Nursing Investigation Results -

Pennsylvania Department of Health
EMBASSY OF HILLSDALE PARK
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
EMBASSY OF HILLSDALE PARK
Inspection Results For:

There are  36 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 June 30, 2022, 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 June 30, 2022, 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 Exit Signage: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.
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on observation and interview, it was determined that the facility failed to ensure exit signage was displayed properly, affecting one of three building levels.

Findings include:

Observation on June 30, 2022, at 12:03 p.m., revealed the basement corridors lacked exit and directional signage to the designated egress pathway.

Interview with the maintenance supervisor on June 30, 2022, at 12:03 p.m., confirmed the above areas lacked proper exit and directional signage.





 Plan of Correction - To be completed: 07/09/2022

The facility Maintenance Director completed the placement of exit and directional signage to the designated egress pathway in the basement corridors on 7/9/22.
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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 requirements for one of one fire alarm system, affecting the entire building.

Findings include:

1. Document review on June 30, 2022, at 11:08 a.m., revealed the fire alarm inspection report stated that the Protecto wiring outside the ACU needed installed. The facility lacked documentation that the deficiency was addressed.

Interview with the maintenance supervisor on June 30, 2022, at 11:08 a.m., confirmed the above deficiency was not resolved at the time of the survey.
2. Observation on June 30, 2022, at 12:25 p.m., revealed the fire alarm panel indicated a trouble mode and was silenced on June 23, 2021.
Interview with the maintenance supervisor on June 30, 2022, at 12:25 p.m., confirmed the above fire alarm panel indicated a trouble mode.





 Plan of Correction - To be completed: 08/15/2022

The facility is working with vendor on placing protecto wiring outside ACU. The fire alarm panel in trouble mode was reviewed by Monitronics in July 2022. At this time Monitronics is waiting on the main control panel in order to complete installation. Monitronics anticipates the arrival of the parts in August of 2022 and plans to have the fire alarm panel replaced by the end of September 2022. Nursing Home Administrator will complete time limited waiver.
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 maintain compliance with sprinkler system regulations for one of two systems.

Findings include:

1. Document review on June 30, 2022, at 11:00 a.m., revealed the facility failed to provide documentation that the blocked check valve deficiency, noted in the February 24, 2022 sprinkler report, was corrected.

Interview with the maintenance supervisor on June 30, 2022, at 11:00 a.m., confirmed the above documentation was not available at the time of the survey.






 Plan of Correction - To be completed: 08/15/2022

The facility is working with vendor to correct the blocked check valve in the sprinkler to ensure the deficiency is corrected. The facility will have sprinkler system checks completed per regulation and will address identified concern. Facility will be in compliance before compliance date.
NFPA 101 STANDARD Corridor - Doors: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.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined that the facility failed to inspect and maintain corridor doors for one of more than 75 corridor doors.

Findings include:

1. Observation on June 30, 2022, at 12:20 p.m., revealed the first floor, ACU wing, room 117 corridor door failed to close and latch into the frame.

Interview with the maintenance supervisor on June 30, 2022, at 12:20 p.m., confirmed the above corridor door failed to close and latch into the frame.





 Plan of Correction - To be completed: 07/07/2022

The facility Maintenance Director completed service to door 117 on 7/7/22 and it is now closing and latching properly into the frame. Room 117 was added to TELS system for daily checks to ensure it is continues to close properly.
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 three levels.

Findings include:

Observation on June 30, 2022, at 12:32 p.m., revealed the fire-rated door and frame, located at the north wing ramp to the ACU wing, lacked a legible UL-approved label that identified the fire rating.

Interview with the maintenance supervisor on June 30, 2022, at 12:32 p.m., confirmed the above door and frame lacked a UL-approved label.






 Plan of Correction - To be completed: 08/15/2022

The facility is working with Vendor to recertify door and frame with UL-approved label to the north wing ramp to the ACU wing. This is anticipated to be completed prior to 8/15/22.
NFPA 101 STANDARD Electrical Systems - Other: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 - 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, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, in one of seven wings.

Findings include:

Observation on June 30, 2022, at 12:20 p.m., revealed the ACU porch had an extension cord placed in conduit to supply power to the outdoor light, which was used for flag etiquette.

Reference: NFPA 70-400.8

Interview with the maintenance supervisor on June 30, 2022, at 12:20 p.m., confirmed the above extension cord was being used for permanent wiring.







 Plan of Correction - To be completed: 07/13/2022

The facility Maintenance Director removed extension cord and placed permanent wiring to outdoor light on 7/13/22. Maintenance Director or designee will review all seven wings monthly to ensure that there is no use of extension cords.
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, it was determined that the facility failed to conduct emergency generator testing and inspections for two of two emergency generators.

Findings include:

1. Document review on June 30, 2022, at 11:20 a.m., revealed the facility failed to provide documentation that the below tests had been conducted:
A. Monthly generator battery testing for specific gravity or conductance;
B. 3-year, four-hour load test;
C. Annual fuel quality test.

Interview with the maintenance supervisor on June 30, 2022, at 11:20 a.m., confirmed the above generator deficiencies existed at the time of the survey.






 Plan of Correction - To be completed: 08/15/2022

The facility Maintenance Director will reach out to vendor to obtain annual fuel quality test results. The facility purchased necessary equipment to be able to complete the monthly generator battery testing for specific gravity or conductance. The battery will be tested by the compliance date. The facility has contacted the vendor for the 4 hour load test and it is scheduled to be completed by the compliance date. Monthly generator battery testing will be completed by Maintenance Director or Designee to remain in compliance.

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