Nursing Investigation Results -

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

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WYNDMOOR HILLS REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  38 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.
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 a Revisit to an Emergency Preparedness Survey completed on July 7, 2021, 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 Revisit to a Medicare/Medicaid Recertification Survey completed on July 7, 2021, it was determined Wyndmoor Hills Health Care & Rehab 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 structure, with a basement, which 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: FORMERLY MONTGOMERY REHAB CENTER OF CHESTNUT HILL - Component: 01 - Tag: 0100

Based on observation, interview and document review, it was determined the facility failed to submit plans to the Division of Safety Inspection Plan Review Office prior to performing facility modifications, affecting the entire facility.

Findings include:

1. Observation on July 7, 2021, at 8:30 a.m., revealed the facility failed to obtain required Department of Health, Division of Safety Inspection Plan approval prior to starting major HVAC related modifications.

Exit Interview with the Administrator and Maintenance Supervisor on July 7, 2021, at 3:05 p.m., confirmed the facility failed to obtain Department of Health plan approval.

2. Observation on July 7, 2021, at 1:34 p.m., revealed the facility failed to obtain required Department of Health, Division of Safety Inspection Plan approval prior to starting work on creating an Outpatient Occupational Therapy Unit, First Floor.

Exit Interview with the Administrator and Maintenance Supervisor on July 7, 2021, at 3:05 p.m., confirmed the facility failed to obtain Department of Health plan approval.
_____________________________________________
Based on document and interview, during an onsite Revisit, conducted on September 13, 2021, between 9:45 a.m. and 12:30 p.m., revealed the following:

Item 1 Not Completed. The facility failed to obtain required Department of Health, Division of Safety Inspection Plan approval prior to starting major HVAC related modifications.
As of the date of the revisit survey, the facility hadn't contacted the Department of Health, Division of Safety Inspection Plan Review.

Exit interview with Facility Administrator and Facility Maintenance Supervisor on September 13, 2021, at 12:25 p.m., confirmed the facility hadn't contacted the Department of Health, Division of Safety Inspection Plan Review.

Item 2 Not Completed. The facility failed to obtain required Department of Health, Division of Safety Inspection Plan approval prior to starting work on creating an Outpatient Occupational Therapy Unit, First Floor. As of the date of the revisit survey, the facility hadn't contacted the Department of Health, Division of Safety Inspection Plan Review.

Exit interview with Facility Administrator and Facility Maintenance Supervisor on September 13, 2021, at 12:25 p.m., confirmed the facility hadn't contacted the Department of Health, Division of Safety Inspection Plan Review.

****************************************

Based on an onsite Revisit, conducted on October 29, 2021, between 1:00 p.m. and 3:30 p.m., revealed the following:

Item 1 - Not Completed. The facility failed to obtain required Department of Health, Division of Safety Inspection Plan approval prior to starting major HVAC related modifications.

Item 2 - Not Completed. The facility failed to obtain required Department of Health, Division of Safety Inspection Plan approval prior to starting work on creating an Outpatient Occupational Therapy Unit, First Floor.

Exit interview with the Director of Maintenance on October 29, 2021, at 3:30 p.m., confirmed documentation was unavailable verifying contact with the Department of Health, Plan Review for the above renovation projects.




 Plan of Correction - To be completed: 11/26/2021

The facility has located appropriate plans and submitted to Plan Review.
Contacted Dept of Health Life Safety Division spoke with Carlo Dittono and working in conjunction for plan review.

NFPA 101 STANDARD Multiple Occupancies - Construction Type: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 - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: FORMERLY MONTGOMERY REHAB CENTER OF CHESTNUT HILL - Component: 01 - Tag: 0133

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

Findings include:

1. Observation on July 7, 2021, at 1:05 p.m., revealed the following deficiencies with the second floor common wall fire rated door, separating the heathcare component from the tunnel to the assisted living component:

a) Multiple holes in rated door;
b) Damaged push bar hardware and no rating label on the hardware;
c) No rating label on the door frame.

Exit Interview with the Administrator and Maintenance Supervisor on July 7, 2021, at 3:05 p.m., confirmed the common wall door deficiencies listed above.
_____________________________________________
Based on observation and interview, during an onsite Revisit, conducted on September 13, 2021 between 9:45 a.m. and 12:30 p.m., revealed the following:

Item 1 Not Completed. The following deficiencies, Second Floor, common wall, fire rated door, separating the heathcare component from the tunnel to the assisted living component:

a) Multiple holes in rated door;
b) Damaged push bar hardware and no rating label on the hardware;
c) No rating label on the door frame.

Exit interview with Facility Administrator and Facility Maintenance Supervisor on September 13, 2021, at 12:25 p.m., confirmed the common wall door deficiencies listed above.

****************************************
Based on an onsite Revisit, conducted on October 29, 2021, between 1:00 p.m. and 3:30 p.m., revealed the following:

Item 1 - Not Completed. The following deficiencies were located, Second Floor, common wall fire rated door, separating the Heathcare Building from the tunnel to the Assisted Living Building:

a) Multiple holes in the rated door. A hole remained in the door;

b) Damaged push bar hardware and no rating label on the hardware. The damaged push bar was repaired. The replacement hardware was listed as panic in lieu of fire rated hardware;

c) No rating label on the door frame. The door frame label was painted. The fire rating could not be determined at the time of inspection.

Exit interview with Maintenance Director on October 29, 2021, at 3:30 p.m., confirmed the common wall door deficiencies listed above.




 Plan of Correction - To be completed: 11/29/2021

Holes repaired, Push bar replaced, and fire rating documents obtained for fire rating
NFPA 101 STANDARD Vertical Openings - 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.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: FORMERLY MONTGOMERY REHAB CENTER OF CHESTNUT HILL - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of vertical openings between floors, affecting one of four levels within the facility.

Findings include:

1. Observation on July 7, 2021, at 12:20 p.m., revealed in the Third Floor dining room, there was an approximately two foot by two foot unprotected square cut-out,in the rated HVAC vertical chase wall.

Exit Interview with the Administrator and Maintenance Supervisor on July 7, 2021, at 3:05 p.m., confirmed the unprotected opening in the rated HVAC chase wall.
_____________________________________________
Based on observation and interview, during an onsite Revisit, conducted on September 13, 2021, between 9:45 a.m. and 12:30 p.m., revealed the following:

Item 1 Not Completed. Third Floor, dining room, there was an approximately two foot by two foot unprotected square cut-out, rated HVAC vertical chase wall.

Exit interview with Facility Administrator and Facility Maintenance Supervisor on September 13, 2021, at 12:25 p.m., confirmed the unprotected opening, rated HVAC chase wall.

***************************************

Based on an onsite Revisit, conducted on October 29, 2021, between 1:00 p.m. and 3:30 p.m., revealed the following:

Item 1 - Not Completed. Third Floor, Dining Room, had an approximately two foot by two foot unprotected square cut-out within the rated chase wall. A non-labeled frame and door were installed.

Exit interview with the Director of Maintenance on October 29, 2021, at 3:30 p.m., confirmed the unprotected opening in the rated partition.




 Plan of Correction - To be completed: 11/29/2021

2x2 cut out sealed with cinder blocks and concrete
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: FORMERLY MONTGOMERY REHAB CENTER OF CHESTNUT HILL - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of hazardous areas, affecting three of four levels within the facility.

Findings include:

1. Observation on July 7, 2021, at 12:17 p.m., revealed the Third Floor rated door, to the soiled utility room, failed to positively latch.

Exit Interview with the Administrator and Maintenance Supervisor on July 7, 2021, at 3:05 p.m., confirmed the door failed to latch.

2. Observation on July 7, 2021, at 1:14 p.m., revealed the Second Floor rated door, to the soiled utility room, failed to positively latch.

Exit Interview with the Administrator and Maintenance Supervisor on July 7, 2021, at 3:05 p.m., confirmed the door failed to latch.

3. Observation on July 7, 2021, at 1:50 p.m., revealed the basement fire rated emergency generator room had the following deficiencies:

a) Three rated entry doors to the enclosure were propped open;
b) One rated entry door to the enclosure had a painted over rating label;
c) There were multiple unsealed penetrations in the generator enclosure rated walls.

Exit Interview with the Administrator and Maintenance Supervisor on July 7, 2021, at 3:05 p.m., confirmed the deficiencies listed above.
_____________________________________________
Based on observation and interview, during an onsite Revisit, conducted on September 13, 2021, between 9:45 a.m. and 12:30 p.m., revealed the following:

Item 1 Not Completed. Third Floor, rated door, soiled utility room, failed to positively latch.

Exit interview with Facility Administrator and Facility Maintenance Supervisor on September 13, 2021, at 12:25 p.m., confirmed the door failed to latch.

Item 2 Not Completed. Second Floor, rated door, soiled utility room, failed to positively latch.

Exit interview with Facility Administrator and Facility Maintenance Supervisor on September 13, 2021, at 12:25 p.m., confirmed the door failed to latch.

Item 3a and 3c Not Completed. basement, fire rated emergency generator room, had the following deficiencies:

a) Three rated entry doors to the enclosure were propped open;
c) There were multiple unsealed penetrations, generator enclosure rated walls. As of the time of the revisit survey, penetrations had been sealed with an unknown expanding spray foam.

Exit interview with Facility Administrator and Facility Maintenance Supervisor on September 13, 2021, at 12:25 p.m., confirmed the deficiencies listed above.

******************************************

Based on an onsite Revisit, conducted on October 29, 2021, between 1:00 p.m. and 3:30 p.m., revealed the following:

Item 2 - Not Completed. Second Floor, rated corridor door, soiled utility room, failed to positively latch. In addition, there were holes in the door.

Exit interview with the Director of Maintenance on October 29, 2021, at 3:30 p.m., confirmed the door failed to latch.


Item 3 - Not Completed. Basement, emergency generator room, rated drywall enclosure had the following deficiencies:

c) Penetrations were sealed with an unknown expanding spray foam.

Exit interview with the Director of Maintenance on October 29, 2021, at 3:30 p.m., confirmed an approved through penetration fire stop system was not used to seal the penetrations.

All other deficiencies listed under this tag were corrected.




 Plan of Correction - To be completed: 12/28/2021

The latches for the soiled utility rooms on the second and third floors have been replaced and latch.

Item 2- The identified penetrations have been sealed with: installed steel fasteners that completely sealed the holes;filled the screw/bolt holes with the same material as the door.

Item 3 - After the non-rated foam material removed, 3M fire barrier sealant CP 25WB+ Intumescent applied/sealed. UL approved through penetration system number=ASTM E 814 (UL approved 1479) and ASTM E 84(UL723). Information obtained from the product label and listed above.

A weekly walk-through of the facility will be conducted for one month and then for a period of three months to ensure no fire rated doors are propped open. The director of maintenance or designee will be responsible for this audit. Results of the audit will be taken to the quality assurance performance improvement committee for review and recommendations.

NFPA 101 STANDARD Sprinkler System - Installation: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.
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: FORMERLY MONTGOMERY REHAB CENTER OF CHESTNUT HILL - Component: 01 - Tag: 0351

Based on observation and interview, it was determined the facility failed to maintain required sprinkler coverage, affecting one of four levels within the component.
Findings include:
1. Observation on July 7, 2021, at 12:41 p.m., revealed the rooftop elevator machine room lacked sprinklers.
Exit Interview with the Administrator and Maintenance Supervisor on July 7, 2021, at 3:05 p.m., confirmed the rooftop elevator machine room lacked sprinklers. _____________________________________________
Based on observation and interview, during an onsite Revisit, conducted on September 13, 2021, between 9:45 a.m. and 12:30 p.m., revealed the following:

Item 1 Not Completed. The rooftop elevator machine room lacked sprinklers. The facility requested a Time Limited Waiver for this deficiency.
Exit interview with Facility Administrator and Facility Maintenance Supervisor on September 13, 2021, at 12:25 p.m., confirmed the rooftop elevator machine room lacked sprinklers.

**************************************

Based on an onsite Revisit, conducted on October 29, 2021, between 1:00 p.m. and 3:30 p.m., revealed the following:

Item 1 - Not Completed. The rooftop elevator machine room lacked sprinklers.
Exit Interview with the Director of Maintenance on October 29, 2021, at 3:30 p.m., confirmed the rooftop elevator machine room lacked sprinklers.




 Plan of Correction - To be completed: 12/28/2021

As per the Division of Life Safety and life safety company recommendation, the elevator room will be evaluated for appropriate sprinkler
The facility is working with its contracted vendor for installation of the sprinkler in the rooftop elevator machine room. The facility has requested a time limited waiver- 3/30/2022 to give the contracted vendor time to obtain materials and complete the installation.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 observation, document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire facility.

Findings include:

1. Document review on July 7, 2021, at 8:15 a.m., revealed the sprinkler inspection report dated March 10, 2021, listed the following items as deficiencies:

a) No record of FDC having hydro test performed;
b) BFV are starting to seize. (Valves before and after backflow);
c) Main drain is not piped to anywhere unable to flow.

The facility was unable to provide documentation the deficiencies listed above had been corrected.

Exit Interview with the Administrator and Maintenance Supervisor on July 7, 2021, at 3:05 p.m., confirmed the documentation was not available.

2. Observation on July 7, 2021, between 12:54 p.m. and 1:30 p.m., revealed missing sprinkler escutcheons in the following locations:

a. 12:54 p.m., Third Floor, corridor, near Resident Room 302;
b. 1:30 p.m., First Floor, Dietician's office.

Exit Interview with the Administrator and Maintenance Supervisor on July 7, 2021, at 3:05 p.m. confirmed the missing sprinkler escutcheons.
_____________________________________________
Based on observation, document and interview, during an onsite Revisit, conducted on September 13, 2021, between 9:45 a.m. and 12:30 p.m., revealed the following:

Item 1a,1b and 1c Not Completed. The sprinkler inspection report dated March 10, 2021, listed the following items as deficiencies:

a) No record of FDC having hydro test performed;
b) BFV are starting to seize. (Valves before and after backflow);
c) Main drain is not piped to anywhere unable to flow.

The facility was unable to provide documentation the deficiencies listed above had been corrected.

Exit interview with Facility Administrator and Facility Maintenance Supervisor on September 13, 2021, at 12:25 p.m., confirmed the documentation was not available.

Item 2a and 2b Not Completed. There were missing sprinkler escutcheons, in the following locations:

a. 12:54 p.m., Third Floor, corridor, near Resident Room 302;
b. 1:30 p.m., First Floor, Dietician's office.

Exit interview with Facility Administrator and Facility Maintenance Supervisor on September 13, 2021, at 12:25 p.m., confirmed the missing sprinkler escutcheons.

******************************************
Based on an onsite Revisit, conducted on October 29, 2021, between 1:00 p.m. and 3:30 p.m., revealed the following:

Item 1 - Not Completed. The sprinkler inspection report dated March 10, 2021, listed the following items as deficiencies:

a) No record of FDC having hydro test performed;
b) BFV are starting to seize. (Valves before and after backflow);
c) Main drain is not piped to anywhere unable to flow.

Exit interview with the Director of Maintenance on October 29, 2021, at 3:30 p.m., confirmed documentation the above listed deficiencies had been corrected was not available at the time of inspection.

All other deficiencies listed under this tag were corrected.




 Plan of Correction - To be completed: 12/28/2021

a) Director of Maintenance acquired from Keystone Fire sufficient documentation that these problems have been repaired and will maintain that documentation in the state inspection log binders as appropriate.
b) BFV (Backflow Preventer Valves) before and after backflow will be replaced as required. The facility has requested a time limited waiver-3/30/2022 to give the contracted vendor time to obtain materials and complete the installation.
Date: 3/30/2022

NFPA 101 STANDARD Utilities - Gas and Electric: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.
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: FORMERLY MONTGOMERY REHAB CENTER OF CHESTNUT HILL - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was protected, affecting three of four levels within the facility.

Findings include:

1. Observation on July 7, 2021, at 12:21 p.m., revealed in the Third Floor dining room, inside the approximately two foot by two foot unprotected square cut-out in the rated HVAC vertical chase wall, there were two cut metal clad electrical cables with exposed wiring.

Exit Interview with the Administrator and Maintenance Supervisor on July 7, 2021, at 3:05 p.m., confirmed there were two cut metal clad electrical cables with exposed wiring.

2. Observation on July 7, 2021, at 12:42 p.m., revealed in the rooftop elevator machine room, there were multiple electrical panels missing covers.
Exit Interview with the Administrator and Maintenance Supervisor on July 7, 2021, at 3:05 p.m., confirmed there were multiple electrical panels missing covers.

3. Observation on July 7, 2021, at 1:10 p.m., revealed in the Second Floor west hallway, near Resident Room 216, a duplex outlet junction box was dislodged from the wall.
Exit Interview with the Administrator and Maintenance Supervisor on July 7, 2021, at 3:05 p.m., confirmed the duplex outlet junction box was dislodged from the wall.

4. Observation on July 7, 2021, at 1:46 p.m., revealed in the Basement, across from the chillers, there was an electrical panel missing a cover.
Exit Interview with the Administrator and Maintenance Supervisor on July 7, 2021, at 3:05 p.m., confirmed there was an electrical panel missing a cover.
5. Observation on July 7, 2021, at 1:55 p.m., revealed in the Basement generator room, a light fixture was hanging by its electrical wiring.
Exit Interview with the Administrator and Maintenance Supervisor on July 7, 2021, at 3:05 p.m., confirmed the light fixture was hanging by its electrical wiring.
_____________________________________________
Based on observation and interview, during an onsite Revisit, conducted on September 13, 2021, between 9:45 a.m. and 12:30 p.m., revealed the following:
Item 1 Not Completed. Third Floor, dining room, the approximately two foot by two foot unprotected square cut-out, rated HVAC vertical chase wall, there were two cut metal clad electrical cables with exposed wiring.

Exit interview with Facility Administrator and Facility Maintenance Supervisor on September 13, 2021, at 12:25 p.m., confirmed there were two cut metal clad electrical cables with exposed wiring.

***************************************

Based on an onsite Revisit, conducted on October 29, 2021, between 1:00 p.m. and 3:30 p.m., revealed the following:

Item 1 - Not Completed. Third Floor, Dining Room, had an approximately two foot by two foot unprotected square cut-out within the rated chase wall. There were two cut metal clad electrical cables with exposed wiring. The exposed wiring had been covered with a pvc type material.

Exit interview with the Director of Maintenance on October 29, 2021, at 3:30 p.m., confirmed the exposed wiring was sealed with an unknown material.




 Plan of Correction - To be completed: 12/28/2021

Facility will Have HVAC contractor the two-cut metal clad electrical cables with exposed wiring are capped and the cut out is sealed.
A visual inspection of the entire facility will be conducted to ensure there are no other exposed wires.
Roof top elevator room panels repaired/replaced
Duplex outlet junction box secured in its place
Electric panel in basement across from chiller cover replaced
Light fixture in generator room secured appropriately
The facility will do a visual audit monthly, for a period of three months, to ensure there are no exposed wires. Any exposed wires noted will be corrected. Results of the audits will be taken to the quality assurance performance improvement meeting for review and recommendations.
The director of maintenance or designee will be responsible for this audit.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu: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.
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 resistive rating of laundry chutes, affecting two of four levels within the facility.

Findings include:

1. Observation on July 7, 2021, at 12:18 p.m., revealed in the Third Floor soiled utility room, the door to the laundry chute failed to positively latch.

Exit Interview with the Administrator and Maintenance Supervisor on July 7, 2021, at 3:05 p.m., confirmed the chute door failed to latch.

2. Observation on July 7, 2021, at 1:15 p.m., revealed in the Second Floor soiled utility room, the door to the laundry chute failed to positively latch.

Exit Interview with the Administrator and Maintenance Supervisor on July 7, 2021, at 3:05 p.m., confirmed the chute door failed to latch.
_____________________________________________
Based on observation and interview, during an onsite Revisit, conducted on September 13, 2021, between 9:45 a.m. and 12:30 p.m., revealed the following:

Item 1 Not Completed. Third Floor, soiled utility room, laundry chute door failed to positively latch.

Exit interview with Facility Administrator and Facility Maintenance Supervisor on September 13, 2021, at 12:25 p.m., confirmed laundry chute door failed to positively latch.

Item 2 Not Completed. Second Floor, soiled utility room, laundry chute door failed to positively latch.

Exit interview with Facility Administrator and Facility Maintenance Supervisor on September 13, 2021, at 12:25 p.m., confirmed laundry chute door failed to positively latch.

***************************************
Based on an onsite Revisit, conducted on October 29, 2021, between 1:00 p.m. and 3:30 p.m., revealed the following:

Item 1 - Not Completed. Third Floor, soiled utility room, laundry chute door failed to positively latch. A non-rated latch & hook was secured to the exterior of the laundry chute door frame. In addition, the door would not positively latch after testing multiple times.

Exit interview with the Director of Maintenance on October 29, 2021, at 3:30 p.m., confirmed the use of non-rated hardware and the laundry chute door failed to positively latch.


Item 2 - Not Completed. Second Floor, soiled utility room, laundry chute door failed to positively latch. A non-rated latch & hook was secured to the exterior of the laundry chute door frame. In addition, there was a hole in the chute access door, further compromising the chute enclosure rating.

Exit interview with the Director of Maintenance on October 29, 2021, at 3:30 p.m., confirmed the use of non-rated hardware.




 Plan of Correction - To be completed: 12/28/2021

The identified doors have been repaired and latch. Penetrations sealed.
The director of maintenance or designee will do a monthly audit for a period of three months to ensure all doors that are required to positively latch are in working order. Results of the audit will be taken to the quality assurance performance improvement committee for review and recommendations.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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 and interview, it was determined the facility failed to maintain the emergency generator, affecting the entire facility.

Findings include:

1. Document review on July 7, 2021, at 8:15 a.m., revealed the facility could not provide the following testing documentation for the facility's emergency generator:

a) Monthly battery conductance testing on the maintenance free batteries;
b) Weekly battery voltage testing on the maintenance free batteries (facility was performing voltage checks on a monthly basis only).

Exit Interview with the Administrator and Maintenance Supervisor on July 7, 2021, at 3:05 p.m., confirmed the deficiencies listed above.
_____________________________________________
Based on document and interview, during an onsite Revisit, conducted on September 13, 2021, between 9:45 a.m. and 12:30 p.m., revealed the following:

Item 1a, 1b Not Completed. Facility could not provide the following testing documentation for the facility's emergency generator:

a) Monthly battery conductance testing on the maintenance free batteries.
b) Weekly battery voltage testing on the maintenance free batteries.

Exit interview with Facility Administrator and Facility Maintenance Supervisor on September 13, 2021, at 12:25 p.m., confirmed the documentation was not available.

***************************************

Based on an onsite Revisit, conducted on October 29, 2021, between 1:00 p.m. and 3:30 p.m., revealed the following:

Item 1 - Not Completed. The Facility could not provide documentation clearly identifying testing for emergency generator components. Readings for two of three batteries were documented for the following:

a) Monthly battery conductance testing on the maintenance free batteries;
b) Weekly battery voltage testing on the maintenance free batteries.

Exit interview with the Director of Maintenance on October 29, 2021, at 3:30 p.m., confirmed the documentation was incomplete.




 Plan of Correction - To be completed: 12/28/2021

Director of Maintenance has modified inspection documentation forms as required to include monthly battery conductance testing and weekly battery voltage testing on the maintenance free battery in use. These checks will continue to be documented weekly x 4 and monthly as required by PA Life Safety inspection requirements.
Weekly and monthly test result forms changed to incorporate indicated changes to the testing requirements for the maintenance free battery used to start this generator engine


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