Pennsylvania Department of Health
HILLCREST CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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.


HILLCREST 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 5, 2025, it was determined that Hillcrest Center was not in compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a)(1)-(2), 416.54(a)(1)-(2), 418.113(a)(1)-(2), 441.184(a)(1)-(2), 482.15(a)(1)-(2), 483.475(a)(1)-(2), 483.73(a)(1)-(2), 484.102(a)(1)-(2), 485.542(a)(1)-(2), 485.625(a)(1)-(2), 485.68(a)(1)-(2), 485.727(a)(1)-(2), 485.920(a)(1)-(2), 486.360(a)(1)-(2), 491.12(a)(1)-(2), 494.62(a)(1)-(2) STANDARD Plan Based on All Hazards Risk Assessment:

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.

§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)

[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*

(2) Include strategies for addressing emergency events identified by the risk assessment.

* [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.

*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.

Observations:
Name: - Component: -- - Tag: 0006

Based on documentation review and interview, it was determined the facility failed to ensure the Emergency Preparedness Plan was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach and include strategies for addressing emergency events identified by the risk assessment.

Findings include:

Document review on May 5, 2025, at 9:30 a.m., revealed the Facility's Emergency Preparedness Plan did not include a documented community-based risk assessment, utilizing an all-hazards approach and include strategies for addressing emergency events identified by the risk assessment.

Exit interview with the Administrator and Maintenance Director on May 5, 2025, at 1:20 p.m. confirmed the documentation was not available.

Plan of Correction - To be completed: 06/11/2025

The facility will continue in its efforts to obtain the local township's EOP.
The facility is part of the local emergency coalition and will continue to collaborate with it.
The facility continues to coordinate a community approach to local emergencies.

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

Facility ID# 034402
Component 01
Healthcare Building

Based on a Medicare/Medicaid Recertification Survey completed on May 5, 2025, it was determined that Hillcrest Center 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 V (000), unprotected wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on observation and interview, it was determined the facility failed to maintain portable floor plans outlining designated rated partitions, affecting one floor plan.

Findings Include:

Document review on May 5, 2025, at 9:30 a.m., revealed the facility failed to provide a set of accurate portable floor plans. The Division of Safety Inspection is requiring that all facilities under our jurisdiction provide a portable, accurate floor plan on site to be used during the Life Safety Code Survey.

The Life Safety Code Floor Plan shall include the following:
a. Smoke Barrier Walls (outside wall to outside wall)
b. Fire Barrier Walls (2-hour walls)
c. Horizontal Exits
d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan.
e. Required Exits should be clearly noted; and
f. Shafts Walls

In addition to the above, the following information is required on the portable floor plans for facilities utilizing the Fire Safety Evaluation System (FSES):
dimensions (length and width)
Room numbers and numbers of residents in each room
station locations to include # of nurses at each location
arrows for emergency movement routes
room use must be identified (dining, soiled linen, housekeeping, office, etc.)
where FSES deficiency exists on floor plans.

Exit Interview with the Administrator and Maintenance Director on May 5, 2025, at 1:20 p.m., confirmed accurate floor plans were not available at time of survey.

Plan of Correction - To be completed: 06/11/2025

The facility obtained accurate portable floor plans that meet the Life Safety Code.

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, document review, and interview, it was determined the facility failed to maintain the building construction requirements, affecting the entire facility.

Findings include:

Observation and document review on May 5, 2025, at 10:30 a.m., revealed the building is classified as a three story, Type V (000), unprotected wood frame construction, which is fully sprinklered. The story height exceeds the maximum allowance for this construction type by two stories.

Exit Interview with the Administrator and Maintenance Director on May 5, 2025, at 1:20 p.m., confirmed the story height exceeded the maximum allowance for this construction type.

Plan of Correction - To be completed: 06/11/2025

The center has already engaged FREDERICK WARD ASSOCIATES to conduct a site visit. The purpose is to review the rated floor ceiling assembly, which may have been compromised and affected the building's construction type.

Within the next five business days, Frederick Ward will provide a cost proposal for their services. Once approved, they will schedule a site visit to develop a detailed action plan for the affected areas. Following the site visit, they will provide the necessary drawings and product information to enable the center to carry out the required repairs. We estimate this phase will take approximately 30 business days.

After receiving the plan and product details, the facility will order the necessary materials and proceed with the installation, utilizing in-house resources where feasible. This final step is estimated to take between 30 to 45 business days, depending on the specific products chosen and their availability.

Facility submitted a Time Limited Waiver request until 10/31/2025

NFPA 101 STANDARD Means of Egress - General:

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 May 5, 2025, at 11:45 a.m., revealed, on the first floor, in service hall a pipe stub was protruding from the floor, creating a tripping hazard within the means of egress.

Exit Interview with the Administrator and Maintenance Director on May 5, 2025, at 1:20 p.m., confirmed the obstructions in the means of egress.

Plan of Correction - To be completed: 06/11/2025

The pipe stub that was protruding from the floor, creating a tripping hazard within the means of egress, will be cut, removed, and capped by June 30th 2025

will be removed within 30 days to ensure it is not a tripping hazard.
The Maintenance Director inspected the rest of the service hallway to ensure no other pipe stubs protruding from the floor.
The Maintenance Director will inspect the services hallway monthly for 3 months to ensure means of egress are free of obstacles and will report his findings to the QAPI Committee.

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

Based on observation and interview, it was determined that the facility failed to maintain stair towers, affecting two of three levels.

Findings include:

Observation on May 5, 2025, revealed stair tower deficiencies in the following locations:

a. 11:10 a.m., on the second floor, stair tower door by the elevator lacked fire-rated hardware.
b. 11:20 a.m., on the second floor, short hall stair tower door failed to latch.
c. 12:30 p.m., on the first floor short hall stair tower- unsealed penetration around wires.

Exit Interview with the Administrator and Maintenance Director on May 5, 2025, at 1:20 p.m., confirmed the stair tower deficiencies.

Plan of Correction - To be completed: 06/11/2025

On the second floor, stair tower door by the elevator, fire-rated hardware was installed.
On the second floor, the short hall stair tower door is now latching.
On the first floor's short hall stair tower- penetration around wires was sealed with 3M Fire Protection system W-L-3009 with F rating of 2 (3M Fire Barrier Silicone Sealant 2000+ and 3M Fire Barrier Water Tight Sealant 1000NS.
The Maintenance Director audited the stair towers to ensure fire rated hardware is installed.
The Maintenance Director audited the stair towers doors to ensure they all latch.
The Maintenance Director will audit stair towers doors monthly for three months to ensure compliance.
The Maintenance Director will report his results to the QAPI Committee.

NFPA 101 STANDARD Alcohol Based Hand Rub Dispenser (ABHR):

Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0325

Based on observation and interview, it was determined the facility failed to protect Alcohol Based Hand Rub Dispenser (ABHR), affecting one of three levels.

Findings include:

Observation on May 5, 2025, at 11:00 a.m., revealed an ABHR was installed directly above a light switch, dining on the third floor.

Exit Interview with the Administrator and Maintenance Director on May 5, 2025, at 1:20 p.m., confirmed the ABHR location.

Plan of Correction - To be completed: 06/11/2025

The ABHR that was installed directly above a light switch in dining on the third floor was removed.
The Director of Maintenance completed an audit of ABHRs around the facility to ensure compliance.
The Maintenance Director was educated on the proper placement of ABHRs.
The maintenance Director will audit all ABHRs every six months to ensure compliance and will report his findings to the QAPI Committee.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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 and interview, it was determined the facility failed to maintain the fire alarm system, affecting one of three levels.

Findings include:

Observation on May 5, 2025, at 9:30 a.m., revealed the March 12, 2025, fire alarm service report listed the following deficiency, which remained uncorrected at time of survey:

a. The fire alarm annunciator is faulty- will need an Edwards vendor.

Exit Interview with the Administrator and Maintenance Director on May 5, 2025, at 1:20 p.m., confirmed the fire alarm deficiency.

Plan of Correction - To be completed: 06/11/2025

The fire alarm annunciator will be repaired/replaced by June 30th 2025.

The fire alarm annunciator will be maintained per regulation.

The facility continues to work with an outside contractor to inspect the device regularly per regulation.

The Maintenance Director will check its functioning monthly for three months and will report his findings to the QAPI Committee

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based upon observation and interview, it was determined the facility failed to ensure that portable fire extinguishers were accessible, affecting one of three levels.

Observation on May 5, 2025, at 11:40 a.m., revealed, on the second floor, in dining area, the wall mounted fire extinguisher was obstructed by a vinyl fence gate.

Exit Interview with the Administrator and Maintenance Director on May 5, 2025, at 1:20 p.m., confirmed the obstructed fire extinguisher.

Plan of Correction - To be completed: 06/11/2025

In the dining area, the wall mounted fire extinguisher was removed and is no longer obstructed by a vinyl fence gate.
The Maintenance Director audited the facility to ensure no other fire extinguishers are obstructed by vinyl fence gates.
The Maintenance Director was in serviced of preventing fire extinguishers' obstructions.
The Maintenance Director will audit the facility monthly for 3 months to ensure compliance and will report his findings to the QAPI Committee.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:

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, document review, and interview, it was determined the facility failed to ensure smoke compartments did not exceed minimum travel distances, affecting two of six smoke zones.

Findings include:

Observation on May 5, 2025, between 10:30 a.m. and 12:00 p.m.. revealed the following smoke compartments travel distances were in excess of 200 feet, at the following locations:

a. 10:30 a.m., on the second floor, South Short Hall and Administrative Wing.
b. 12:00 p.m., on the first floor, South Short Hall and Service Wing.

Exit Interview with the Administrator and Maintenance Director on May 5, 2025, at 1:20 p.m., confirmed the travel distances.

Plan of Correction - To be completed: 06/11/2025

The center requests that Division of Life Safety conduct a FSES Survey

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 smoke barrier walls free of unsealed penetrations, affecting one of three levels.

Findings include:

Observation on May 5, 2025, at 12:30 p.m., revealed, above smoke doors by room 118, an unsealed penetration around conduit.

Exit Interview with the Administrator and Maintenance Director on May 5, 2025, at 1:20 p.m., confirmed the penetrations.

Plan of Correction - To be completed: 06/11/2025

An unsealed penetration around conduit above smoke doors by room 118 was repaired per regulation using 3M UL System W-L-3001 1,2, Fire barrier Sealant CP25WB+, 3M Fire barrier Moldable Putty StixMP+ and 3M Fire Barrier Moldable Putty Pads MPP+.
The Maintenance Director audited conduits above smoke doors to ensure penetrations are sealed accordingly.
The Maintenance Director will conduct yearly inspection of conduits above smoke doors and will report his findings to the QAPI Committee.

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

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting two of three levels.

Findings include:

Observations on May 5, 2025, revealed, non-GFCI outlets located within 6 feet of a sink in the following locations: (Per NFPA 70 210.8(B)5, a GFCI outlet is required where receptacles are installed within 6 ft of the outside edge of the sink.)

a. 10:45 a.m., on the third floor, beauty salon.
b. 11:35 a.m., on the second floor, soiled.

Exit Interview with the Administrator and Maintenance Director on May 5, 2025, at 1:20 p.m., confirmed the unprotected outlets.

Plan of Correction - To be completed: 06/11/2025

The facility replaced the non- GFCI outlets in the two locations with GFCI outlets.

The Maintenance Director will audit the facility to ensure no other non-GFCI outlets exist in prohibited locations.

The Maintenance Director will conduct a yearly audit to ensure no non-GFCI exist in prohibited locations and will report his findings to the QAPI Committee.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined that the facility failed to maintain oxygen storage requirements, affecting one of three levels.

Findings Include:

Observation on May 5, 2025, at 11:20 a.m., revealed, on the second floor, oxygen storage room door had multiple open holes around the handle.

Exit Interview with the Administrator and Maintenance Director on May 5, 2025, at 1:20 p.m., confirmed the door penetrations.

Plan of Correction - To be completed: 06/11/2025

The facility sealed the second floor- oxygen storage room door's multiple open holes around the handle by installing steel fasteners that completely seal the holes.

The Maintenance Director inspected the other doors to oxygen storage rooms to ensure no holes exist in the doors.

The Maintenance Director will inspect oxygen room storage doors semi-annually and will report his findings to the QAPI Committee.

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