Pennsylvania Department of Health
EXTON POST ACUTE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 13 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.


EXTON POST ACUTE - 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, 2025, at Exton Post Acute, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000

Facility ID #24600201
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 24, 2025, it was determined that Exton Post Acute, was not in compliance with the following requirements of the Life Safety Code for an existing 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 II (111), protected noncombustible structure, with a partial basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

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.

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain exit access to be readily accessible, affecting two of five smoke compartments within the component.

Findings include:

1. Observation on February 24, 2025, at 1:00 PM, revealed the 1st floor outside exit door, by Resident Room 118, could only opened after several forcefully tries.

Interview with Maintenance Assistant on February 24, 2025, at 1:00 PM, confirmed the door was very difficult to open.

Plan of Correction - To be completed: 03/25/2025

1. The First floor outside exit door by room 118 was adjusted to open freely without resistance.
2. All residents have the potential to be affected.
3. Plant Operation Manager was educated on ensuring all exit doors are exercised on a routine basis to ensure they are in proper working order.
4. Center Exit signs will be audited monthly x12, exit external doors will be exercised weekly x 12 months and reviewed at the quarterly QA meeting by the administrator or designee with suggested recommendations made by the committee.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain stairtower doors to be within the allowed gap margins, on one of two floors within the component.

Findings include:

1. Observation on February 24, 2025, at 1:00 PM, revealed the 1st floor stairtower vestibule door, by Resident Room 118, had gaps greater than 1/8 inch.

Interview with Maintenance Assistant on February 24, 2025, at 1:00 PM, confirmed the door exceeded the allowed gap margins.

Plan of Correction - To be completed: 03/25/2025

1. The 1st floor stair tower vestibule door will be sealed with a fire rated gasket material from Crown to close the gaps greater than 1/8 inch.
2. All residents have the potential to be affected.
3. The Plant Operation Manager will conduct monthly audit x12 to identify and correct any gaps greater than 1/8 inch on all center fire doors. Additionally, the plant operations manager will audit the stair tower vestibule fire door weekly x 3 months and then monthly thereafter.
4. Plant Operation Manager was educated on requirements for Fire and smoke door regulations.
5. The contents of the audit above will be reported by the Plant Operations Manager or his designee and reviewed at the quarterly QA meeting.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of hazardous area enclosures, affecting two of five smoke compartments within the component.

Findings include:

1. Observation on February 24, 2025, between 12:10 PM and 2:00 PM, revealed doors were impaired from closing or failed the fire door gap requirement, at the following locations:

a. 12:10 PM, first floor, Maintenance Storage held open by an air compressor;
b. 12:30 PM, first floor, Soiled-Laundry side, with a wooden wedge;
c. 12:40 PM, first floor, MEP Utilities Room was held open with a trash container;
d. 12:50 PM, first floor, Clean-Laundry side, with a wood block, at the top hinge;

Interview with Maintenance Assistant on February 24, 2025, at 2:00 PM, confirmed the doors were held open by unauthorized means.

2. Observation on February 24, 2025, between 12:10 PM and 2:00 PM, revealed hazardous area rated doors exceeded the allowed gap margins, at the following locations:

a. 12:30 PM, first floor, Soiled-Laundry side;
b. 2:00 PM, first floor, Resident Storage, by Resident Room 149.

Interview with Maintenance Assistant on February 24, 2025, at 2:00 PM, confirmed the hazardous area rated doors exceeded the allowed gap margins.

Plan of Correction - To be completed: 03/25/2025

1a. The air compressor was removed that held open the door to the first floor Maintenance Storage room so that door could close and latch properly
1b. The wooden door wedge was reviewed from the first floor Soiled Laundry side to allow the door to close and latch properly.
1c. The trash can was removed that held open the door on the first floor MEP Utilities Room
1d. The wooden block was removed from the top hinge that held open the door to the first floor Clean-Laundry side to allow the door to close and latch properly.
The Maintenance Staff was educated on hazardous areas doors and to ensure they are not held open by any device.
All residents have the potential to be affected.
The Plant Operation Manager will audit Weekly x 12 months for all hazardous area doors to ensure they close and latch properly.
The contents of the audit above will be reported by the Plant Operations Manager or his designee and reviewed at the quarterly QA meeting.
2a. The gaps that exceeded the allowed gap margins to the first floor Soiled Laundry was sealed with a rated door gasket assembly from Crown to make sure door is smoked tight.
2b. The gaps that exceeded the allowed gap margins to the first floor Resident Storage by room 149 was sealed with a rated door gasket assembly from Crown to make sure door is smoked tight.
All residents have the potential to be affected.
The contents of the audit above will be reported by the Plant Operations Manager or his designee and reviewed at the quarterly QA meeting.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

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 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 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical panels to be secured, affecting the entire component.

Findings include:

1. Observation, during the survey, on February 25, 2025, at 12:40 PM, revealed all the electrical panels inside the 1st floor MEP Utilities Room were unlocked and accessible to any unauthorized persons.

Interview with Maintenance Assistant on February 25, 2025, at 12:40 PM, confirmed all the electrical panels were not secured.

Plan of Correction - To be completed: 03/25/2025

1. The electrical panels inside the 1st floor MEP Utilities Room were locked so they are not accessible to any unauthorized persons.
2. All residents have the potential to be affected.
3. Plant Operation Manager was educated on K920 and the importance of assuring that all electrical boxes are secured throughout the center.
4. The Plant Operation Manager or designee will audit monthly all electrical boxes to ensure all are locked throughout the center.
5. The contents of the audit above will be reported by the Plant Operations Manager or his designee and reviewed at the quarterly QA meeting.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

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 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to properly store portable oxygen cylinders, affecting one of five smoke compartments within the component.

Findings include:

1. Observation on February 24, 2025, at 12:00 PM, revealed 35 "E" size portable oxygen cylinders being stored in the egress corridor, outside the 1st floor Central Storage.

Interview with Maintenance Assistant on February 24, 2025, at 12:00 PM, confirmed the cylinders were being stored outside a rated assembly.

Plan of Correction - To be completed: 03/25/2025

1. The 35 "E" size portable oxygen cylinders being stored in the egress corridor, outside the 1st floor Central Storage were removed and center installed an exterior outside storage container to prevent from happening in the future.
2. All residents have the potential to be affected.
3. Plant Operation Manager and Central Supply Staff was educated on making sure no tanks are stored improperly throughout the center.
4. The Plant Operation Manager will audit the entire center monthly x12 to indemnify any non-authorized O2 storage throughout the center.
5. The contents of the audit above will be reported by the Plant Operations Manager or his designee and reviewed at the quarterly QA meeting.

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