Pennsylvania Department of Health
FOREST HILLS REHABILITATION & HEALTHCARE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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FOREST HILLS REHABILITATION & HEALTHCARE 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 7, 2025, at Forest Hills Rehabilitation and Healthcare 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# 030602
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 7, 2025, it was determined that Forest Hills Rehabilitation and Healthcare 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 two story, Type II (000), unprotected, noncombustible building, 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 ensure that exit access was always being maintained readily accessible, in one location, on one of two floors.

Findings include:

1. Observation on May 7, 2025, at 11:33 a.m., revealed the Chapel Emergency exit door to the outside required excessive force to open.

Interview at exit with the Facility Administrator and the Maintenance Director on May 7, 2025, at 12:30 p.m., confirmed the door opening difficulty.

Plan of Correction - To be completed: 05/13/2025

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Chapel Emergency exit door has been adjusted to open with less than 15 lbs. of force to open.
2. The Nursing Home Administrator will provide education on proper door adjustments and requirements. The Maintenance Director or Designee will conduct audits of facility Emergency Exit doors weekly for four weeks and then monthly thereafter to verify they open and close properly. Quality Assurance Performance Improvement committee to review the audits to monitor ongoing compliance.

NFPA 101 STANDARD Doors with Self-Closing Devices:

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain doors with self-closing devices, in two locations, affecting two of two floors.
Findings include:

1. Observation on May 7, 2025, between 10:54 a.m., and 11:46 a.m., revealed the following:

a. At 10:54 a.m., 2nd floor, Main dining room, left set of double doors, Left leaf failed to latch into frame when tested.
b. At 11:46 a.m., 1st floor, Area 1, Dining room door, failed to fully close and latch into frame when tested.

Interview at exit with the Facility Administrator and the Maintenance Director on May 7, 2025, at 12:30 p.m., confirmed the self-closure door deficiencies.

Plan of Correction - To be completed: 05/13/2025

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. 2ND floor Main dining room left set of double doors, left leaf has been adjusted to properly latch.
1st floor Area 1 Dining room door has been adjusted to fully close and latch into frame.
2. The Nursing Home Administrator will provide education on proper door adjustments and latching requirements. Maintenance Director or Designee will conduct audits of dining room doors weekly for four weeks and then monthly thereafter to verify they open and close properly. Quality Assurance Performance Improvement committee to review the audits to monitor ongoing compliance.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of ten smoke compartments.

Findings include:

1. Observation on May 7, 2025, at 11:18 a.m., 2nd floor, Area Four, Storage Room door required adjustment to fully latch.

Interview at exit with the Facility Administrator and the Maintenance Director on May 7, 2025, at 12:30 p.m., confirmed the hazardous area enclosure deficiency.

Plan of Correction - To be completed: 05/13/2025

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Area 4 Storage room door has been adjusted to fully latch.
2. The Nursing Home Administrator will provide education on proper door adjustments and latching requirements. Maintenance Director or Designee will conduct audit of Area 4 Storage door to be conducted weekly for 4 weeks then monthly x 3 with results to the Quality Assurance Performance Improvement committee to review the audits to monitor ongoing compliance.

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

Based on observations and interview, it was determined the facility failed to maintain the sprinkler system on one of one floor.

Findings include:

1. Observation on May 7, 2025, between 11:14 a.m., and 11:35 a.m., revealed the following:

a. At 11:14 a.m., 2nd floor, Nursing office was missing an escutcheon.
b. At 11:35 a.m., 1st floor, Central Supply was missing an escutcheon.

Interview at exit with the Facility Administrator and the Maintenance Director on May 7, 2025, at 12:30 p.m., confirmed the missing escutcheons.

Plan of Correction - To be completed: 05/13/2025

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Replaced missing escutcheon on 2nd floor Nursing Office.
Replaced missing escutcheon on 1st floor Central Supply.

2. The Nursing Home Administrator will provide education on the importance of maintaining escutcheons properly. Maintenance Director or Designee will conduct a monthly visual of all sprinkler heads, make any adjustments if necessary and document sprinkler head findings to the Quality Assurance Performance Improvement committee to review the audits to monitor ongoing compliance.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:

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.

Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0371

Based on observation and interview, it was determined the facility failed to provide acceptable travel distances, affecting two of ten smoke compartments.

Findings include:

1. Observation on May 7, 2025, at 11:30 a.m., revealed the second floor, Main Hall, Zone One, and first floor, Main Hall Zone Two, smoke compartments exceeded maximum allowable travel distances.

Interview at exit with the Facility Administrator and the Maintenance Director on May 7, 2025, at 12:30 p.m., confirmed the travel distance deficiencies.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain one smoke barrier separation wall, affecting two of ten smoke compartments.

Findings include:

1. Observation on May 7, 2025, at 11:57 a.m., revealed the 1st floor, Area Two, smoke barrier separation wall, located closest to Resident Room 222, had an unsealed penetration around an MC cable.

Interview at exit with the Facility Administrator and the Maintenance Director on May 7, 2025, at 12:30 p.m., confirmed the smoke barrier wall deficiency.

Plan of Correction - To be completed: 05/13/2025

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Maintenance will seal the Penetration around an MC cable on Area 2 smoke separation wall located closest to Resident Room 222 with fire caulk ensuring a tight seal.

2. The Nursing Home Administrator will provide education on the importance of sealing smoke barrier penetrations. Maintenance Director or Designee will inspect all smoke barrier separation walls and repair any identified issues, if any, as they are identified. Audit of all smoke barrier separation walls will be conducted, and results presented to the Quality Assurance Performance Improvement committee to monitor ongoing compliance.

NFPA 101 STANDARD Electrical Equipment - Other:

Electrical Equipment - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, 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 10 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0919

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

Findings include:

1. Observation on May 7, 2025, at 10:57 a.m., 2nd floor, revealed the Conference Room had exposed electrical wiring within the room, due to removal of a hardwired wall mounted clock.

Interview at exit with the Facility Administrator and the Maintenance Director on May 7, 2025, at 12:30 p.m., confirmed the electrical system deficiency.

Plan of Correction - To be completed: 05/13/2025

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. The exposed electrical wiring in the Conference Room has been corrected by returning, plugging in and properly fitting the hardwired wall mounted clock after the clock was repaired.
2. Maintenance Director or designee will conduct an audit to determine if other exposed electrical wiring issues exist and rectify them as identified. Audits will continue weekly for four weeks and then monthly thereafter to identify any other exposed wiring, if any. The results of the audits will be presented to the Quality Assurance Performance Improvement committee to monitor ongoing compliance.

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