Nursing Investigation Results -

Pennsylvania Department of Health
HILLSDALE PARK REHAB CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HILLSDALE PARK REHAB CENTER
Inspection Results For:

There are  31 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.
HILLSDALE PARK REHAB 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 October 2, 2019 at Hillsdale Park Rehab 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 # 134402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on October 2, 2019, it was determined that Hillsdale Park Rehab Center, 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 Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview it was determined that the facility failed to provide a hard packed surface from emergency exits, on one of six emergency exits.

Findings include:

Observation on October 2, 2019, at 11:50 a.m., revealed the penthouse rear steps exit, lacked a concrete or blacktop hard packed surface from the exit door to a public way (parking lot or driveway).

Interview with the maintenance supervisor on October 2, 2019, at 11:50 a.m., confirmed the penthouse rear steps exit, lacked a concrete or blacktop hard packed surface from the exit door to a public way.




 Plan of Correction - To be completed: 10/10/2019

Director of Maintenance has placed cement hard packed surface connecting the penthouse exit doorway to the driveway.
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 that the facility failed to inspect and maintain the automatic sprinkler system, on one of two levels.

Findings include:

Observation on October 2, 2019, at 11:12 a.m., revealed the north ACU ramp had an upright automatic sprinkler located within twelve inches of a suspended light fixture, that would obstruct the flow of the automatic sprinkler.

Interview with the maintenance supervisor on October 2, 2019, at 11:12 a.m., confirmed the automatic sprinkler was obstructed by the suspended light fixture.





 Plan of Correction - To be completed: 10/10/2019

Director of Maintenance removed the light fixture from it's obstructing placement of the sprinkler flow to an area further than 12 inches from the automatic sprinkler so not to obstruct the flow of water.
NFPA 101 STANDARD Portable Fire Extinguishers: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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview it was determined that the facility failed to inspect and maintain portable fire extinguishers, on one of to levels.

Findings include:

Observation on October 2, 2019, at 11:36 a.m., revealed the lower level, dining room, had a portable fire extinguisher obstructed by a refrigerator and folding chairs.

Interview with the maintenance supervisor on October 2, 2019, at 11:36 a.m., confirmed the lower level, dining room, had a portable fire extinguisher obstructed by a refrigerator and folding chairs.



 Plan of Correction - To be completed: 10/10/2019

Director of Maintenance removed the portable fire extinguisher from this area to an accessible area that is not obstructed by any furniture or appliances. The fire extinguisher has been secured in it's new location on other side of dining room.
NFPA 101 STANDARD Maintenance, Inspection & Testing - 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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on observation and interview it was determined that the facility failed to maintain fire rated doors, on one of two levels.

Findings include:

Observation on October 2, 2019, at 11:10 a.m., revealed the cross corridor fire rated door, by room # 202, lacked a UL approved label on the panic hardware, verifying the hardware was fire rated.

Interview with the maintenance supervisor on October 2, 2019, at 11:10 a.m., confirmed the cross corridor fire rated door, by room # 202, lacked a UL approved label on the panic hardware, verifying the hardware was fire rated.




 Plan of Correction - To be completed: 11/10/2019

Director of Maintenance will place the proper UL approved label on the panic hardware, verifying that the hardware was fire rated or will purchase new fire rated hardware for the cross corridor fire rated door.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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 - 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 document review and interview it was determined that the facility failed to test the emergency generator batteries, on forty of fifty-two weeks.

Findings include:

Document review on October 2, 2019, at 9:30 a.m., revealed the facility had conducted monthly battery voltage tests, on the sealed batteries, for the emergency generator, rather than weekly as required.

Interview with the maintenance supervisor on October 2, 2019, at 9:30 a.m., confirmed the facility check the emergency generator batteries monthly, rather than weekly.



 Plan of Correction - To be completed: 11/10/2019

Director of Maintenance has initiated weekly testing of the battery voltage for the emergency generator on 10/03/2019 and is capturing the testing results in a log book.

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