Pennsylvania Department of Health
HIGHLAND HILLS POST ACUTE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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HIGHLAND HILLS POST ACUTE - 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 December 3, 2024, at Highland Hills Post Acute, 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# 127902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on December 3, 2024, it was determined that Highland Hills Post Acute 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 (111), protected noncombustible building, without a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Cooking Facilities:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on observation and interview, it was determined the facility failed to maintain cooking facilities in two instances, affecting one of 12 smoke compartments.

Findings include:

1. Observation and document review on December 3, 2024, revealed the facility lacked documentation for the following:

a) 9:20 a.m., semi-annual Kitchen fire suppression Testing/Maintenance for 2nd half of 2024;
b) 9:25 a.m., both semi-annual Kitchen exhaust Hood/Duct cleanings for 2024.

Interview with the Facility Administrator and Maintenance Director on December 3, 2024, at 12:30 p.m., confirmed the kitchen fire suppression system and hood deficiencies.

Plan of Correction - To be completed: 01/17/2025

Unable to correct past deficient practice.

The Administrator will educate the Maintenance Director on requirements of K0324.

Maintenance Director will secure a vendor to complete testing and maintenance of kitchen fire suppression system, exhaust and hood/duct. Vendor will complete kitchen fire suppression system, exhaust hood/duct cleaning.

Maintenance Director will secure ongoing agreement with vendor to complete semiannual testing and maintenance of kitchen fire suppression system, exhaust and hood/duct cleanings, to assure that the centers cooking facilities/equipment are protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Copies of service/inspection records will be maintained in the Life Safety Survey Preparedness Manual. Reports will be shared in the following safety committee for any additional review and or recommendations, ongoing.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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.

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 documentation review, observation, and interview, it was determined the facility failed to maintain the fire alarm system in one instance, for one of two semiannual inspections.

Findings Include:

1. Review of documentation on December 3, 2024, at 8:40 a.m., revealed the facility lacked documentation of a semiannual visual fire alarm system inspection.

Interview with the Facility Administrator and Maintenance Director, on December 3, 2024, at 12:30 p.m., confirmed the facility lacked documentation of a semiannual fire alarm system inspection.

Plan of Correction - To be completed: 01/17/2025

Unable to correct past deficient practice.

The Administrator will educate the Maintenance Director on requirements of K0325.

The Maintenance Director will complete and document a visual inspection of the fire alarm system. Maintenance Director will have TELS tracking system (electronic maintenance ticketing and preventative maintenance program) updated to include semiannual visual inspections of the fire alarm system added to the PM (Preventative Maintenance) tasks.

The Maintenance Director will complete and document a visual inspection of the fire alarm system semiannually and maintain record in the Life Safety Survey Preparedness Manual. Reports will be shared in the following safety committee for any additional review and or recommend dations, ongoing.

NFPA 101 STANDARD Sprinkler System - Installation:

Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0351

Based on observation and interview, it was determined the facility failed to maintain automatic sprinkler system installation requirements in eight instances, in eight of over 100 sprinklered compartments inspected throughout the building.

Findings Include:

1. Observation on December 3, 2024, between 11:35 a.m. and 11:55 a.m., revealed standard response sprinkler heads mixed with quick response sprinkler heads, in the following locations on the second floor:

a) Room 236;
b) Room 237;
c) Room 238;
d) Room 239;
e) Room 240;
f) Room 223;
g) Room 233;
h) Room 234.

Interview with the Facility Administrator and Maintenance Director on December 3, 2024, at 12:30 p.m., confirmed the mixed response sprinkler heads were present.

Plan of Correction - To be completed: 01/17/2025

Unable to correct past deficient practice.

The Administrator will educate the Maintenance Director on requirements of K0351.

The Maintenance Director will secure vendors to complete a walkthrough of the center to identify all mixed head sprinklers for replacement.

The Maintenance Director will secure bids for repairs, choose a best vendor and have repairs completed.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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 automatic sprinkler system in three instances, affecting the entire facility.

Findings include:

1. Observation on December 3, 2024, revealed the following automatic sprinkler system deficiencies:

a) 9:05 a.m., the facility failed to conduct the required 1st and 3rd quarterly sprinkler inspections;
b) 10:41 a.m., the facility failed to maintain storage below the 18-inch horizontal sprinkler plane in the Janitor's/Housekeeping closet;
c) 11:15 a.m., there were two ceiling tiles missing in the Paint Room above the grease trap.

Interview with the Facility Administrator, and Maintenance Director on December 3, 2024, at 12:30 p.m., confirmed the listed automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 01/17/2025

Houskeeping/Laundry Supervisor removed storage that was higher than 18 inches from the ceiling. Maintenance Director replaced missing ceiling tiles.

The Administrator will educate the Maintenance Director on requirements of K0353. Staff Development Director will educate managers on storage guideline of 18 inches below ceiling.

Maintenance Director/designee will complete a round of the center to identify and correct any storage located higher than 18 inches from the ceiling or ceiling penetrations and correct deficiencies upon notation.

Maintenance Director/designee will complete monthly checks for storage above 18 inches from ceiling, and ceiling penetrations, documented in TELS, ongoing. Maintenance Director will secure ongoing agreement with vendor to complete quarterly sprinkler inspections to test and maintain the centers automatic sprinkler and standpipe systems. Copies of service/inspection records will be maintained in the Life Safety Survey Preparedness Manual. Reports will be shared in the following safety committee for any additional review and or recommendations, ongoing.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of twelve smoke compartments.

Findings include:
1. Observation on December 3, 2024, at 11:45 a.m., revealed a microwave was plugged into a surge protector in the Human Resources office.

Interview with the Facility Administrator and Maintenance Director on December 3, 2024, at 12:30 p.m., confirmed the misuse of electrical wiring.

Plan of Correction - To be completed: 01/17/2025

Microwave was immediately put out of service and removed from the surge protector.

The Administrator will educate the Maintenance Director on requirements of K0920.

Maintenance Director and/or Assistant will conduct a round of the center to identify and correct any extension cord/power strip use that is being used as a substitute for fixed wiring of a structure. Small appliances will be removed from all office areas. Staff Development Director will educate managers on allowable power strip use.

Maintenance Director will conduct, once monthly, documented safety rounding of the center to identify and correct an extension cord/power strip use that is being substituted for fixed wiring of a structure. Findings will be reported through Safety Committee Monthly for review and/or recommendations, ongoing.

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