Pennsylvania Department of Health
ACCELERATE SKILLED NURSING AND REHABILITATION WILLOW GROVE
Building Inspection Results

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ACCELERATE SKILLED NURSING AND REHABILITATION WILLOW GROVE
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.
ACCELERATE SKILLED NURSING AND REHABILITATION WILLOW GROVE - 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 November 20, 2023, at Accelerate Skilled Nursing and Rehab - Willow Grove, 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# 069002
Component 01
Main Building

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on November 20, 2023, it was determined that Accelerate Skilled Nursing and Rehab- Willow Grove 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 II (111), protected non-combustible building, with a basement and partial attic space, 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: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain the means of egress free of impediments, affecting one of three levels.

Findings Include:

Observation on November 20, 2023, at 11:45 a.m., revealed the first floor emergency exit door by room 132 required excessive force to open.

Exit Interview with the Administrator and Maintenance Director on November 20, 2023, at 12:50 p.m., confirmed the egress door required excessive force to open.

***************
Observation during an onsite Revisit conducted on January 23, 2024, between 8:30 a.m. and 9:45 a.m., determined the following:

Item 1 - Not Completed. The first floor emergency exit door by room 132 required excessive force to open at time of revisit.

Exit Interview with the Administrator and Maintenance Director on January 23, 2024, at 9:45 a.m., confirmed the above item was not completed.










 Plan of Correction - To be completed: 02/08/2024

The first floor emergency exit door by room 132 had its magnetic lock replaced and keypad for release repaired by the door vendor on January 29, 2024.
A daily audit of the emergency exit door by room 132 will be conducted by the Director of Maintenance, or designee, for two weeks to ensure it is fully operational in case of emergencies.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0345

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

Findings include:

Document review on November 20, 2023, at 9:30 a.m., revealed the following required fire alarm inspection reports were not available for review at time of survey:

a. annual fire alarm inspection;
b. semi-annual fire alarm visual inspection;
c. biennial smoke detector sensitivity testing.

Exit Interview with the Administrator and Maintenance Director on November 20, 2023, at 12:50 p.m., confirmed the missing documentation.

***************
Observation during an onsite Revisit conducted on January 23, 2024, between 8:30 a.m. and 9:45 a.m., determined the following:

Item 1 - Not Completed. The following required fire alarm inspection reports were not available for review at time of Revisit:

a. annual fire alarm inspection;
b. semi-annual fire alarm visual inspection;
c. biennial smoke detector sensitivity testing.

Exit Interview with the Administrator and Maintenance Director on January 23, 2024, at 9:45 a.m., confirmed the above item was not completed.









 Plan of Correction - To be completed: 03/02/2024

The inspection reports for the annual inspection, semi-annual fire alarm visual inspection, and the biennial smoke detector sensitivity testing will be available for review. NHA provided education to the Director of Maintenance regarding appropriate documentation preparation and retention for survey readiness.
NHA will audit the Life Safety survey readiness binder with the Director of Maintenance to ensure compliance with documentation retention.
Audit result will be reviewed at the QAPI meeting.


An additional Time Limited Waiver request was submitted for completion by 3/1/2024.

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