Pennsylvania Department of Health
REHABILITATION CENTER AT JEFFERSON HILLS, THE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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REHABILITATION CENTER AT JEFFERSON HILLS, THE - 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 18, 2025, at The Rehabilitation Center at Jefferson Hills, 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# 024002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 17, 2025, it was determined that The Rehabilitation Center at Jefferson Hills had deficiencies that have the potential for minimal harm as related to 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 III (200), unprotected ordinary building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

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.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain the building construction requirements for the entire building.

Findings include:

1. Observation on March 17, 2025, at 8:45 a.m., revealed the building is a two-story, Type III (200), unprotected ordinary structure, with a basement and attic, that is fully sprinklered. This type of construction is not permitted to be greater than one story in height.

Interview with the Owner of the facility, Facility Administrator and Maintenance Director on March 17, 2025, at 1:00 p.m., confirmed the building construction type did not meet the requirements for an existing health care building.

Plan of Correction - To be completed: 04/15/2025

I. New owner will have an architect review the blueprint and construction plan of the building in order to determine a solution to correct the deficiency for building construction.

II. After architectural review, the facility will be able to determine a date for correction of deficiency.

III. Director of Maintenance/Designee will monitor progress of correcting the deficiency for building construction.

IV. Progress will be reported to the Quality Assurance Committee monthly for tracking and trending purposes.

V. Facility will be submitting a request for a one time waiver.

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 document review and interview, it was determined the facility failed to maintain emergency lighting in one instance, for one out of 15 emergency lights.

Findings include:

1. Observation on March 17, 2025, at 10:00 a.m., revealed the battery back-up light in the generator room failed to illuminate when tested.

Interview with the Owner of the facility, Facility Administrator, and Maintenance Director on March 17, 2025, at 1:00 p.m., confirmed the emergency lighting failed to illuminate when tested.

Plan of Correction - To be completed: 04/15/2025

I. The back-up battery light in the generator was turned back on at the time of the surveyors observation.

II. No other emergency lights failed to illuminate when tested.

III. Nursing Home Administrator will re-educate Director of Maintenance on the requirement to maintain emergency lighting.

IV. Director of Maintenance will conduct 5 audits weekly for 8 weeks to ensure the back-up battery light in the generate illuminates when tested. Audit results will be taken through Quality Assurance Committee Meeting for tacking and trending purposes.

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