Pennsylvania Department of Health
 MOUNTAIN VIEW REHABILITATION AND SENIOR LIVING CENTER
Building Inspection Results

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MOUNTAIN VIEW REHABILITATION AND SENIOR LIVING CENTER
Inspection Results For:

There are  47 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.
MOUNTAIN VIEW REHABILITATION AND SENIOR LIVING 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 28, 2025, at Mountain View, A 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: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 390302
Component 01
Main Building
Based on a Medicare/Medicaid Recertification Survey completed on May 28, 2025, it was determined that Mountain View, A Nursing and Rehabilitation Center, 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 one story, Type II (000), unprotected, noncombustible building, with a partial basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Number of Exits - Story and Compartment: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.
Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0241

Based on observation and interview, it was determined the facility failed to provide two acceptable means of egress for each floor, or fire section, affecting one of two floors.

Findings include:
1. Observation on May 28, 2025, at 11:30 a.m., revealed the basement level lacked two acceptable means of egress.
Exit interview on May 28, 2025, between 12:35 p.m., and 12:45 p.m., with the Facility Administrator and the Facilities Manager, confirmed the lack of a second acceptable means of egress from the basement.






 Plan of Correction - To be completed: 06/16/2025

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set for the in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of the federal and state law.


K-241 | SS=C

Number of Exits – Story and Compartment

1. The Facility requests that a new FSES be done under the 2012 Life Safety Code.
NFPA 101 STANDARD Emergency Lighting: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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on observation and interview, it was determined the facility failed to maintain emergency lighting in one location, affecting one of two floors.

Findings include:

1. Observation on May 28, 2025, at 10:40 a.m., revealed the emergency lighting fixture, located closest to the Administrator's Office, did not illuminate when tested.

Exit interview on May 28, 2025, between 12:35 p.m., and 12:45 p.m., with the Facility Administrator and the Facilities Manager, confirmed the emergency lighting deficiency.




 Plan of Correction - To be completed: 06/16/2025

1. Emergency lighting fixture, located closest to the administrators office was replaced and does illuminate appropriately.
2. The Director of Maintenance/Designee conducted a facility wide audit of emergency lighting to ensure proper illumination.
3. The NHA educated the Director of Maintenance on the requirements of emergency lighting illumination.
4. Random audits will be completed by Director of Maintenance or Designee, monthly x 3 and will be fixed immediately upon findings. Findings will be submitted to QUAPI meeting.

NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on documentation review and interview, it was determined the facility failed to maintain cooking facilities in one instance, affecting one of two floors.

Findings include:

1. Observation on May 28, 2025, at 12:55 p.m., revealed the facility lacked one of two required exhaust hood/duct cleanings for the previous twelve month period (facility supplied the report dated 9/23/24).

Exit interview with the Facility Administrator and the Facilities Manager between 1:10 p.m., and 1:15 p.m., on May 28, 2025, confirmed the cooking facilities deficiency.



 Plan of Correction - To be completed: 06/16/2025

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set for the in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of the federal and state law.

K-324 | SS= C

Cooking Facilities

1. The 2nd required exhaust hood/duct cleaning inspection report that was missing during the survey was located and confirmed to have been completed to maintain cooking facilities for the previous 12-month period.

2. The NHA educated the Director of Maintenance on the requirement to maintain cooking facilities in accordance with NFPA 96 standards. The Director of Maintenance/Designee conducted an audit of hood/duct cleanings to maintain cooking facilities in accordance with NFPA 96 standards.

3. Random audits will be completed by the Director of Maintenance/Designee monthly x3 months to ensure cooking facilities are maintained in accordance with NFPA 96 standards and findings will be given to the administrator. Any concerns will be corrected immediately.

4. Audit findings will be presented at the monthly Quality Assurance Performance Improvement (QAPI) meeting to determine if additional interventions are needed.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on documentation review, observation, and interview, it was determined the facility failed to maintain the automatic sprinkler system in two instances, affecting two of two floors.

Findings include:

1. Observation on May 28, 2025, between 11:50 a.m., and 12:45 p.m., revealed the following:

a. 11:50 a.m., damaged ceiling tiles and a missing escutcheon plate, located within the basement-level Laundry.
b. 12:45 p.m., the facility lacked a quarterly sprinkler report for the first quarter of calendar year 2025.

Exit interview on May 28, 2025, between 12:35 p.m., and 12:45 p.m., with the Facility Administrator and the Facilities Manager, confirmed the sprinkler system deficiencies.




 Plan of Correction - To be completed: 06/16/2025

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set for the in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of the federal and state law.

K-353 | SS=E

Sprinkler System – Maintenance and Testing

1. The Director of Maintenance/Designee immediately replaced the damaged ceiling tiles and installed the missing escutcheon plate located within the basement-level Laundry. The missing quarterly sprinkler report for the first quarter of calendar year 2025 was located and confirmed to have been completed in accordance with NFPA 25 standards.

2. The Director of Maintenance/Designee conducted a facility wide audit to maintain the automatic sprinkler system. The NHA educated the Director of Maintenance on the NFPA 25 requirements to maintain the automatic sprinkler system.

3. Random audits will be completed by the Director of Maintenance/Designee monthly x3 months to maintain the automatic sprinkler system in in accordance with NFPA 25 standards and findings will be given to the administrator. Any concerns will be corrected immediately.

4. Audit findings will be presented at the monthly Quality Assurance Performance Improvement (QAPI) meeting to determine if additional interventions are needed.


NFPA 101 STANDARD Corridor - 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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain one corridor opening, affecting one of two floors.

Findings include:

1. Observation on May 28, 2025, at 10:55 a.m., revealed the A-5 Resident Room door was not smoke-tight.

Exit interview on May 28, 2025, between 12:35 p.m., and 12:45 p.m., with the Facility Administrator and the Facilities Manager, confirmed the corridor opening deficiency.



 Plan of Correction - To be completed: 06/16/2025

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set for the in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of the federal and state law.

K-363 | SS=E

Corridor Doors

1. The Director of Maintenance/Designee immediately repaired the A-5 Resident Room door to be smoke tight and maintain the corridor opening.

2. The Director of Maintenance/Designee conducted a facility wide audit to maintain corridor openings. The NHA educated the Director of Maintenance on the NFPA 101 requirement to maintain corridor openings.

3. Random audits will be completed by the Director of Maintenance/Designee monthly x3 months to maintain corridor openings and findings will be given to the administrator. Any concerns will be corrected immediately.

4. Audit findings will be presented at the monthly Quality Assurance Performance Improvement (QAPI) meeting to determine if additional interventions are needed.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier separation doors in two locations, affecting one of two floors.

Findings include:

1. Observation on May 28, 2025, between 10:52 a.m., and 11:44 a.m., revealed the following:

a. 10:52 a.m., a chair prevented the smoke barrier separation door, located closest to the A Wing Nurse's Station, from closing.
b. 11:44 a.m., the distance between the B Hall smoke barrier separation doors exceeded one-eighth-inch.

Exit interview on May 28, 2025, between 12:35 p.m., and 12:45 p.m., with the Facility Administrator and the Facilities Manager, confirmed the smoke barrier door deficiencies.





 Plan of Correction - To be completed: 06/16/2025

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set for the in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of the federal and state law.

K-374 | SS=E

Subdivision of Building Spaces – Smoke Barriers

1. The Director of Maintenance/Designee immediately removed the chair that was preventing the smoke barrier separation door located closest to the A wing nurse's station from closing. The Director of Maintenance/Designee immediately corrected the distance between the B hall smoke barrier separation doors not to exceed one eight-inch.

2. The Director of Maintenance/Designee conducted a facility wide audit of smoke barrier separation doors to ensure no distance between doors exceeded one eighth-inch. The NHA educated the Director of Maintenance on the NFPA 101 requirements to maintain smoke barrier separation doors.

3. Random audits will be completed by the Director of Maintenance/Designee monthly x3 months to maintain smoke barrier separation doors. Findings will be given to the administrator. Any concerns will be corrected immediately.

4. Audit findings will be presented at the monthly Quality Assurance Performance Improvement (QAPI) meeting to determine if additional interventions are needed.
NFPA 101 STANDARD Smoking Regulations: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.
Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain smoking regulations, in one location, affecting one of two floors.

Findings include:
1. Observation on May 28, 2025, at 11:14 a.m., revealed cigarette butts were located within a trash receptacle at the outdoor smoking location.
Exit interview on May 28, 2025, between 12:35 p.m., and 12:45 p.m., with the Facility Administrator and the Facilities Manager, confirmed the smoking regulations deficiency.



 Plan of Correction - To be completed: 06/16/2025

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set for the in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of the federal and state law.

K-741 | SS=E

Smoking Regulations

1. The Director of Maintenance/Designee immediately disposed the cigarette butts located in the trash receptacle at the outdoor smoking location.

2. The Director of Maintenance/Designee conducted an exterior wide audit of trash and cigarette butt receptacles. The NHA educated the Director of Maintenance on the NFPA 101 requirements to maintain smoking regulations.

3. Random audits will be completed by the Director of Maintenance/Designee monthly x3 months to maintain smoking regulations. Findings will be given to the administrator. Any concerns will be corrected immediately.

4. Audit findings will be presented at the monthly Quality Assurance Performance Improvement (QAPI) meeting to determine if additional interventions are needed.

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