Pennsylvania Department of Health
HERITAGE POINTE REHABILITATION AND HEALTHCARE CENTER
Building Inspection Results

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HERITAGE POINTE REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

There are  40 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.
HERITAGE POINTE REHABILITATION AND 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 January 9, 2024, at Heritage Pointe 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# 070102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 9, 2024, it was determined Heritage Pointe Rehabilitation and Healthcare Center was not in compliance with the 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 one-story, Type III (200), unprotected ordinary building, with an unused attic, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 observation and interview, it was determined the facility failed to maintain the sprinkler system, affecting one of three smoke compartments in the facility.

Findings include:

Observation on January 9, 2024, at 9:56 a.m., revealed, in the Laundry, excessive debris on the sprinklers.

Exit interview with the Administrator and Maintenance Director on January 9, 2024, at 10:15 a.m., confirmed the excessive debris on the sprinklers.



 Plan of Correction - To be completed: 02/12/2024

1. Sprinkler heads in laundry area were immediately cleaned
2. Facility wide audit to be completed to check all sprinkler heads to assure cleanliness
3. NHA/designee will provide education to maintenance staff on sprinkler head cleanliness to avoid possible delay of the sprinkler activation
4. Director of Maintenance/designee will conduct audits on sprinkler heads weekly x4, then monthly x3 and report findings to QAPI committee
5. Date of Compliance: 2/12/24

NFPA 101 STANDARD Electrical Systems - 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.
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, it was determined the facility failed to ensure electrical wiring was protected in accordance with NFPA 99 Chapter 6 Electrical Systems, in one of the three smoke compartments in this facility.

Findings include:

Observation made on January 9, 2024, at 9:43 a.m., revelaed, above the smoke doors by resident room 24, an unsupported junction box above the ceiling.

Exit interview with the Administrator and Maintenance Director on January 9, 2024, at 10:15 a.m., confirmed the unsupported junction box.



 Plan of Correction - To be completed: 02/12/2024

1. Junction box above the smoke door near resident room 24 was immediately secured
2. Facility wide audit to be completed to check all junction boxes to assure they are secured
3. NHA/designee will provide education to maintenance staff on properly securing junction boxes where needed
4. Date of Compliance: 2/12/24

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
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 the facility failed to maintain gas cylinder and container storage, affecting one of the three smoke compartments in the facility.

Findings include:

Observation on January 9, 2024, at 9:39 a.m., revealed the Oxygen Storage across from resident room 6 lack signage stating "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Exit interview with the Administrator and Maintenance Director on January 9, 2024, at 10:15 a.m., confirmed the lack of signage.



 Plan of Correction - To be completed: 02/12/2024

1. A "NO SMOKING" sign was immediately posted on the oxygen storage room near resident room 6
2. A facility wide audit to be completed to check all oxygen storage areas to assure proper "NO SMOKING" signage
3. NHA/designee will provide education to maintenance staff on proper signage requirements near oxygen storage
4. Date of Compliance: 2/12/24


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