Pennsylvania Department of Health
EMBASSY OF HILLSDALE PARK
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
EMBASSY OF HILLSDALE PARK
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.
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 April 18, 2024, 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 April 18, 2024, 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 Fire Alarm System - Testing and Maintenance: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 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 document review and interview, the facility failed to meet fire alarm system requirements for one of one facility.

Findings include:

Document review on April 18, 2024, between 10:10 a.m. and 10:12 a.m., revealed the facility failed to provide the below documentation at the time of the survey:
A. (10:10 a.m.) Sensitivity testing of wire-in smoke detectors one year after install;
B. (10:12 a.m.) Battery-operated smoke detector alarm policy;
C. (10:12 a.m.) CO detector alarm policy.

Interview with the administrator and maintenance supervisor on April 18, 2024, at 10:12 a.m., confirmed the deficiencies.










 Plan of Correction - To be completed: 06/01/2024

The facility contacted vendor to complete Sensitivity testing of wire-in smoke detectors and will be completed by Alta Fire Protection. The facility will obtain policies for the battery-operated smoke detector and the CO Detector Alarm and ensure they are followed. Any issues related to compliance will be reviewed in the monthly Safety Meetings as well as the Quality Assurance Process Improvement meetings.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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, the facility failed to meet essential electrical system requirements for one of one facility.

Findings include:

Document review on April 18, 2024, between 10:10 a.m. and 10:12 a.m., revealed the following generator deficiencies:
A. (10:10 a.m.) Generator diesel sample, taken May 4, 2023, had "abnormal" results that failed to meet ASTM specifications;
B. (10:12 a.m.) Weekly generator visual inspection not available;
C. (10:12 a.m.) Weekly battery voltage testing not availabe.

Interview with the administrator and maintenance supervisor on April 18, 2024, at 10:12 a.m., confirmed the deficiencies at the time of the survey.







 Plan of Correction - To be completed: 06/01/2024

The facility contacted local vendor and a fuel test is to be completed on 4/29/24. An audit form was created and weekly general visual inspections audits have started and will remain in compliance. Audit form was created for weekly battery voltage testing on the generator and audits has been started. Any issues related to compliance will be reviewed in the monthly Safety Meetings as well as the Quality Assurance Process Improvement meetings.

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port