Pennsylvania Department of Health
EMBASSY OF HILLSDALE PARK
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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EMBASSY OF HILLSDALE PARK - 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 24, 2026, at Embassy of Hillsdale Park, 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 #134402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 24, 2026, it was determined that Embassy of Hillsdale Park 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 V (111), protected, wood frame building, that 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 document review, observation, and interview, the facility failed to maintain portable floor plans that outlined designated rated partitions, affecting the entire facility.

Findings include:

Document review on February 24, 2026, at 9:05 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 its 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 (1-2 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 its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls.

Interview with the maintenance supervisor on February 24, 2026, at 9:05 a.m., confirmed the Life Safety Code Floor Plan failed to accurately contain the listed items.

Plan of Correction - To be completed: 03/20/2026

The Director of Maintenance or designee will work with vendor and Corporate Maintenance to maintain portable floor plans that outlines designated rated partitions, including smoke barrier walls (outside wall to outside wall), fire barrier walls (1-2 hour walls), Horizontal exits, rated rooms (storage rooms, soiled utility), required exits should be clearly noted, and shaft walls. The floor plan will be reviewed in Quality Assurance Process Improvement Meeting.

NFPA 101 STANDARD Egress Doors:

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.

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0222

Based on observation and interview, the facility failed to maintain egress door requirements, affecting two of three smoke compartments on the lower level.

Findings include:

Observation on February 24, 2026, at 11:40 a.m., revealed the lower level emergency exit door, near the resident lounge, required significant force to open. The door had one hinge connected to the door. The egress stairs were also not maintained free of snow.

Interview with the maintenance supervisor on February 24, 2026, at 11:40 a.m., confirmed the egress door deficiencies at the time of the survey.

Plan of Correction - To be completed: 03/20/2026

The Director of Maintenance or designee will repair egress door, as well as ensure the stairs are free of snow. Audits will be completed weekly for 2 weeks to ensure steps are free of snow. The repairs and audit results will be reviewed in Quality Assurance Process Improvement Meeting.

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on document review and interview, the facility failed to provide functional test documentation of battery-powered emergency lighting for two of two lights.

Findings include:

Document review on February 24, 2026, at 11:30 a.m., revealed the facility lacked documentation for the monthly 30-second testing of the battery back-up lighting.

Interview with the maintenance supervisor on February 24, 2026, at 11:30 a.m., confirmed the facility could not provide the monthly testing documentation.

Plan of Correction - To be completed: 03/20/2026

The Director of Maintenance or designee will complete monthly 30-second testing of the battery back up lighting. This task was added to the Maintenance System for Compliance. Results of the testing will be reviewed in Quality Assurance Process Improvement Meeting.

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 document review and interview, the facility failed to remain in compliance with sprinkler system regulations for two of two systems.

Findings include:

Document review on February 24, 2026, at 11:00 a.m., revealed the facility could not provide documentation for an internal valve and pipe inspection that was completed within the previous five years.

Interview with the maintenance supervisor on February 24, 2026, at 11:00 a.m., confirmed the inspection was not completed at the time of the survey.

Based on observation and interview, the facility failed to remain in compliance with sprinkler system regulations for two of two systems.

Findings include:

Observation on February 24, 2026, at 10:33 a.m., revealed the following sprinkler system deficiencies in the basement:

A. (10:33 a.m.) Above the washing machine, yellow plastic material was present on the sprinkler pipe;
B. (10:33 a.m.) Cage storage area had a zip tie wrapped around the sprinkler hanger.

Interview with the maintenance supervisor on February 24, 2026, at 10:33 a.m., confirmed the material on the sprinkler system.

Plan of Correction - To be completed: 03/20/2026

The Director of Maintenance removed the yellow plastic material from the sprinkler pipe and the zip tie around the sprinkler hanger on 2/24/26. Weekly audits will be completed for 4 weeks to ensure sprinkler pipes are free from plastic material and zip ties. The results of the audit will be reviewed in Quality Assurance Process Improvement Meeting.

The Director of Maintenance or designee will work with vendor to complete the internal valve and pipe inspection to meet the 5 year requirement. Results of the inspection will be reviewed in Quality Assurance Process Improvement Meeting.

NFPA 101 STANDARD Electrical Systems - Receptacles:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on observation and interview, the facility failed to maintain electrical receptacles in one of over fifty rooms.

Findings include:

Observation on February 24, 2026, at 10:15 a.m., revealed an electrical receptacle lacked ground fault circuit interrupter (GFCI) protection in the basement employee break room. The receptacle was located within six feet of the sink.

Interview with the maintenance supervisor on February 24, 2026, at 10:15 a.m., confirmed the electrical outlet deficiency.

Plan of Correction - To be completed: 03/20/2026

The Director of Maintenance or designee added ground fault circuit interruption (GFCI) protection in the basement employee break room on 2/26/26. �Full house audit will be completed of receptacles within six feet of a sink to ensure compliance.� Results of audit will be reviewed in Quality Assurance Process Improvement Meeting.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on observation and interview, the facility failed to meet essential electric service maintenance and testing requirements for one of two generators.

Findings include:

Observation on February 24, 2026, at 11:00 a.m., revealed the Kohler generator annunciator panel failed to operate at the time of the survey. The facility stated the generator damage resulted from a lighting strike that occured in 2025. The incident was recorded and submitted.

Interview with the maintenance supervisor on February 24, 2026, at 11:00 a.m., confirmed the remote annunciator panel failed to operate when tested.

Plan of Correction - To be completed: 03/20/2026

The Director of Maintenance will work with Penn Power or approved vendor to complete repair of the Kohler generator annunciator panel.� Repairs will be reviewed in Quality Assurance Process Improvement Meeting.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

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.

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, the facility failed to meet electrical equipment requirements for one of three building levels.

Findings include:

Observation on February 24, 2026, at 10:30 a.m., revealed an extension cord secured to the wall with a soap dispenser plugged into it behind the basement washing machine.

Interview with the maintenance supervisor on February 24, 2026, at 10:30 a.m., confirmed the extension cord was mounted to the wall.

Plan of Correction - To be completed: 03/20/2026

The Director of Maintenance or designee will remove extension cord for soap dispenser and place an outlet for direct insertion of the soap dispenser.� Repairs will be reviewed in Quality Assurance Process Improvement Meeting.

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