Pennsylvania Department of Health
ACCELA REHAB AND CARE CENTER AT SPRINGFIELD
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 43 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.


ACCELA REHAB AND CARE CENTER AT SPRINGFIELD - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on March 10, 2025, it was determined that Accela Rehab And Care Center At Springfield had deficiencies that have potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(b)(6), 416.54(b)(5), 418.113(b)(4), 441.184(b)(6), 482.15(b)(6), 483.475(b)(6), 483.73(b)(6), 484.102(b)(5), 485.542(b)(6), 485.625(b)(6), 485.68(b)(4), 485.727(b)(4), 485.920(b)(5), 491.12(b)(4), 494.62(b)(5) STANDARD Policies/Procedures-Volunteers and Staffing:

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.

§403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5).

[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]

(6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

*[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency.

*[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Observations:
Name: - Component: -- - Tag: 0024

Based on document review and interview, it was determined the facility failed to ensure policies and procedures were in place addressing the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency, affecting the entire facility.

Findings include:

Document review on March 10, 2025, at 9:00 a.m., revealed the Emergency Preparedness plan did not include policies for the use of volunteers in an emergency, to be reviewed and updated at least annually.

Exit Interview with the Administrator and Maintenance Director on March 10, 2025, at 1:50 p.m., confirmed the Emergency Preparedness plan did not include a policy for utilizing volunteers, in the event of an emergency.

Plan of Correction - To be completed: 04/20/2025

Corrective action:

Emergency staffing policy and plan added to EPM plan, details added to binder and general EPP education.

Residents affected:

Potentially every resident.

Systemic change:

Review regulatory requirements to ensure EPP includes all required EPP plans. Audit binders monthly for 3 months. Then quarterly thereafter.

Audit change:

Findings of audit will be brought to QAPI committee held monthly.

403.748(b)(8), 416.54(b)(6), 418.113(b)(6)(C)(iv), 441.184(b)(8), 482.15(b)(8), 483.475(b)(8), 483.73(b)(8), 485.542(b)(7), 485.625(b)(8), 485.920(b)(7), 494.62(b)(7) STANDARD Roles Under a Waiver Declared by Secretary:

§403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7).

[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]

(8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

*[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Observations:
Name: - Component: -- - Tag: 0026

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness Plan to include the facilities role under a waiver declared by the Secretary of the Department of Health, affecting the entire facility.

Findings include:

Document review on March 10, 2025, at 9:00 a.m., revealed the facility lacked a written Emergency Preparedness Plan to include the facilities role under a waiver declared by the Secretary of the Department of Health, to include providing care at alternate care sites during emergencies.

Exit Interview with the Administrator and Maintenance Director on March 10, 2025, at 1:50 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 04/20/2025

Re- education regarding the role of the facility under a waiver declared by the Secretary of the Department of Health, affecting the entire facility will be conducted by the Maintenance Director or designee
All residents can be potentially affected by this deficient practice
The facility will develop an Emergency Preparedness Plan to include the role of the facility under a waiver declared by the Secretary of the Department of Health, affecting the entire facility.
An audit of the Emergency Prep manual will be conducted monthly for 3 months then quarterly for 1 year to ensure that the role of the facility under a waiver declared by the Secretary of the Department of Health, affecting the entire facility is included
The findings of the audit will be brought to Quality improvement committee monthly for three months and quarterly thereafter

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

Facility ID# 580502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 10, 2025, it was determined that Accela Rehab And Care Center At Springfield - Main Building 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 III (200), unprotected ordinary building, with basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies:

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 - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:
Name: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to ensure common fire wall separations maintained a fire resistance rating, affecting one of four levels.

Findings include:

Observation on March 10, 2025, at 11:00 a.m., revealed on the first floor, the fire doors separating the Main and Pavilion Buildings failed to latch and had multiple unsealed penetrations where door hardware had been removed.

Exit Interview with the Administrator and Maintenance Director on March 10, 2025, at 1:50 p.m., confirmed the fire door deficiencies.

Plan of Correction - To be completed: 04/20/2025

Corrective action
Appropriate hardware to be installed and penetrations will be sealed, ensure door latches appropriately.
Other areas potentially affected
All residents located in above mentioned area
Systemic change
Audit all fire rated doors weekly x4, upon successful weekly x4 will be followed by monthly audit and documented, the audits will be conducted by maintenance director or designee.
Audit change
Results of audits will be reported to QAPI for next 3 monthly QAPI meetings.

NFPA 101 STANDARD Building Construction Type and Height:

Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0161

Based on observation, document review, and interview, it was determined the facility failed to maintain the fire resistance rating for building construction, affecting the entire component.

Findings include:

Observation on March 10, 2025, at 9:00 a.m., revealed this building component has been classified as a three story, Type III (200), unprotected ordinary construction, with a basement, which is fully sprinklered. The building height exceeds the maximum allowable story height for unprotected ordinary construction by two stories.

Exit Interview with the Administrator and Maintenance Director on March 10, 2025, at 1:50 p.m., confirmed minimum building construction requirements were not maintained.

Plan of Correction - To be completed: 04/20/2025

Corrective action
NHA will submit the completed Time Limited Waiver template in conjunction with an FSES for this deficiency type lease to be forwarded to the Norristown field office supervisor via email for review. NHA will provide accurate up to date floor plans.

NFPA 101 STANDARD Means of Egress - General:

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.

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 01 (MAIN BUILDING) - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain the means of egress without obstructions, affecting three of five smoke compartments.

Findings include:

Observation on March 10, 2025, at 10:30 a.m., revealed headroom height in the following areas were less than 6' feet 8" inches:

a. In the basement, corridor by the maintenance shop;
b. On the third floor, corridor by the stair tower.

Exit Interview with the Administrator and Maintenance Director on March 10, 2025, at 1:50 p.m., confirmed the minimum headroom clearance was not maintained.

Plan of Correction - To be completed: 04/20/2025

In reference headroom height in the areas were less than 6' feet 8" inches to The facility respectfully requests DOH Life Safety to perform a new FSES. Until the results are compiled from the FSES the facility will, in the interim, apply for a time limited waiver to remain in compliance.

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements.

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: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0225

Based on observation and interview, it was determined that the facility failed to maintain the fire-resistance rating of stair towers, affecting one of four levels.

Findings include:

Observation on March 10, 2025, at 11:40 a.m., revealed on the second floor, the main stair tower door had an open hole above the handle.

Exit Interview with the Administrator and Maintenance Director on March 10, 2025, at 1:50 p.m., confirmed the stair tower door deficiency.

Plan of Correction - To be completed: 04/20/2025

Corrective action
Penetration on door above handle on 2nd floor sealed with appropriate fire/ smoke rated materials.
Other residents affected
All residents potentially affected
Systemic change
Audit of all fire rated doors to ensure no penetration to be done monthly x3, followed by quarterly x 3 months will be conducted by maintenance director or designee After 1 year the annual inspection of fire doors will be re instated.
Audit change
Results of audits will be submitted to QAPI.

NFPA 101 STANDARD Aisle, Corridor, or Ramp Width:

Aisle, Corridor or Ramp Width
2012 EXISTING
The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5.
19.2.3.4, 19.2.3.5

Observations:
Name: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0232

Based on observation and interview, it was determined the facility failed to maintain required corridor widths, affecting one of five smoke compartments within this component.

Findings include:

Observation on March 10, 2025, between 10:00 a.m.. and 12:15 p.m., revealed corridor widths, in several locations on the first floor, were less than the minimum requirement of 48" inches.

Exit Interview with the Administrator and Maintenance Director on March 10, 2025, at 1:50 p.m., confirmed the minimum corridor widths were not maintained.

Plan of Correction - To be completed: 04/20/2025

The facility respectfully requests DOH Life Safety to perform a new FSES in regards to this deficiency.

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements.

NFPA 101 STANDARD Vertical Openings - Enclosure:

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: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of vertical openings between floors, affecting the entire component.

Findings include:

Observation on March 10, 2025, at 9:00 a.m., revealed the non-used dumbwaiter shaft lacked a two-hour, fire rated enclosure. Vertical openings require a two-hour fire rating in openings greater than three stories in height.

Exit Interview with the Administrator and Maintenance Director on March 10, 2025, at 1:50 p.m., confirmed the vertical enclosure was not completed.

NFPA 101 STANDARD Smoke Detection:

Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2

Observations:
Name: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0347

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

Findings include:

Observation on March 10, 2025, at 11:15 a.m., revealed a smoke detector detached from its housing, on the first floor corridor by room 113.

Exit Interview with the Administrator and Maintenance Director on March 10, 2025, at 1:50 p.m., confirmed the detached smoke detector.

Plan of Correction - To be completed: 04/20/2025

Corrective action
Smoke detector outside room 113 will be secure and attached to its housing
Residents affective
All residents in surrounding area potentially affected
Systemic change
Visual audit of all smoke detectors will be completed and documented to ensure secure and attached in housing to be conducted. Following weekly x4 then by monthly x3 months by maintenance director or designee
Audit change
Results of all audits will be brought to monthly QAPI meetings

NFPA 101 STANDARD Corridor - Doors:

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

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

Observations:
Name: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure corridor doors were maintained to resist the passage of smoke, affecting one of four levels.

Findings include:

Observations on March 10, 2025, revealed the following corridor door deficiencies:

a. 11:20 a.m., on the second floor, linen closet door had multiple holes around the handle;
b. 11:25 a.m., on the second floor, room 212- failed to latch when tested.

Exit Interview with the Administrator and Maintenance Director on March 10, 2025, at 1:50 p.m., confirmed the corridor door deficiencies.

Plan of Correction - To be completed: 04/20/2025

Corrective action
2nd floor linen closet holes in door to be sealed with appropriate fire rated materials.
212 ensure repair door in order to confirm positive latching capability
Other residents affected
Potentially all resident can be affected
Systemic change
Audit all resident doors and document for testing of positive latching. Then following 10 resident doors x4 weeks followed by monthly audit of 20 doors x3 months to be conducted by maintenance director or designee.
Audit change
Audit results will be submitted monthly to QAPI

NFPA 101 STANDARD Utilities - Gas and Electric:

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 01 (MAIN BUILDING) - Component: 01 - Tag: 0511

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

Findings include:

Observation on March 10, 2025, at 11:50 a.m., revealed a light switch was missing its protective cover, exposing the inner wiring, on the first floor, main-office.

Exit Interview with the Administrator and Maintenance Director on March 10, 2025, at 1:50 p.m., confirmed the exposed wiring.

Plan of Correction - To be completed: 04/20/2025

Corrective action
Protective cover of light switch at 1st floor main office will be installed
Other residents affected
Potentially all residents in surrounding areas
Systemic change
Audit of all light switches and documentation for intact cover plates and switches will be performed. Following this 10 light switches weekly x4 weeks followed by monthly x3 months will be conducted by maintenance director or designee
Audit changes
Audit results will be submitted monthly to QAPI

NFPA 101 STANDARD Electrical Systems - 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.

Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)

Observations:
Name: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0914

Based on document review and interview, it was determined the facility failed to provide annual receptacle testing in patient care rooms at bed locations within this facility.

Findings include:

Document review on March 10, 2025, at 9:30 a.m., revealed the facility was unable to provide documentation indicating required annual receptacle testing at patient bed locations was performed within the prior 12 months.

Exit Interview with the Administrator and Maintenance Director on March 10, 2025, at 1:50 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 04/20/2025

Corrective action
Annual receptacle testing will be conducted for all receptacles at all locations. Results of this test will be documented. Appropriate tension tools and polarity testing will be acquired for proper testing procedures.
Other residents affected
Potentially all residents can be effected
Systemic change
Director to be educated on requirements for annual receptacle test, and given the proper equipment and documentation to get this inspection completed appropriately.
Audit change
Test results and education will be completed and documented. then reported to the next QAPI

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: BUILDING 01 (MAIN BUILDING) - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain required testing of emergency generator components, affecting five of twelve required tests.

Findings Include:

Document review on March 10, 2025, at 9:30 a.m., revealed the facility lacked verifying documentation of monthly conductance testing of the generator's maintenance free batteries since September 2024.

Exit Interview with the Administrator and Maintenance Director on March 10, 2025, at 1:50 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 04/20/2025

Corrective action
Maintenance director or designee to conduct and document monthly conductance testing of the generator's maintenance free batteries
Other Residents affected
All residents potentially affected
Systemic change
NHA or designee to audit test documentation to ensure this test is listed on monthly load testing to confirm it will be done monthly as is the regulation.
Audit change
Results of documentation change, and 2 quarters of documentation completed will be reported to QAPI

Initial comments:Name: BUILDING 02 (PAVILION BUILDING) - Component: 02 - Tag: 0000

Facility ID# 580502
Component 02
Pavilion Building

Based on a Medicare/Medicaid Recertification Survey completed on March 10, 2025, it was determined that Accela Rehab And Care Center At Springfield - Pavilion Building, was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a three-story, Type II (222), fire resistive building, that is fully sprinklered.

Plan of Correction:

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: BUILDING 02 (PAVILION BUILDING) - Component: 02 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the fire-resistance rating of stair towers, affecting one of three floors.

Findings include:

Observation on March 10, 2025, at 12:05 p.m., revealed a large ( 3 ' x5 ' ) wall penetration, on the ground level of the B01 stair tower.

Exit Interview with the Administrator and Maintenance Director on March 10, 2025, at 1:50 p.m., confirmed the open penetration.

Plan of Correction - To be completed: 04/20/2025

Corrective action
Penetration of large ( 3 ' x5 ' ) wall penetration, on the ground level of the B01 stair tower will be sealed with appropriate fire rated materials to ensure 2 hour fire resistance.
Other residents potentially affected
All residents potentially affected
Systemic change
Audit of all fire rated doors and stairwells with documentation to ensure no penetration to be done initially. Then weekly x4, followed by monthly x 3 months will be conducted by maintenance director or designee
Audit change
Results of audits will be submitted to QAPI

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: BUILDING 02 (PAVILION BUILDING) - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of hazardous area enclosures, affecting one of three floors.

Findings include:

Observation on March 10, 2025, at 12:30 p.m., revealed a detached self-closer on the second floor, Biohazard Room.

Exit Interview with the Administrator and Maintenance Director on March 10, 2025, at 1:50 p.m., confirmed the detached closer.

Plan of Correction - To be completed: 04/20/2025

Corrective action
facility will maintain the fire resistive rating of hazardous area enclosures for self closer in biohazard room on 2nd floor
Other residents affected
Potentially all residents in surrounding areas
Systemic change
Maintenance director or designee will audit all hazardous area enclosures initially. Then weekly x4 weeks followed by monthly x3 months
Audit change
Results to be submitted to monthly QAPI meeting

NFPA 101 STANDARD Fire Alarm System - Initiation:

Fire Alarm System - Initiation
Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200' travel distance is not exceeded.
18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5

Observations:
Name: BUILDING 02 (PAVILION BUILDING) - Component: 02 - Tag: 0342

Based on observation and interview, it was determined the facility failed to maintain fire alarm initiating devices, affecting one of three floors.

Findings include:

Observation on March 10, 2025, at 12:00 p.m., revealed a smoke detector was not securely mounted to the ceiling, on the ground floor, Sprinkler Room.

Exit Interview with the Administrator and Maintenance Director on March 10, 2025, at 1:50 p.m., confirmed the detached smoke detector.

Plan of Correction - To be completed: 04/20/2025

Corrective action
Smoke detector to be secured in ground floor sprinkler room
Other residents affected
Potentially all residents in surrounding area
Systemic change
Initial inspection of all smoke detectors to ensure secured in their housing fixtures and documented. Then following that, a visual Audit of 10 smoke detectors to be conducted by maintenance director or designee
Audit Change
For weekly x4 weeks followed by monthly x3
To be reported to QAPI

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: BUILDING 02 (PAVILION BUILDING) - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain sprinkler system components, affecting one of three floors.

Findings include:

Observation made on March 10, 2025, at 12:15 p.m., revealed two sprinklers with missing escutcheon plates, on the first floor, Dry Storage Room.

Exit Interview with the Administrator and Maintenance Director on March 10, 2025, at 1:50 p.m., confirmed the missing sprinkler component.

Plan of Correction - To be completed: 04/20/2025

Corrective action
1st floor dry storage 2 sprinkler escutcheon plates to be added to sprinkler.
Other residents affected
Potentially all residents affected
Systemic change
Initially all sprinklers will be inspected and escutcheon and smoke barrier confirmed and documented. Then following an audit of 10 random sprinkler heads will be conducted by maintenance director or designee weekly x4 and monthly x3 months
Audit change
Audits to be reported to QAPI meeting held monthly

NFPA 101 STANDARD Corridor - Doors:

Observations:
Name: BUILDING 02 (PAVILION BUILDING) - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure corridor doors were maintained to resist the passage of smoke and positively latch when tested, affecting one of three floors.

Findings include:

Observation on March 10, 2025, at 12:40 p.m., revealed the door failed to close and latch when tested on the first floor, Central Supply Room.

Exit Interview with the Administrator and Maintenance Director on March 10, 2025, at 1:50 p.m., confirmed the door failed to close and latch.

Plan of Correction - To be completed: 04/20/2025

Corrective action
Failure of door to close and latch to be corrected on 1st floor central supply storage room
Other residents affected
Potentially all residents
Systemic change
Initial inspection of all doors to confirm close and positive latching will be done first with documentation. Then following that we Audit 10 resident doors x4 weeks followed by monthly audit of 10 doors x3 months to be conducted by maintenance director or designee
Audit change
Audit results will be submitted monthly to QAPI

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement