, a smoke detector detached from its housing.

Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the detached smoke detector.

Plan of Correction - To be completed: 10/10/2024

1. Facility will maintain smoke detectors.
2. Administrator or designee will re-educate the Maintenance Director on maintaining all smoke detectors to avoid safety of the facility.
3. The Maintenance Director will conduct weekly audits to verify all smoke detectors are maintained, accounted for, and attached to its housing.
4. The Maintenance Director or Administrator will review outcome audits at QAPI Committee x 3 months.

NFPA 101 STANDARD Utilities - Gas and Electric:

Observations:
Name: NORTHEAST ADDITION - Component: 03 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting one of two levels.

Findings include:

Observation on August 19, 2024, at 12:05 p.m., revealed, in lower-level dialysis, 2- non-GFCI outlets located within 6 feet of a sink. Per NFPA 70 210.8(B)5, a GFCI outlet is required where receptacles are installed within 6 ft of the outside edge of the sink.

Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the unprotected outlets.

Initial comments:Name: THERAPY WING ADDITION - Component: 04 - Tag: 0000

Facility ID# 125902
Building 04
Therapy Wing Addition

Based on a Medicare/Medicaid Recertification Survey completed on August 19, 2024, it was determined that King of Prussia Skilled Nursing and Rehabilitation Center - Therapy Wing Addition, 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 one-story, Type II (111), protected non-combustible building, that is fully sprinklered.

Plan of Correction:

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: THERAPY WING ADDITION - Component: 04 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, affecting one emergency generator.

Findings Include:

Document review on August 19, 2024, at 9:30 a.m., revealed the generator hour meter records indicated the generator had not run full 30-minutes on multiple monthly load tests.

Exit interview with the Administrator and Maintenance Director on August 19, 2024, at 12:45 p.m., confirmed the conflicting documentation.

Plan of Correction - To be completed: 10/10/2024

1. Facility will maintain the emergency generator.
2. Administrator or designee will re-educate the Maintenance Director on the importance of maintaining the emergency generator and running a full 30 minute test monthly to ensure its operating and fully functioning.
3. The Maintenance Director will conduct weekly audits x 12 weeks to ensure all logs are up to date and the emergency generator is testing for the accurate amount of time, documented accurately, and fully functioning.
4. The Maintenance Director or Administrator will review outcome audits at QAPI Committee x 3 months.

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