Pennsylvania Department of Health
SPRING HILL REHABILITATION AND NURSING CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 37 surveys for this facility. Please select a date to view the survey results.

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SPRING HILL REHABILITATION AND NURSING 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 29, 2024, it was determined that Spring Hill Rehabilitation and Nursing Center, was not in compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:

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.

§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.

Observations:
Name: - Component: -- - Tag: 0004

Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to review and update their emergency plan at least annually.

Findings include:

1. Interview and documentation review on April 29, 2024, at 8:30 a.m., revealed the Emergency Preparedness Plan was not updated in over 12 months.

Interview with the Facility Administrator and Maintenance Director on April 29, 2024, at 11:30 a.m., confirmed the EP plan was not reviewed and updated at least annually.

Plan of Correction - To be completed: 06/17/2024

1. There were no negative outcomes due to the emergency preparedness plan.
2. The facility emergency preparedness plan will be updated.
3. The emergency preparedness plan will be audited by NHA/Designee monthly for four months.
4. Results returned to QAPI for review.

403.748(c)(1), 416.54(c)(1), 418.113(c)(1), 441.184(c)(1), 482.15(c)(1), 483.475(c)(1), 483.73(c)(1), 484.102(c)(1), 485.542(c)(1), 485.625(c)(1), 485.68(c)(1), 485.727(c)(1), 485.920(c)(1), 486.360(c)(1), 491.12(c)(1), 494.62(c)(1) STANDARD Names and Contact Information:

§403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1).

[(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:]

(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [facilities].
(v) Volunteers.

*[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [hospitals and CAHs].
(v) Volunteers.

*[For RNHCIs at §403.748(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Next of kin, guardian, or custodian.
(iv) Other RNHCIs.
(v) Volunteers.

*[For ASCs at §416.45(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For Hospices at §418.113(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Hospice employees.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Other hospices.

*[For HHAs at §484.102(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For OPOs at §486.360(c):] The communication plan must include all of the following:
(2) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Volunteers.
(iv) Other OPOs.
(v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA).

Observations:
Name: - Component: -- - Tag: 0030

Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to include names and contact information.

Findings include:

1. Interview and documentation review on April 29, 2024, at 8:50 a.m., revealed the EP Plan did not include updated and accurate names and contact information for residents and residents physicians contact information.

Interview with the Facility Administrator and Maintenance Director on April 29, 2024, at 11:30 a.m., confirmed the EP Communication Plan lacked accurate residents and physicians contact information.

Plan of Correction - To be completed: 06/17/2024

1. There were no negative outcomes due to out-of-date names and contact information.
2. The emergency preparedness plan will be updated to have accurate names and physician contact information.
3. This is to be audited by the NHA/Designee once monthly for four months.
4. Results returned to QAPI for review.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 192902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 29, 2024, it was determined that Spring Hill Rehabilitation and Nursing 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 II (222), fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Cooking Facilities:

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.

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on observation and interview, it was determined the facility failed to properly install and maintain equipment protected by the kitchen hood extinguishing system in one instance, affecting one of seven smoke compartments.

Findings Include:

1. Observation on April 29, 2024, at 10:00 a.m., revealed a gas-fired range and an oven on wheels, in the main kitchen, was not provided with an approved method that would ensure the appliance was returned to an approved design location after it had been moved for maintenance and cleaning, as required by section 12.1.2.3 and 12.1.2.3.1 of NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

Interview with the Facility Administrator and Maintenance Director on April 29, 2024, at 11:30 a.m., confirmed the gas-fired cooking appliance was not tethered in a way so it could not be moved from the ventilation hood and gas connection.

Plan of Correction - To be completed: 06/17/2024

1. There were no negative outcomes due to an untethered gas-fire range stove.
2. The gas-fire range stove will be corrected and tethered appropriately.
3. Gas-fire range stove to be audited by NHA/Designee for correct tether once weekly for four weeks.
4. Results returned to QAPI for review.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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 documentation review and interview, it was determined the facility failed to maintain the fire alarm system, in one instance, affecting the entire facility

Findings Include:

1. Review of documentation on April 29, 2024, at 8:30 a.m., revealed the facility lacked documentation for the semi-annual fire alarm inspection.

Interview with the Facility Maintenance Director on April 29, 2024, at 8:30 a.m., confirmed the fire alarm system deficiency.

Plan of Correction - To be completed: 06/17/2024

1. There were no negative outcomes due to a missed semi-annual fire alarm inspection.
2. The facility fire alarm system will be tested again.
3. The fire alarm system test will be audited by the NHA/Designee every month for four months.
4. Results returned to QAPI for review.

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 documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in two instances, affecting the entire facility.

Findings include:

1. Review of documentation and observation on April 29, 2024, revealed the following:

a) 8:45 a.m., the facility lacked documentation that the 5 year internal obstruction inspection was performed;
b) 9:00 a.m., there was an unsealed ceiling penetration in the elevator machine room in the basement.

Interview with the Facility Administrator and Maintenance Director on April 29, 2024, at 11:30 a.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 06/17/2024

1. There were no negative outcomes related to sprinkler system maintenance and testing.
2. The five-year internal obstruction inspection will be performed.
3. The ceiling penetration in elevator maintenance room in the basement will be corrected.
4. Ceiling penetration area and internal obstruction inspection results will be audited once a month for four months by NHA/Designee.
5. Results returned to QAPI for review.

NFPA 101 STANDARD Corridor - Doors:

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 the facility failed to maintain corridor doors that would resist the passage of smoke or fire, in two instances, affecting two of the seven smoke compartments surveyed.

Findings Include:

1. Observation on April 29, 2024, revealed the following corridor doors had multiple penetrations around the door handles:

a) 9:20 a.m. the door to the Activities Room on the second floor;
b) 9:35 a.m., the door to Room 112.

Interview with the Facility Administrator and Maintenance Director on April 29, 2024, at 11:30 a.m., confirmed the multiple penetrations around the door handles.

Plan of Correction - To be completed: 06/17/2024

1. There were no negative outcomes related to doors in the facility.
2. The penetrations on the activity room door on the second floor will be corrected.
3. The penetrations on room 112 door will be corrected.
4. NHA/Designee to audit random doors weekly for four weeks.

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 documentation review and interview, it was determined the facility failed to maintain emergency generator maintenance testing documentation, in three instances, affecting the entire facility.

Findings include:

1. Review of documentation on April 29, 2024, at 8:45 a.m., revealed the facility lacked documentation verifying that the following items were performed in the last 12 and months:

a) 8:30 a.m., the annual 90-minute load bank;
b) 8:45 a.m., the annual preventitive maintenance;
c) 8:50 a.m., the annual fuel quality test.

Interview with the Facility Administrator and Maintenance Director, on April 29, 2024, at 8:50 a.m., confirmed the required annual generator testing documentation was not available at the time of the survey.

Plan of Correction - To be completed: 06/17/2024

1. There were no negative outcomes related to the facility electrical systems maintenance.
2. Annual 90 minute load bank test to be completed.
3. Annual preventative maintenance to be completed.
4. Annual fuel quality test to be completed.
5. Results to be audited by NHA/Designee once every month for four months.
6. Results returned to QAPI for review.

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