Pennsylvania Department of Health
 ACCELA REHAB AND CARE CENTER AT SOMERTON
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
ACCELA REHAB AND CARE CENTER AT SOMERTON
Inspection Results For:

There are  56 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.
ACCELA REHAB AND CARE CENTER AT SOMERTON - 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 February 24, 2026, at Accela Rehab and Care Center at Somerton, 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 (A, B, C WINGS) - Component: 01 - Tag: 0000
Facility ID# 131602Component 01A, B, and C WingsBased on a Medicare/Medicaid Recertification Survey completed on February 24, 2026, it was determined that Accela Rehab and Care Center at Somerton - A, B, C Wings 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 III (200), unprotected ordinary building, with three separate basements, that is fully sprinklered.
 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
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: MAIN BUILDING 01 (A, B, C WINGS) - Component: 01 - Tag: 0161 Based on document review and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire component. Findings include: Document review made on February 24, 2026, at 9:30 a.m., revealed this component has been classified as a two-story, Type III (200), unprotected ordinary construction, which is fully sprinklered. The story height exceeds the maximum allowance for this construction type by one story. Exit Interview with the Administrator and Maintenance Director on February 24, 2026, at 2:00 p.m., confirmed the building exceeded the maximum allowable story height by one story.
 Plan of Correction - To be completed: 04/21/2026

Accela Rehab at Somerton would like the Department of Health and Human Services Life Safety Divisions assistants with reapplying for another FSES for two-story type III (200), unprotected ordinary construction which is fully sprinklered, the story height exceeds the maximum allowance for this construction type one story, with time limited waver completed
NFPA 101 STANDARD Number of Exits - Corridors: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.
Number of Exits - Corridors
Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies.
18.2.5.4, 19.2.5.4




Observations:
Name: MAIN BUILDING 01 (A, B, C WINGS) - Component: 01 - Tag: 0252 Based on document review and interview, it was determined the facility failed to provide two exits, remote from one another, for each floor, affecting one of two levels within this component. Based on document review and interview, it was determined the facility failed to provide two exits, remote from one another, for each floor, affecting one of two levels within this component. Findings include: Document review February 24, 2026, 9:30 a.m., revealed there were less than two exits from the Second Floor, former office area. Exit Interview with the Administrator and Maintenance Director on February 24, 2026, at 2:00 p.m., confirmed, on the second floor, the former office space lacked two exits.
 Plan of Correction - To be completed: 04/21/2026

Accela Rehab and Care Center at Somerton would like the Department of Health and Human Services Life Safety Divisions assistants with reapplying for another FSES, where the second-floor former office space lacked two exits.
NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
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: MAIN BUILDING 01 (A, B, C WINGS) - Component: 01 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintainhazardous area enclosures, affecting one of two levels within this facility. Findings include: 1. Observation on February 24, 2026, between 11:00 a.m., and 1:45 p.m., revealed: a) First floor, A- Wing, Soiled utility door, failed to positively latch when tested due to binding in door frame. b) First floor, B 115, Soiled utility door, failed to positively latch when tested due to paper and a plastic bag stuffed into door strike. c) First floor, Laundry room door was not equipped with a door closure or spring hinge and did not latch in frame when closed. Exit Interview with the Administrator and Maintenance Director on February 24, 2026, at 2:00 p.m., confirmed the hazardous areas door deficiencies.
 Plan of Correction - To be completed: 04/21/2026

Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements.
Identification of other residents or areas having the potential to be affected due to the nature of the deficiency:
The deficient practice has the potential to affect all residents.
Corrective action
1. Obstructions to soiled utility rooms on A and B wings removed laundry room closure device was repaired.
2. Maintenance director or designee to re-educate maintenance staff on the importance of maintaining self -closure devices
3. Maintenance director or designee to audit laundry rooms and soiled utility rooms for self -closure device and obstructions. Weekly X4 monthly X2
4. Results will be reviewed at the quarterly QAPI meeting.

NFPA 101 STANDARD Cooking Facilities: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.
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: MAIN BUILDING 01 (A, B, C WINGS) - Component: 01 - Tag: 0324 Based on observation and interview, it was determined the facility failed to ensure the kitchen Ansul extinguishing system was inspected on one of two floors within this facility. 1.Findings include: Observations made on February 24, 2026, at 1:00 pm, revealed the Ansul extinguishing system tag was blank and missing monthly quick-check inspections. Exit Interview with the Administrator and Maintenance Director on February 24, 2026, at 2:00 p.m., confirmed the missing monthly quick checks.
 Plan of Correction - To be completed: 04/21/2026

Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements.
Identification of other residents or areas having the potential to be affected due to the nature of the deficiency:
The deficient practice has the potential to affect all residents.
Corrective action
1. Obstructions to soiled utility rooms on A and B wings removed laundry room closure device was repaired.
2. Maintenance director or designee to re-educate maintenance staff on the importance of maintaining self -closure devices
3. Maintenance director or designee to audit laundry rooms and soiled utility rooms for self -closure device and obstructions. Weekly X4 monthly X2
4. Results will be reviewed at the quarterly QAPI meeting.
1.Ansul extinguishing system was inspected
2.Maintenance director or designee to re-educate maintenance staff on the importance of maintaining documentation for the kitchen Ansul extinguishing system monthly quick check
3.Maintenance director or designee to audit kitchen Ansul extinguishing system monthly quick check. Weekly X4 monthly x2
4.Results will be reviewed at the quarterly QAPI meeting


NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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: MAIN BUILDING 01 (A, B, C WINGS) - Component: 01 - Tag: 0345 Based on observation, document review and interview, it was determined the facility failed to maintain fire alarm system components in operable condition, affecting the entire facility. Findings Include: 1. Documentation reviewed on February 24, 2026, at 9:15 a.m., revealed the fire alarm report dated October 21, 2025, listed devices that were not tested but were also not listed in the Deficiency/ Fail results. Verification of testing or repair was not available at the time of survey a) Smoke Detector, 1st floor by medical supply, device not found. b) Fire hat, Maintenance does not have key to reset elevator. c) Primary Recall, Maintenance does not have key to reset elevator. d) Smoke Detector, by house laundry, device not found. e) Shunt trip, Elevator control, not tested. Exit Interview with the Administrator and Maintenance Director on February 24, 2026, at 2:00 p.m.,confirmed the fire alarm deficiencies.
 Plan of Correction - To be completed: 04/21/2026

Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements.
Identification of other residents or areas having the potential to be affected due to the nature of the deficiency:
The deficient practice has the potential to affect all residents.
Corrective action
1.Smoke detector by medical supply room and laundry room replaced. Facility retrieved elevator key to reset elevator Shunt trip, Elevator control, tested.
2.Maintenance director or designee to re-educate maintenance staff on the importance of maintaining smoke detectors and ensuring elevator testing is maintained.
3.Maintenance director or designee to audit laundry rooms and medical supply rooms for smoke detectors weekly X4 monthly X2
4.Maintenance director or designee to audit elevator inspections weekly X4 monthly X2
5.Results will be reviewed at the quarterly QAPI meeting.

NFPA 101 STANDARD Sprinkler System - Installation: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.
Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)
Observations:
Name: MAIN BUILDING 01 (A, B, C WINGS) - Component: 01 - Tag: 0351 Based on observation, document review and interview, it was determined the facility failed to provide complete sprinkler coverage, affecting the entire facility. Findings include: 1. Observation made on February 24, 2026, at 12:15 p.m., revealed inside the 1st floor dining room, floor to ceiling millwork cabinetry, with doors, was installed and in use without interior sprinkler coverage. Document review of approved DOH renovation plan H-22-0980 and Sprinkler Plan H-24-1079 shows that all built in millwork was not shown or depicted on plans. Subsequently, DOH Plan Review cannot accurately verify conditions for sprinkler coverage within a fully sprinklered facility. Millwork was installed and in use without DOH life safety occupancy approval for use, during survey. Sprinkler Protection is required by one of the following means: a. Protection by heat detection which activates the fire alarm system. b. Protection by automatic sprinkler protection. c. Construction of non-combustible or limited-combustible construction. d. Construction of fire-retardant-treated wood. Exit Interview with the Administrator and Maintenance Director on February 24, 2026, at 2:00 p.m.,confirmed the lack of fire protection within the floor to ceiling built-in, closed-door storage cabinetry.
 Plan of Correction - To be completed: 04/21/2026

Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements.
Identification of other residents or areas having the potential to be affected due to the nature of the deficiency:
The deficient practice has the potential to affect all residents.
Corrective action
1.Sprinkler heads have been ordered for Millwork Cabinetry
2.Maintenance director or designee to re-educate maintenance staff on the importance of ensuring sprinkler heads are in accordance with NFPA13 standards
3.Maintenance director or designee to audit built in millwork to ensure sprinklers are in place. Weekly X4 monthlyX2
4.Results will be reviewed at the quarterly QAPI meeting.

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: MAIN BUILDING 01 (A, B, C WINGS) - Component: 01 - Tag: 0363 Based on observation and interview it was determined the facility failed to ensure that corridor doors were maintained to resist the passage of smoke and positively latch on of over 60 doors within the component. 1.Findings include: Observations on February 24, 2026, between 11:00 a.m., and 1:45 p.m., revealed: a) A Wing Dining Hall had paper towels stuffed into the doorframe strike plate and taped over to keep paper in, which inhibits the door ability to latch. b) 2nd floor Resident room 218 failed to latch when tested. c) 1st floor door A31 doesn't fit smoke tight in frame when latched. Interior room's light source can be seen when door is latched and closed, atop of door from hallway, d) 1st floor Shared Central Supply Room's door doesn't fit smoke tight in frame when latched. Interior room's light source can be seen when door is latched and closed, on right side of door from hallway. Exit Interview with the Administrator and Maintenance Director on February 24, 2026, at 2:00 p.m.,confirmed the door deficiencies listed.
 Plan of Correction - To be completed: 04/21/2026

Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements.
Identification of other residents or areas having the potential to be affected due to the nature of the deficiency:
The deficient practice has the potential to affect all residents.
Corrective action
1.Obstruction removed from A wing dining hall door, Room 218, A31, central supply room adjusted to ensure appropriate closure.
2.Maintenance director or designee to re-educate maintenance staff on the importance of maintaining facility doors
3.Maintenance director or designee to randomly audit facility doors to ensure appropriate closure. Weekly X4 monthly X2
4.Results will be reviewed at the quarterly QAPI meeting.


NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
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: MAIN BUILDING 01 (A, B, C WINGS) - Component: 01 - Tag: 0374 Based on observation and interview, it was determined the facility failed to ensure doors in smoke barrier walls were maintained to resist the passage of smoke, affecting one of two levels within the component. Findings include: 1. Observation on February 24, 2026, at the following times revealed: a) 11:35 a.m., The smoke barrier doors (A09) hallway, outside of nurse's station, failed to close smoke tight when tested due to an unsecured door frame within the wall. b) 11:50 a.m., The smoke barrier doors, A- Wing, outside of lobby, failed to swing and close smoke tight due to a broken door closure. Exit Interview with the Administrator and Maintenance Director on February 24, 2026, at 2:00 p.m., confirmed the smoke barrier door deficiencies listed.
 Plan of Correction - To be completed: 04/21/2026

Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements.
Identification of other residents or areas having the potential to be affected due to the nature of the deficiency:
The deficient practice has the potential to affect all residents.
Corrective action
1.smoke barrier doors closures repaired and adjusted to ensure appropriate closure
2.Maintenance director or designee to re-educate maintenance staff on the importance of maintaining facility smoke barrier doors
3.Maintenance director or designee to audit facility smoke barrier doors to ensure appropriate closure. Weekly X4 monthly X2
4.Maintenance director or designee to audit laundry rooms and medical supply rooms for smoke detectors weekly X4 monthly X2
5.Results will be reviewed at the quarterly QAPI meeting.

NFPA 101 STANDARD HVAC - Any Heating Device: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.
HVAC - Any Heating Device
Any heating device, other than a central heating plant, is designed and installed so combustible materials cannot be ignited by device, and has a safety feature to stop fuel and shut down equipment if there is excessive temperature or ignition failure. If fuel fired, the device also:
* is chimney or vent connected.
* takes air for combustion from outside.
* provides for a combustion system separate from occupied area atmosphere.
19.5.2.2
Observations:
Name: MAIN BUILDING 01 (A, B, C WINGS) - Component: 01 - Tag: 0522 Based on observation and interview, it was determined the facility failed to maintain that heatingunits were free of combustible materials, affecting one of two levels within the component. Findings include: 1. Observation made on February 24, 2026, at 12:22 p.m., 1st floor, within the laundry folding room,an electric coil heater was in use and left unattended, surrounded by combustible clothing items. Exit Interview with the Administrator and Maintenance Director on February 24, 2026, at 2:00 p.m., confirmed the unattended electric heater was discovered during survey.
 Plan of Correction - To be completed: 04/21/2026

Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements.
Identification of other residents or areas having the potential to be affected due to the nature of the deficiency:
The deficient practice has the potential to affect all residents.
Corrective action
1.Portable heating unit immediately removed.
2.Maintenance director or designee to re-educate maintenance staff on the importance of not using portable heating units and leaving it unattended.
3.Maintenance director or designee to audit laundry rooms for portable heating units left unattended weekly X4 monthly X2
4.Results will be reviewed at the quarterly QAPI meeting.


NFPA 101 STANDARD Combustible Decorations: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.
Combustible Decorations
Combustible decorations shall be prohibited unless one of the following is met:
o Flame retardant or treated with approved fire-retardant coating that is listed and labeled for product.
o Decorations meet NFPA 701.
o Decorations exhibit heat release less than 100 kilowatts in accordance with NFPA 289.
o Decorations, such as photographs, paintings and other art are attached to the walls, ceilings and non-fire-rated doors in accordance with 18.7.5.6(4) or 19.7.5.6(4).
o The decorations in existing occupancies are in such limited quantities that a hazard of fire development or spread is not present.
19.7.5.6
Observations:
Name: MAIN BUILDING 01 (A, B, C WINGS) - Component: 01 - Tag: 0753 Based on observation and interview, it was determined the facility failed to monitor the combustible load of decorations, on twenty of at least 70 doors within the component. Findings include: 1. Observation on February 24, 2016, at 12:15 p.m., revealed an excessive amount of combustible paper privacy curtains on resident rooms A-01 thru A-20, twenty-five minutes, with glass panel, rated doors. Exit Interview with the Administrator and Maintenance Director on February 24, 2026, at 2:00 p.m., confirmed the taped, paper privacy curtain on the resident room doors.
 Plan of Correction - To be completed: 04/21/2026

Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements.
Identification of other residents or areas having the potential to be affected due to the nature of the deficiency:
The deficient practice has the potential to affect all residents.
Corrective action
1.Paper shades were removed from resident room doors.
2.Maintenance director or designee to re-educate maintenance staff on the importance of not using Combustible decorations
3.Maintenance director or designee to randomly audit facility doors to ensure Combustible decorations are not used. Weekly X4 monthly X3
4.Results will be reviewed at the quarterly QAPI meeting.


NFPA 101 STANDARD Electrical Systems - Other: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.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 (A, B, C WINGS) - Component: 01 - Tag: 0911 Based on observation and interview, it was determined the facility failed to maintain electricalwiring, on one of two levels within the component. Installation shallbe in accordance with NFPA 99 Section 6.3.2.1. Findings include: 1. Observation made on February 24, 2026 at 12:40 p.m., revealed (1) missing light switch and (1) outlet cover within the first floor, laundry room. Exit Interview with the Administrator and Maintenance Director on February 24, 2026, at 2:00 p.m., confirmed the exposed wires.
 Plan of Correction - To be completed: 04/21/2026

Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements.
Identification of other residents or areas having the potential to be affected due to the nature of the deficiency:
The deficient practice has the potential to affect all residents.
Corrective action
1.Missing light switch and cover replaced in laundry room
2.Maintenance director or designee to re-educate maintenance staff on the importance of maintaining light witches and covers
3.Maintenance director or designee to audit laundry rooms for missing light switches and covers. Weekly X4 monthly X2
4.Results will be reviewed at the quarterly QAPI meeting.


NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
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: MAIN BUILDING 01 (A, B, C WINGS) - Component: 01 - Tag: 0920 Based upon observation and interview, it was determined the facility failed to ensure thatextension cords were not used as a substitute for fixed wiring and outlet multipliers were notused in place of permanent wiring on one of two floors within the component. Findings include: 1. Observations made on February 24, 2016, between 11:00 a.m., and 1:45 p.m., revealed the unauthorized use of extension cords/outlet multipliers in the following areas: a) Laundry room utilized two orange extension cords as a substitute for fixed wiring to power multiple sanitizer/chemical pumps behind and for the washing machines. b) Resident room A32 utilized multiple extension cords/ multipliers, tied to the bed rail, for power. c) Laundry folding room utilized an extension cord that ran above the monolithic ceiling and down to a surge protector that was powering a mini fridge and microwave. Exit Interview with the Administrator and Maintenance Director on February 24, 2026, at 2:00 p.m., confirmed use of unauthorized electrical equipment.
 Plan of Correction - To be completed: 04/21/2026

Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements.
Identification of other residents or areas having the potential to be affected due to the nature of the deficiency:
The deficient practice has the potential to affect all residents.
Corrective action
1.Extension cords in laundry room and A32 were removed
2.Maintenance director or designee to re-educate maintenance staff on the importance of NFPA regulations regarding power strips
3.Maintenance director or designee to randomly audit laundry rooms and resident rooms for inappropriate usage of powers strips. Weekly X4 Monthly X3
4.Results will be reviewed at the quarterly QAPI meeting

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
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: MAIN BUILDING 01 (A, B, C WINGS) - Component: 01 - Tag: 0923 Based on observation and interview it was determined the facility failed to ensure portable oxygen cylinders were secured on one of two levels. Findings include: 1. Observation made on February 24, 2026, at 12:55 p.m., revealed the exterior oxygen storage room on loading dock, there were five unsecured free-standing oxygen cylinders in the room. Exit Interview with the Administrator and Maintenance Director on February 24, 2026, at 2:00 p.m., confirmed the five unsecured oxygen cylinders.
 Plan of Correction - To be completed: 04/21/2026

Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements.
Identification of other residents or areas having the potential to be affected due to the nature of the deficiency:
The deficient practice has the potential to affect all residents.
Corrective action
1.free-standing oxygen cylinders were immediately secured
2.Maintenance director or designee to re-educate maintenance staff on the importance of securing free standing oxygen cylinders
3.Maintenance director or designee to audit oxygen storage area for unsecured cylinders. Weekly X4 monthly X2
4.Results will be reviewed at the quarterly QAPI meeting

Initial comments:Name: BUILDING 02 (D WING) - Component: 02 - Tag: 0000
Facility ID# 131602Component 02D WingBased on a Medicare/Medicaid Recertification Survey completed on February 24, 2026, it was determined that Accela Rehab and Care Center At Somerton - D Wing 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 (000), unprotected non-combustible building, that is fully sprinklered.
 Plan of Correction:


NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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 02 (D WING) - Component: 02 - Tag: 0345 Based on observation, document review and interview, it was determined the facility failed to maintain fire alarm system components in operable condition, affecting the entire facility. Findings Include: 1. Documentation reviewed on February 24, 2026, at 9:15 a.m., revealed the fire alarm report dated October 21, 2025, listed devices that were not tested but were also not listed in the Deficiency/ Fail results. Verification of testing or repair was not available at the time of survey a) Smoke Detector, 1st floor by medical supply, device not found. b) Fire hat, Maintenance does not have key to reset elevator. c) Primary Recall, Maintenance does not have key to reset elevator. d) Smoke Detector, by house laundry, device not found. e) Shunt trip, Elevator control, not tested. Exit Interview with the Administrator and Maintenance Director on February 24, 2026, at 2:00 p.m.,confirmed the fire alarm deficiencies.
 Plan of Correction - To be completed: 04/21/2026

Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements.
Identification of other residents or areas having the potential to be affected due to the nature of the deficiency:
The deficient practice has the potential to affect all residents.
Corrective action
1.Smoke detector by medical supply room and laundry room replaced. Facility retrieved elevator key to reset elevator Shunt trip, Elevator control, tested.
2.Maintenance director or designee to re-educate maintenance staff on the importance of maintaining smoke detectors and ensuring elevator testing is maintained.
3.Maintenance director or designee to audit laundry rooms and medical supply rooms for smoke detectors weekly X4 monthly X2
4.Maintenance director or designee to audit elevator inspections weekly X4 monthly X2
5.Results will be reviewed at the quarterly QAPI meeting.






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