Nursing Investigation Results -

Pennsylvania Department of Health
GUARDIAN HEALTHCARE HIGHLAND VIEW
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

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GUARDIAN HEALTHCARE HIGHLAND VIEW
Inspection Results For:

There are  38 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.
GUARDIAN HEALTHCARE HIGHLAND VIEW - 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 17, 2022, at Highland View Healthcare 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 # 027702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 17, 2022, it was determined that Highland View Healthcare 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 V (111), protected, wood frame building, that is fully sprinklered.





 Plan of Correction:


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

Based on observation and interview, it was determined that the facility failed to maintain the means of egress for one of over fifty rooms.

Findings include:

Observation on May 17, 2022, at 11:11 a.m., revealed the room egress door between the kitchen and dining hall had a two-step locking arrangement, possibly delaying egress during an emergency.

Interview with the administrator on May 17, 2022, at 11:11 a.m., confirmed the door between the kitchen and dining hall had a two-step locking arrangement.






 Plan of Correction - To be completed: 06/30/2022

Maintenance Director will replace current deadbolt with a passage lockset with key.
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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 document review, observation, and interview, the facility failed to maintain fire alarm systems for one of one fire alarm system, affecting the entire facility.

Findings include:

Document review on May 17, 2022, at 9:23 a.m., revealed the facility lacked documentation that the smoke detector sensitivity test was completed at the time of the survey.

Interview with the administrator and maintenance supervisor on May 17, 2022, at 9:23 a.m., confirmed the above sensitivity results were unavailable.





 Plan of Correction - To be completed: 05/27/2022

The most recent smoke detector sensitivity test results were obtained from Advanced Fire Company. NHA will manage the oversight and scheduling of routine third party vendor maintenance.
NFPA 101 STANDARD Electrical Systems - Other: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.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, for one of over 50 rooms.

Findings include:

Observation on May 17, 2022, at 11:54 a.m., revealed the housekeeping storage closet had a damaged section of conduit on the bottom of the electrical panel.

Reference: NFPA 70-314.17

Interview with the administrator on May 17, 2022, at 11:54 a.m., confirmed the above conduit was damaged.







 Plan of Correction - To be completed: 06/15/2022

The conduit was repaired on 5/17/2022 by Maintenance Director.

Maintenance Director/designee will check electrical panels monthly for damage and report findings to NHA.


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: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on document review and interview, the facility failed to maintain essential electric system maintenance and testing for one of one emergency generator.

Findings include:

Document review on May 17, 2022, at 10:48 a.m., revealed the facility lacked documentation that an annual fuel analysis report was conducted for the emergency generator.

Interview with the administrator and the maintenance supervisor on May 17, 2022, at 10:48 a.m., confirmed the annual fuel analysis report was not available at the time of the survey.






 Plan of Correction - To be completed: 06/01/2022

A sample of generator fuel was obtained on 05/18/2022. NHA/designee will manage the oversite and scheduling of routine third party vendor maintenance.

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

Visit the PA Power Port