Pennsylvania Department of Health
 MONTGOMERYVILLE SKILLED NURSING AND REHABILITATION CENTER
Building Inspection Results

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MONTGOMERYVILLE SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  42 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.
MONTGOMERYVILLE SKILLED NURSING AND REHABILITATION 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 May 30, 2024 at Montgomeryville Skilled Nursing 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: BUILDING 02 (ARCADIA UNIT AND MAIN BUILDING) - Component: 02 - Tag: 0000


Facility ID# 382402
Component 02
Building 02
Arcadia Unit and Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 30, 2024, it was determined that Montgomeryville Skilled Nursing And 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 two-story, Type V (111), protected wood frame building, with unused attic spaces, that 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: BUILDING 02 (ARCADIA UNIT AND MAIN BUILDING) - Component: 02 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain means of egress free from all obstructions, affecting one of two levels in the facility.

Findings include:

Observation on May 30, 2024, at 11:21 a.m., revealed on the first floor, the exit door next to resident room 32 required excessive force to open.

Exit Interview with the Administrator and Maintenance Director on May 30, 2024, at 11:30 a.m., confirmed the exit door required excessive force to open.




 Plan of Correction - To be completed: 07/10/2024

K0211
SS=E

The exit door next to resident room 32 was adjusted in the door frame to ensure it opens without excessive force.

Maintenance Staff or Designee will audit all exit doors to ensure they open without excessive force.

Maintenance Staff will audit exit doors on an ongoing basis as part of monthly preventative maintenance rounds.

Results of the audits/findings will be presented to the monthly QAPI meeting for review and recommendation.

NFPA 101 STANDARD Egress Doors: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.
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: BUILDING 02 (ARCADIA UNIT AND MAIN BUILDING) - Component: 02 - Tag: 0222

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

Findings include:

Observation on May 30, 2024, at 11:11 a.m., revealed in the first floor Therapy, the delayed-egress door failed to open within 15 seconds.

Exit Interview with the Administrator and Maintenance Director on May 30, 2024, at 11:30 a.m., confirmed the door failed to open.




 Plan of Correction - To be completed: 07/10/2024

K0222
SS=E

First Floor Therapy Room Door was repaired to ensure it opened with the delayed-egress within 15 seconds.

Maintenance Staff or designee will audit all delayed-egress systems on exit doors to ensure it releases within 15 seconds.

Maintenance staff will audit delayed-egress systems during monthly preventative maintenance rounds.

Results of the audits/findings will be presented to the monthly QAPI meeting for review and recommendation.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: BUILDING 02 (ARCADIA UNIT AND MAIN BUILDING) - Component: 02 - Tag: 0345

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

Findings include:

Document review on May 30, 2024, at 8:30 a.m., revealed the facility could not produce documentation of a two year smoke detector sensitivity report. This is a repeat deficiency from previous Life Safety Surveys conducted on June 8, 2023 and July 18, 2022.

Exit Interview with the Administrator and Maintenance Director on May 30, 2024, at 11:30 a.m., confirmed the lack of documentation.







 Plan of Correction - To be completed: 07/10/2024

K0345
SS=F

The two year smoke detector sensitivity testing was completed and documentation obtained.

The Maintenance Director will create a binder to review all tests and audits that are required by Life Safety. This binder will be monitored monthly to determine any inspections/audits that are coming due.

Inspections and Audits will also be entered into the monthly preventative maintenance system to ensure compliance.

Results of the audits/findings will be presented to the monthly QAPI meeting for review and recommendation.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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: BUILDING 02 (ARCADIA UNIT AND MAIN BUILDING) - Component: 02 - Tag: 0353

Based on document review, observation, and interview, it was determined the facility failed to maintain and inspect the sprinkler system, affecting two of eleven required inspections.

Findings include:

1. Document review on May 30, 2024, at 8:30 a.m., revealed the facility could not produce documentation of the following tests and inspections:

a. 4th quarter sprinkler inspection (Repeat Deficiency from June 8, 2023 Life Safety Survey);
b. 3 year dry system full flow trip test.

Exit Interview with the Administrator and Maintenance Director on May 30, 2024, at 11:30 a.m., confirmed the lack of documentation.


2. Observation on May 30, 2024, at 11:05 a.m., revealed on the first floor, in Food Service Storage, a missing sprinkler escutcheon.

Exit Interview with the Administrator and Maintenance Director on May 30, 2024, at 11:30 a.m., confirmed the missing sprinkler escutcheon.







 Plan of Correction - To be completed: 07/10/2024

K0353
SS=E

The quarterly sprinkler inspection was conducted and the documentation was obtained. The missing escutcheon around the sprinkler head in the first floor Food Service Storage was replaced.

The Maintenance Director will create a binder to review all tests and audits that are required by Life Safety. This binder will be monitored monthly to determine any inspections/audits that are coming due. Maintenance Staff or Designee will audit all sprinkler escutcheons in the center to ensure they are in place.

Inspections and Audits will also be entered into the monthly preventative maintenance system to ensure compliance. Sprinkler escutcheons will be monitored during monthly preventative maintenance rounds.

Results of the audits/findings will be presented to the monthly QAPI meeting for review and recommendation.

NFPA 101 STANDARD Portable Fire Extinguishers: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.
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: BUILDING 02 (ARCADIA UNIT AND MAIN BUILDING) - Component: 02 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers, affecting one of two levels in the facility.

Findings include:

Observation on May 30, 2024, at 11:10 a.m., revealed on the first floor, in Kitchen, the K-rated fire extinguisher was blocked by trash cans.

Exit Interview with the Administrator and Maintenance Director on May 30, 2024, at 11:30 a.m., confirmed the blocked fire extinguisher.




 Plan of Correction - To be completed: 07/10/2024

K0355
SS=E



The trash can was removed to eliminate the barrier to the K-rated fire extinguisher in the first floor kitchen.

Maintenance staff will audit the center to ensure all fire extinguishers are not blocked and any potential barriers are removed.

Staff will be educated to ensure no items are placed in front of fire extinguishers.

Maintenance staff will ensure items are not placed in front of fire extinguishers during monthly preventive maintenance rounds.

Results of the audits/findings will be presented to the monthly QAPI meeting for review and recommendation.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar: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.
Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.
Observations:
Name: BUILDING 02 (ARCADIA UNIT AND MAIN BUILDING) - Component: 02 - Tag: 0371

Based on observation, document review and interview, it was determined the facility failed to provide required smoke compartments on each floor with more than 30 residents, affecting one of two levels.

Findings include:

Document review on May 30, 2024, at 8:30 a.m., revealed the facility lacked complete smoke barrier walls on the second floor. The partitions did not extend above the second-floor attic spaces to the roof deck above.

Exit Interview with the Administrator and Maintenance Director on May 30, 2024, at 11:30 a.m., confirmed the smoke barrier partitions were incomplete.





 Plan of Correction - To be completed: 07/10/2024

K0371
SS=B

Facility Floor Plan was updated to indicate smoke barrier walls on the second floor, that have partitions that extend above the second-floor attic spaces to the roof deck above.

Maintenance staff will review facility floor plans to ensure all smoke barrier walls are clearly indicated.

Facility floor plan and smoke barrier walls will be reviewed annually by the center safety committee to ensure smoke barrier walls are clearly identified and updated if necessary.

Results of the audits/findings will be presented to the monthly QAPI meeting for review and recommendation.

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 Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: BUILDING 02 (ARCADIA UNIT AND MAIN BUILDING) - Component: 02 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of smoke barriers, affecting one of two levels in the facility.

Findings include:

Observation on May 30, 2024, at 11:19 a.m., revealed on the first floor, there was an open penetration by data wires above the ceiling of the smoke barrier leading into Wing C.

Exit Interview with the Administrator and Maintenance Director on May 30, 2024, at 11:30 a.m., confirmed the open penetration.





 Plan of Correction - To be completed: 07/10/2024

K0372
SS=E

The penetration by data wires above the ceiling of the smoke barrier leading into Wing C was patched using fire rated approved materials.

All penetrations through smoke barriers will be audited to ensure they are patched using approved fire rated materials. Moving forward all work done by vendors that require penetrations through smoke barriers will require inspection by center Maintenance Staff prior to completion by the vendor of any projects. The vendor will be required to patch any penetrations with approved fire rated materials.

Smoke barriers will be checked for penetrations during monthly preventative maintenance rounds to ensure they remain appropriately patched.

Results of the audits/findings will be presented to the monthly QAPI meeting for review and recommendation.

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: BUILDING 02 (ARCADIA UNIT AND MAIN BUILDING) - Component: 02 - 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 two of six smoke compartments.

Findings include:

Observation on May 30, 2024, between 10:47 a.m. and 11:07 a.m., revealed storage within three feet of the electrical panels within the following locations.

a. 10:47 a.m., on the second floor, Food Service Storage;
b. 11:07 a.m., on the first floor, Storage outside Kitchen.

Exit Interview with the Administrator and Maintenance Director on May 30, 2024, at 11:30 a.m., confirmed the blocked electrical panels.






 Plan of Correction - To be completed: 07/10/2024

K0511
SS=E

Items in the second floor, Food Service Storage and first floor, storage outside the kitchen were removed to ensure there were no items within three feet of the electrical panels.

Maintenance Staff or designee will audit all electrical panels in the center to ensure there are no items within three feet of the electrical panels.

Staff will be educated to ensure no items are placed within three feet in front of electrical panels.

Maintenance staff will monitor electrical panels during monthly preventative maintenance rounds to ensure they are free of items within three feet.

Results of the audits/findings will be presented to the monthly QAPI meeting for review and recommendation.

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: BUILDING 02 (ARCADIA UNIT AND MAIN BUILDING) - Component: 02 - Tag: 0918

Based on document review and interviews, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire facility.

Findings include:

Document review on May 30, 2024, at 8:30 a.m., revealed the facility could not provide documentation of the following tests and inspections:

a. Monthly testing of battery electrolyte specific gravity or conductance;
b. Monthly operation of transfer switches.

Exit Interview with the Administrator and Maintenance Director on May 30, 2024, at 11:30 a.m., confirmed the lack of documentation.





 Plan of Correction - To be completed: 07/10/2024

K0918
SS=F

The monthly testing of battery electrolyte specific gravity or conductance test was completed and documentation is on file. The Monthly operation of transfer switches was completed and documentation is on file.

The Maintenance Director will create a binder to review all tests and audits that are required by Life Safety. This binder will be monitored monthly to determine any inspections/audits that are coming due.

Inspections and Audits will also be entered into the monthly preventative maintenance system to ensure compliance.

Results of the audits/findings will be presented to the monthly QAPI meeting for review and recommendation.


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