Pennsylvania Department of Health
MIDTOWN OAKS HEALTH & REHAB CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MIDTOWN OAKS HEALTH & REHAB CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Facility ID# 065402
Component 01
Main Building

Based on an Abbreviated survey as part of a complaint investigation completed on July 8, 2024, it was determined that Midtown Oaks Healthcare and Rehabilitation Center was not in compliance with the following requirements of the Life Safety Code for an existing healthcare occupancy.

This is a seven-story, Type II (222), fire-resistive building, with a basement and penthouse, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Fire Drills:

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.

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform two of nine required fire drills, affecting the entire facility.

Findings include:

1. Review of documentation on July 8, 2024, at 12:30 p.m., revealed the facility lacked documentation for the following fire drills:

a) Fourth quarter for the third shift of 2023;
b) Second quarter for the second shift of 2024.

The Facility's most recent annual Life Safety Survey was conducted on September 12, 2023.

Interview with the Facility Administrator and the Maintenance Supervisor on July 8, 2024, at 1:00 p.m., confirmed the facility lacked documentation for the listed fire drills.

Plan of Correction - To be completed: 08/01/2024

-The facility is unable to go back in time and recreate the missing fire drill documentation.

-The maintenance team was educated by the nursing home administrator the importance of timely documentation to reflect fire drills.

-Each quarter after the fire drill the nursing home administrator will review the documentation to ensure it is timely and accurate and on rotating shifts.

-This will be audited by the nursing home administrator and reviewed at the month quality assurance process improvement meeting.

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