Pennsylvania Department of Health
SCENERY HILL HEALTHCARE AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 39 surveys for this facility. Please select a date to view the survey results.

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SCENERY HILL HEALTHCARE AND REHABILITATION 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 April 30, 2025, at Scenery Hill Healthcare and Rehabilitation 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 #192202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 30, 2025, it was determined that Scenery Hill Healthcare and Rehabilitation 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 one-story, Type V (000), unprotected, wood frame building, with two small basements, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Emergency Lighting:

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.

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 observation and interview, the facility failed to maintain emergency lighting, affecting one of more than ten emergency lights.

Findings include:

Observation on April 30, 2025, at 12:35 p.m., revealed the first floor employee entrance battery back-up emergency light unit did not illuminate when the test button was pushed.

Interview with the administrator on April 30, 2025, at 12:35 p.m., confirmed the emergency lighting deficiency.

Plan of Correction - To be completed: 06/03/2025

1. We had previously ordered a new battery for this unit, and it was immediately replaced when it was received the next morning. All other emergency lights were checked, and no other issues were found. A systemic check of the batteries to be replaced annually will be added to the electronic maintenance work order program; TELS, so these batteries are replaced on a routine schedule. The Director of Maintenance will monitor the monthly checklist that will include the emergency lights so that no further issues recur.

2. The Nursing Home Administrator (NHA) will audit the monthly checklist to ensure compliance for the next three months. Results of these audits will be reported to the Quality Assurance Performance Improvement Committee for approval or, in the case of negative results, suggestions for additional action. The date that the corrective action will be completed is June 3, 2025.

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, observation, and interview, the facility failed to meet fire alarm system requirements, affecting one of one system.

Findings include:

1. Document review on April 30, 2025, at 10:10 a.m., revealed the facility failed to provide an annual, functional fire alarm inspection/testing report that was completed within the previous twelve months.

Interview with the administrator on April 30, 2025, at 10:10 a.m., confirmed the documentation was unavailable at the time of the survey.
2. Observation on April 30, 2025, at 12:45 p.m., revealed the basement fire alarm panel displayed a "communication trouble" signal. The panel also was not communicating with the auxiliary panel at first floor nurse station.
Interview with the administrator on April 30, 2025, at 12:45 p.m., confirmed the fire alarm panel displayed a trouble signal.

Plan of Correction - To be completed: 06/03/2025

1. The annual fire alarm report that includes the functional fire alarm inspection and testing was requested from the vendor that performed that specific work. That report was received and will be cataloged. The electronic maintenance work order program will be changed to include not only the quarterly report required but also the annual inspection / testing report. These reports will be cataloged in a binder so they are available at anytime as necessary. The fire alarm panel that was reading "communication trouble" was immediately reported to the monitoring company who came out the following day to provide a bid on performing the necessary repair work. The monitoring company and the three local fire companies that respond to the facility all reported, upon testing, that trouble signals were being received even though the panel at the nursing station was not showing the specific area of a potential fire but was showing the fire alarm itself. Additional clauses are being added to the monitoring contract to include facility and administrator notification in the event of a communication error.

2. The Director of Maintenance will monitor the monthly TELS report to ensure that the quarterly and annual reports alert as needed in the specific months required. The NHA will audit the monthly TELS report for the next three months to ensure that the reports alert as necessary for quarterly and annual report requirements. Once received, the quote for the work to repair the communication trouble signal will be scheduled immediately. Upon completion of the work, the NHA will audit the alarm panel daily for 5 days, weekly for three weeks and monthly for one month to ensure

compliance. The results of both of these audits will be reported to the Quality Assurance Performance Improvement Committee for approval or, in the case of negative results, suggestions for additional action. The date that the corrective action will be completed is June 3, 2025.

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 document review and interview, the facility failed to maintain one of one essential electrical system.

Findings include:

Document review on April 30, 2025, at 11:00 a.m., revealed the facility failed to provide documentation for monthly battery conductance tests occurring during the previous twelve months.

Interview with the administrator on April 30, 2025, at 11:00 a.m., confirmed the monthly battery testing documentation was unavailable at the time of the survey.

Plan of Correction - To be completed: 06/03/2025

1. While the tests were completed monthly, the facility does not have a meter with printable results. The facility contacted Grainger to provide specifications on a new meter that will print results, weather on-screen or paper. This meter will be purchased and used going forward. Once purchased, this will no longer be an issue.

2. The Director of Maintenance will train the maintenance technicians on the use of the new meter. The director will also audit the results weekly for the next four weeks to ensure compliance. . Results of these audits will be reported to the Quality Assurance Performance Improvement Committee for approval or, in the case of negative results, suggestions for additional action. The date that the corrective action will be completed is June 3, 2025.

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