Pennsylvania Department of Health
ROSEMONT CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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ROSEMONT 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 February 22, 2024, at Rosemont Center, 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 - Component: 01 - Tag: 0000

Facility ID #181402
Component 01
Main Building 01

Based on a Medicare/Medicaid Recertification Survey completed on February 22, 2024, it was determined that Rosemont Center 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 three-story, Type III (200), unprotected, ordinary building, 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 - Component: 01 - Tag: 0161

Based on document review and interview, it was determined the facility failed to maintain the building construction fire resistance rating, affecting the entire facility.

Findings Include:

Document review on February 22, 2024, at 8:30 a.m., revealed the building exceeded the story height for a three-story, unprotected, ordinary building, that is fully sprinklered.

Exit interview with the Administrator and Maintenance Director on February 22, 2024, at 10:00 a.m., confirmed the construction type.

Plan of Correction - To be completed: 03/11/2024

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. Rosemont Center 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.

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 - 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 facility.

Findings include:

Observation on February 22, 2024, at 9:38 a.m., revealed on the first floor, the smoke barrier doors next to resident room 105 failed to close together and maintain smoke tight resistance.

Exit interview with the Administrator and Maintenance Director on February 22, 2024, at 10:00 a.m., confirmed the smoke barrier doors were not smoke tight in their frame.

Plan of Correction - To be completed: 03/11/2024

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. The smoke barrier doors next to resident room 105 was fixed and now closes together to maintain smoke tight. NHA/Designee will audit the smoke barrier doors in the facility to ensure all smoke barrier doors close smoke tight. NHA/Designee will reeducate the Maintenance staff on the need for all smoke barrier doors to close smoke tight. NHA/Designee will do random smoke barrier doors audits weekly x4 and then monthly x3 to ensure smoke barrier doors close smoke tight. Results will be shared at the QAPI meeting.

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