Pennsylvania Department of Health
EDGEHILL NURSING AND REHABILITATION CENTER
Building Inspection Results

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EDGEHILL NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  35 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.
EDGEHILL NURSING AND REHABILITATION 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 February 16, 2024, at Edgehill Nursing 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 #052702
Component 01

Based on a Medicare/Medicaid Recertification Survey completed on February 16, 2024, it was determined that Edgehill Nursing And Rehabilitation 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 two-story, Type II (000), unprotected non-combustible construction, which is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
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, document review and interview, it was determined the facility failed to provide accurate, portable floor plans, affecting the entire facility.

Findings Include:

1. Document review on February 16, 2024, at 8:15 am, 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 have a portable, accurate floor plan on site to be used during the course of the Life Safety Code Survey.

The Life Safety Code Floor Plans 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

Exit Interview with the Administrator and the Maintenance Director on February 16, 2024, at 9:45 am, confirmed accurate floor plans were not available.




 Plan of Correction - To be completed: 03/25/2024

The Director of Maintenance was re-educated that the facility must have accurate portable floor plans affecting the entire facility to include: smoke barrier walls, fire barrier walls, Horizontal Exits, and rated rooms, exits clearly noted, and shaft walls. the plans will be updated to reflect the required changes. The Director of Maintenance and/or his designee is responsible to ensure compliance. The plans will be presented to the Quality Assurance team for review and further recommendations as appropriate.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
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 two floors.

Findings include:

Observation made on February 16, at 9:15 am, revealed in the basement, there was an unsealed wall penetration around data and electric wires above the smoke barrier double doors, outside of the elevator,

Exit Interview with Administrator and Maintenance Director on February 16, at 9:45 am, confirmed the unsealed penetrations.






 Plan of Correction - To be completed: 03/25/2024

The Director of Maintenance was re-educated that any penetration must be sealed with fire stop caulk to ensure that there is no passage of smoke. the penetration in the basement around data and electric wires above the smoke barrier double doors, outside the elevator has been sealed with fire stop caulk. The Director of Maintenance and/or his designee will routinely audit to ensure there are no penetrations around data and electric wires. The Director of Maintenance and/or his designee is responsible for continued compliance. The results of those audits will be presented to the Quality Assurance team for review and further recommendations.
NFPA 101 STANDARD Utilities - Gas and Electric: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.
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 maintain proper clearance for electrical equipment, affecting one of two floors.

Findings include:

1. Observation on February 16, 2024, at 9:33 am, revealed inside the ground floor Soiled linen room, laundry was stored within three feet of electrical panels. Per NFPA70 110.26(A)(1), a 3 ft. depth clearance is required in front of electrical equipment with a nominal voltage to ground of 0 to 150 volts.

Exit Interview with the Administrator and the Maintenance Director on February 16, 2024, at 9:45 am, confirmed the improper storage in front of the electrical panels.




 Plan of Correction - To be completed: 03/25/2024

The laundry in the ground floor soiled linen room was moved away from the electrical panels. The Director of Housekeeping and his laundry staff have been re-educated that nothing can be stored within 3 feet of the electric panel. The N.H.A. and/or her designee will randomly audit the soiled linen room weekly X 3 then monthly X 3 to ensure continued compliance. The results of those audits will be presented to the Quality Assurance Team for further review and recommendations as appropriate.

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