Pennsylvania Department of Health
WYNDMOOR HILLS REHABILITATION AND NURSING CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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WYNDMOOR HILLS REHABILITATION AND NURSING 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 March 13, 2024, at Wyndmoor Hills Healthcare 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: FORMERLY MONTGOMERY REHAB CENTER OF CHESTNUT HILL - Component: 01 - Tag: 0000

Facility ID# 21610201
Component 01
Health Care & Rehab Building

Based on a Medicare/Medicaid Recertification Survey completed on March 13, 2024, it was determined Wyndmoor Hills Health Care & Rehabilitation 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 II (222), fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - 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.

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: FORMERLY MONTGOMERY REHAB CENTER OF CHESTNUT HILL - Component: 01 - Tag: 0100

Based on document review and interview, it was determined that the facility failed to test and clean carbon monoxide detectors throughout the building, per PA Act #45.

Findings include:

Document review on March 13, 2024, at 8:45 a.m., revealed the facility failed to replace the batteries in the carbon monoxide detectors within the previous twelve months.

Interview with the Maintenance Supervisor on March 13, 2024, at 8:45 a.m., confirmed the batteries were not replaced in the above carbon monoxide detectors within the previous twelve months.

Plan of Correction - To be completed: 05/06/2024

1. The CO2 monitor batteries were replaced by Maintenance Supervisor/designee
2. CO2 monitors were tested to ensure they are operational. Maintenance will replace batteries annually.

NFPA 101 STANDARD Building Construction Type and Height:

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.

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: FORMERLY MONTGOMERY REHAB CENTER OF CHESTNUT HILL - Component: 01 - Tag: 0161

Based on observation and interview, it was determined that the facility failed to inspect and maintain fire-rated ceiling tiles, part of the two-hour fire separation between floors, on one of four levels.

Findings include:

Observation on March 13, 2024, between 1:00 p.m. and 1:20 p.m., revealed the following locations had damaged or missing fire-rated ceiling tiles:
A. (1:00 p.m.) on the first floor, IT room, had multiple missing fire-rated ceiling tiles;
B. (1:10 p.m.) on the first floor, west hall, medical offices, had multiple missing fire-rated ceiling tiles;
C. (1:20 p.m.) on the first floor, east hall, maintenance shop, had multiple missing fire-rated ceiling tiles.

Interview with the Maintenance Supervisor on March 13, 2024, at 1:20 p.m., confirmed the above deficiencies.

Plan of Correction - To be completed: 05/06/2024

1. Ceiling Tile replacements were started by Maintenance Supervisor/designee. The ceiling tile replacement will continue until the areas identified have ceiling tiles.
2. Maintenance will be inserviced on importance maintaining the 2 hour separation between floors.
Five rooms with ceiling tiles will be audited monthly x 6 months. If ceiling tiles are not present, they will be replaced.

NFPA 101 STANDARD Egress Doors:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

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: FORMERLY MONTGOMERY REHAB CENTER OF CHESTNUT HILL - Component: 01 - Tag: 0222

Based on observation and interview, it was determined the facility failed to maintain egress doors, affecting one of four levels.

Findings include:

Observation on March 13, 2024, at 1:25 p.m., revealed, on the first floor, the maintenance shop egress door failed to open when pushed.

Interview with the Maintenance Supervisor on March 13, 2024, at 1:25 p.m., confirmed the door failed to open when tested.

Plan of Correction - To be completed: 05/06/2024

1. Maintenance Shop egress door will be repaired or a quote for replacement will be obtained to ensure the maintenance shop egress door opens appropriately.
2. Egress doors will be audited weekly x4 weeks then monthly x 3 months

NFPA 101 STANDARD Doors with Self-Closing Devices:

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: FORMERLY MONTGOMERY REHAB CENTER OF CHESTNUT HILL - Component: 01 - Tag: 0223

Based on observation and interview, the facility failed to maintain doors with self-closing devices for one of four levels.

Findings include:

Observation on March 13, 2024, at 11:55 a.m., revealed, on the third floor, the soiled utility room self-closing door failed to close and latch in the frame.

Interview with the Maintenance Supervisor on March 13, 2024, at 11:55 a.m., confirmed the above door failed to close and latch in the frame.

Plan of Correction - To be completed: 05/06/2024

1. The 3rd Floor soiled utility door closure will be adjusted or repaired to ensure itself closes and latches.
2. Five Doors with self latching devices will be audited weekly x 4 weeks then monthly x 3 to ensure they self close and latch

NFPA 101 STANDARD Emergency Lighting:

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: FORMERLY MONTGOMERY REHAB CENTER OF CHESTNUT HILL - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to maintain emergency lighting, affecting the entire facility.

Findings include:

Document review on March 13, 2024, at 11:35 a..m, revealed the facility could not produce documentation that emergency lighting had been tested for 30 seconds on a monthly basis or for 90 minutes on an annual basis.

Interview with the Maintenance Supervisor on March 13, 2024, at 11:35 a..m, confirmed the lack of documentation.

Plan of Correction - To be completed: 05/06/2024

1. Maintenance will test emergency lighting at least for 30 seconds monthly and 90 minutes on an annual basis. The testing will be documented by Maintenance.
2. NHA will audit documentation to ensure that the testing has been completed on a monthly and annual basis.

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: FORMERLY MONTGOMERY REHAB CENTER OF CHESTNUT HILL - Component: 01 - Tag: 0293

Based on document review, observation, and interview, it was determined the facility failed to maintain exit signs, affecting the entire facility.

Findings include:

1. Document review on March 13, 2024, at 11:40 a.m., revealed the facility failed to provide documentation of monthly exit sign inspections. The last documented inspection was July 2023.

Interview with the Maintenance Supervisor on March 13, 2024, at 11:40 a.m., confirmed the exit sign deficiency existed.

2. Observation on March 13, 2024, at 11:50 a.m., revealed, on the third floor, north hall, exit sign above the smoke doors had a broken mount, causing the sign to be hanging by the wires.

Interview with the Maintenance Supervisor on March 13, 2024, at 11:50 a.m., confirmed the exit sign deficiency existed.

Plan of Correction - To be completed: 05/06/2024

1. The exit sign on the third floor, north hall mount was replaced by Maintenance
2. An audit was completed and all are operational. NHA/designee will audit the exit signs monthly to ensure they are operational

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: FORMERLY MONTGOMERY REHAB CENTER OF CHESTNUT HILL - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to maintain the sprinkler system, affecting the entire facility.

Findings include:

Document review on March 13, 2024, at 9:30 a.m., revealed the facility could not provide documentation for the first quarter of 2023 sprinkler inspection.

Interview with the Maintenance Supervisor on March 13, 2024, at 9:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 05/06/2024

1. Cannot retroactively corrected due to the sprinkler inspection not being completed.
2. NHA/designee will audit sprinkler documentation quarterly to ensure quarterly sprinkler inspections are occurring timely and documentation is obtained from the vendor.

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: FORMERLY MONTGOMERY REHAB CENTER OF CHESTNUT HILL - Component: 01 - Tag: 0355

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

Findings include:

Observation on March 13, 2024, at 11:45 a.m., revealed the monthly fire extinguisher inspections were not documented on the tags for the months of July through November 2023.

Interview with the Maintenance Supervisor on March 13, 2024, at 11:45 a.m., confirmed the fire extinguisher deficiency existed.

Plan of Correction - To be completed: 05/06/2024

1. The fire extinguisher checks cannot be retroactively corrected.
2. Maintenance Supervisor has been checking fire extinguishers since started working at the facility in December 2023.
3. NHA/designee will audit fire extinguishers monthly to ensure the fire extinguisher checks are being completed monthly.

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: FORMERLY MONTGOMERY REHAB CENTER OF CHESTNUT HILL - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure corridor doors positively latched in the frames, affecting one of four levels in the facility.

Findings include:

Observation on March 13, 2024, at 12:40 p.m., revealed, on the third floor, the door to resident Room 301 would not latch in the frame.

Interview with the Maintenance Supervisor on March 13, 2024, at 12:40 p.m., confirmed the door would not latch.

Plan of Correction - To be completed: 05/06/2024

1. The door for Room 301 will be adjusted, repaired, or replaced to ensure it properly latches.
2. Maintenance Supervisor will audit 5 doors weekly x4 weeks then monthly x3 months to ensure corridor doors properly latch.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu:

Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82

Observations:
Name: FORMERLY MONTGOMERY REHAB CENTER OF CHESTNUT HILL - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain the fire protection rating for linen chutes, affecting one of four levels.

Findings include:

Observations on March 13, 2024, at 12:58 p.m., revealed, on the second floor, soiled utility room chute door failed to self-close and positively latch.

Interview with the Maintenance Supervisor on March 13, 2024, at 12:58 p.m., confirmed the chute door failed to latch.

Plan of Correction - To be completed: 05/06/2024

1. The linen chute on 2nd Floor will be repaired by Maintenance to ensure it properly latches
2. The 3rd Floor linen chute will be evaluated by Maintenance to ensure it properly latches
3. The linen chutes will be audited monthly for 6 months to ensure both properly latch.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Observations:
Name: FORMERLY MONTGOMERY REHAB CENTER OF CHESTNUT HILL - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to inspect fire doors, affecting the entire facility.

Findings include:

Document review on March 13, 2024, at 9:00 a.m., revealed the facility could not produce documentation the fire doors had been inspected within the past 12 months.

Interview with the Maintenance Supervisor on March 13, 2024, at 9:00 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 05/06/2024

1. The door inspection was completed by the vendor on 03/13/2024 prior to end of survey.
2. A copy is made available to the department. NHA will review the report for any deficiencies and request a Time Limited Waiver from the Department for the due to the cost and timeliness of completing corrections for identified door deficiencies by the 90th day of survey cycle.

NFPA 101 STANDARD Electrical Systems - Other:

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: FORMERLY MONTGOMERY REHAB CENTER OF CHESTNUT HILL - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, affecting one of four levels.

Findings include:

Observations on March 13, 2024, at 8:40 a.m., revealed, on the first floor, main lobby, had a missing light fixture on the ceiling exposing the wiring.

Interview with the Maintenance Supervisor on March 13, 2024, at 8:40 a.m., confirmed the electrical deficiency.

Refer to NFPA 70, National Electric Code, and NFPA 99, 6.3.2.1.

Plan of Correction - To be completed: 05/06/2024

1. The exposed wires and lighting was removed from the lobby light fixture by the Maintenance Supervisor.
2. Maintenance will audit any additional light fixture with exposed wires.

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: FORMERLY MONTGOMERY REHAB CENTER OF CHESTNUT HILL - Component: 01 - Tag: 0918

Based on document review, observation, and interview, it was determined that the facility failed to maintain one of one generator, affecting the entire facility.

Findings include:

1. Document review on March 13, 2024, at 11:00 a.m., revealed the facility failed to provide documentation for the following tests:
A. (weekly) battery voltage or electrolyte levels;
B. (monthly) specific gravity or conductance.

Interview with the Maintenance Supervisor on March 13, 2024, at 11:00 a.m., confirmed the tests had not been completed.

2. Observation on March 13, 2024, at 1:30 p.m., revealed the emergency generator, located inside the building basement, lacked a remote emergency shut off button, located on the exterior of the emergency generator room.

Interview with the maintenance supervisor on March 13, 2024, at 1:30 p.m., confirmed the emergency generator lacked a remote emergency shut off button, located on the exterior of the emergency generator room.

Plan of Correction - To be completed: 05/06/2024

1. The weekly battery voltage test or electrolyte levels on the generator will be completed by the Maintenance Supervisor/designee. A monthly specific gravity test or conductance test by the Maintenance Supervisor/designee. The generator company has been contacted and will install a remote emergency stop for the generator,
2. NHA will audit generator documentation weekly and monthly for each test relative to the timeframe required by regulation. NHA/designee will validate remote emergency stop has been installed generator company

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