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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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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 May 21, 2024 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# 131602
Component 01
A, B, and C Wings

Based on a Medicare/Medicaid Recertification Survey completed on May 21, 2024, 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 May 21, 2024, at 9:00 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 the Maintenance Director on May 21, 2024, at 11:30 a.m., confirmed the building exceeded the maximum allowable story height by one story.

Plan of Correction - To be completed: 06/29/2024

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.

NFPA 101 STANDARD Number of Exits - Corridors:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

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.

Findings include:

Document review May 21, 2024, 9:00 a.m., revealed there were less than two exits from the Second Floor, former office area.

Exit interview with the Administrator and the Maintenance Director on May 21, 2024, at 11:30 a.m., confirmed on the Second Floor, former office space lacked two exits.

Plan of Correction - To be completed: 06/29/2024

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 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 maintain the fire resistance of smoke barrier doors, affecting one of three levels in the component.

Findings include:

Observation on May 21, 2024, at 10:31 a.m., revealed on the first floor, the smoke barrier doors by the lobby failed to close together.

Exit interview with the Administrator and the Maintenance Director on May 21, 2024, at 11:30 a.m., confirmed the smoke barrier doors failed to close together.

Plan of Correction - To be completed: 06/29/2024

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. Fire barrier doors by the lobby to be adjusted to maintain fire rating.
2. Maintenance director or designee to be re-educated on the importance of maintaining fire barrier doors.
3. Maintenance director or designee to do random audits of fire barrier doors by the lobby ensure compliance. Weekly x4 monthlyx3
4. Results will be reviewed at the quarterly QAPI meeting.

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: MAIN BUILDING 01 (A, B, C WINGS) - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, Section 110.26(A)(1), for electrical wiring and equipment, affecting one of three levels in the component.

Findings include:

Observation on May 21, 2024, at 10:23 a.m., revealed a chair within three feet of the electrical panels next to resident room 214.

Exit interview with the Administrator and the Maintenance Director on May 21, 2024, at 11:30 a.m., confirmed the improper storage in front of the electrical panels.

Plan of Correction - To be completed: 06/29/2024

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. The chair near R214 was immediately removed three feet away from the electrical panel.
2. Maintenance director or designee to be re-educated on the importance of maintaining proper storage Infront of electrical panels.
3. Maintenance director or designee to do random audits of electrical panels on the second floor to ensure appropriate clearance. Weekly x4 monthlyx3
4. Results will be reviewed at the quarterly QAPI meeting.

Initial comments:Name: BUILDING 02 (D WING) - Component: 02 - Tag: 0000

Facility ID# 131602
Component 02
D Wing

Based on a Medicare/Medicaid Recertification Survey completed on May 21, 2024, 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 Multiple Occupancies:

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 02 (D WING) - Component: 02 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain the fire rating of fire barrier doors, affecting one of two fire barriers..

Findings include:

Observation on May 21, 2024, at 10:51 a.m., revealed on the first floor, the fire barrier doors near resident room D101 failed to close together and latch.

Exit Interview with the Administrator and the Maintenance Director on May 21, 2024, at 11:30 a.m., confirmed the doors failed to close together and latch.

Plan of Correction - To be completed: 06/29/2024

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. Fire barrier door across D101 to be adjusted to maintain fire rating.
2. Maintenance director or designee to be re-educated on the importance of maintaining fire barrier doors.
3. Maintenance director or designee to do random audits of fire barrier doors on D-wing to ensure compliance. Weekly x4 monthly X3
4. Results will be reviewed at the quarterly QAPI meeting

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