Pennsylvania Department of Health
IVY HILL POST ACUTE NURSING & REHABILITATION LLC
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


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 53 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.


IVY HILL POST ACUTE NURSING & REHABILITATION LLC - 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 March 31, 2025, it was determined that Ivy Hill Post Acute Nursing and Rehabilitation had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(d)(2), 416.54(d)(2), 418.113(d)(2), 441.184(d)(2), 482.15(d)(2), 483.475(d)(2), 483.73(d)(2), 484.102(d)(2), 485.542(d)(2), 485.625(d)(2), 485.68(d)(2), 485.727(d)(2), 485.920(d)(2), 486.360(d)(2), 491.12(d)(2), 494.62(d)(2) STANDARD EP Testing Requirements:

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.

§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).

*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:

(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:

(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.

*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.

(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.

*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.

*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.

*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.

*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.

*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.

*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.

*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.

Observations:
Name: - Component: -- - Tag: 0039

Based on document review and interview, it was determined the facility failed to conduct the required annual-full scale exercise and additional exercise to test the emergency preparedness plan, affecting the entire facility.

Findings include:

1. Document review on March 31, 2025, at 1:15 p.m., revealed the facility failed to conduct the required annual-full scale exercise and additional exercise to test the emergency preparedness plan within the previous 12 months.

Exit Interview with the Administrator and Maintenance Director on March 31, 2025, at 2:00 p.m., confirmed the missing documentation.

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

Facility ID #591902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 31, 2025, it was determined that Ivy Hill Post Acute Nursing and Rehabilitation, LLC, was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 three-story, Type II (222), fire resistive building, that is fully sprinklered.

Plan of Correction:

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 observation, document review, and interview, it was determined the facility failed to maintain fire alarm system components in operable condition, affecting the entire facility.
Findings Include:
1. Documentation reviewed on March 31, 2025, between 8:00 a.m. and 10:30 a.m., revealed the fire alarm report Annual dated November 26, 2024, listed a single deficiency.
a) "Battery panel Fail".
2. Documentation reviewed on March 31, 2025, between 8:00 a.m. and 10:30 a.m., revealed the semi-annual fire alarm report dated May 24, 2024, listed four system deficiencies.
a) Duct Detector - 3rd Hallway by 316
b) Duct Detector - 3rd Room 311
c) Duct Detector - 3rd Room 316
d) Duct Detector - 3rd Room 319
3. Documentation reviewed on March 31, 2025, between 8:00 a.m. and 10:30 a.m., revealed the fire alarm report Annual dated November 26, 2024, revealed 5 pages of untested devices. Totaling 203 untested devices, including pull stations and horn/strobes. Review of the semi annual report dated May 24, 2024, did not confirm testing of the 203 devices prior, leading to uncertainty that complete testing of ALL facility devices occurred within the calendar year. Semi annual report noted testing and passing of monitored devices that were visually confirmed not to exist inside of the facility at time of survey.
Exit Interview with the Administrator and the Director of Maintenance on March 31, 2025, at 2:00 p.m., confirmed verifications of repairs were not available at the time of survey and the incorrect data reporting of devices tested annually.

Plan of Correction - To be completed: 05/17/2025

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

1. There were no adverse effects to residents or staff. Fire Safety Vendor has been scheduled to complete the following: correct the "battery panel fail" deficiency. Repair the duct detectors in the 3rd Hallway by 316, 3rd Room 311, 3rd Room 316, and 3rd Room 319. Perform annual and semi-annual fire alarm system tests.

2. The maintenance director audited the battery panels and duct detectors in the facility to ensure there were no deficiencies noted.

3. Maintenance Director was in-serviced on maintaining compliance with annual and semi-annual fire alarm system testing and ensuring deficiencies cited on annual and semi-annual fire alarm system reports are corrected timely.

4. Maintenance Director/Designee will audit the following for correct function weekly x 4 and then monthly x2 to ensure no deficient practice is occurring: battery panel, duct detectors(random), and fire alarm inspection reports. Results will be reviewed in QA monthly x3.

NFPA 101 STANDARD Portable Fire Extinguishers:

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.

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 document review and interview, it was determined the facility failed to maintain and inspect portable fire extinguishers, affecting 7 out of 23 extinguishers.

Findings include:

Document review on March 31, 2025, between 8:00 a.m., and 10:30 a.m., revealed the facility annual service report dated March 28, 2024, reported 7 failures.

Exit interview with the Administrator and Maintenance Director on March 31, 2025, at 2:00 p.m., confirmed the fire extinguishers needed replacement.

NFPA 101 STANDARD Utilities - Gas and Electric:

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting one of three levels.

Findings include:

1. Observation on March 31, 2025, at 1:35 p.m., revealed, in 2nd floor Med Prep Room, there was one non GFCI outlet located within 6 feet of a sink. Per NFPA 70 210.8(B)5, a GFCI outlet is required where receptacles are installed within 6 ft of the outside edge of the sink.

Exit Interview with the Administrator and Maintenance Director on March 31, 2025, at 2:00 pm, confirmed the unprotected outlet.

Plan of Correction - To be completed: 05/17/2025

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

1. There were no adverse effects to residents or staff. The non GFCI outlet located within 6 feet of the sink on the 2nd floor Med Prep Room was replaced with a GFCI outlet.

2. Outlets within 6 feet of a sink were checked to ensure that they were a GFCI outlet.

3. The Maintenance Director was in-serviced on ensuring that outlets within 6 feet of a sink is a GFCI outlet.

4. The Maintenance Director/designee will conduct a random audit of outlets within 6 feet of a sink, to ensure they are GFCI outlets weekly x 4 and then monthly x 2. Results will be reviewed in QA monthly x3.

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility failed to maintain inspection of Heating, Ventilating and Air Conditioning (HVAC) equipment at required intervals, affecting one damper.

Findings include:

1. Document review on March 31, 2025, between 8:00 a.m. and 10:30 a.m., revealed the March 28, 2024, fire damper inspection report listed 12 of 97 untested. Documentation and date of last complete 4 year exercise not available for review.

Exit interview with the Administrator and Maintenance Director on March 31, 2025, at 2:00 p.m., confirmed the complete facility damper exercising information was not available to review at time of survey.

Plan of Correction - To be completed: 05/17/2025

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

1. There were no adverse effects to residents or staff. Fire damper inspection has been scheduled to be tested and the 4 year damper exercise has been scheduled to be completed by vendor.

2. Maintenance Director has been in serviced on ensuring all fire dampers are tested during inspections and 4 year damper exercises are completed timely, with documentation efficiently maintained.

3. Maintenance Director/designee will audit the Facility's Inspection Binder monthly x3 to ensure inspections are up to date and readily available.

4. Results will be reviewed in QA monthly x3.

NFPA 101 STANDARD Fire Drills:

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to ensure fire drills were conducted quarterly for nine of twelve required drills.

Findings include:

Document review on March 31, 2025, between 8:00 a.m and 10:45 a.m., revealed that fire drills had not been conducted for calendar year 2024, quarter two, three, and four. First quarter, January thru March 2025 provided at survey.

Exit Interview with the Administrator and Maintenance Director on March 31, 2025, at 2:00 p.m., confirmed the missing fire drills.

Plan of Correction - To be completed: 05/17/2025

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

1. There were no adverse effects to residents or staff. Fire drills will be held at least quarterly on each shift in accordance with NFPA 101.

2. The Maintenance Director/Designee created a monthly schedule to conduct fire drills to ensure facility remains compliant.

3. Maintenance Director was in-serviced on ensuring that fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift in accordance with NFPA 101 and that documentation is properly maintained.

4. Maintenance Director or designee will conduct a monthly audit x3 to ensure that fire drills are held at the scheduled dates/shifts, in accordance with NFPA 101 and that documentation is properly maintained. Results will be reviewed in QA monthly x3.

NFPA 101 STANDARD Electrical Systems - Other:

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, on one of three levels of the facility.

Findings include:

1. Observation on March 31, 2025, between 10:30 a.m. and 2:00 p.m., revealed the following electrical deficiencies:

a) First floor, Inside kitchen, deep well electrical box, capped wiring, without cover, wrapped in duct tape.
b) First floor, Inside kitchen, surface mounted duplex, anchors pulling away from wall.
c) First floor, lobby, above ceiling at stairs and elevators, two open junction boxes above ceiling grid.

Reference: NFPA 70-314.17, NFPA 70-314.28 (C), and NFPA 300.11

Exit interview with the Administrator and Regional Maintenance Director on March 31, 2025, at 2:00 p.m., confirmed the above electrical system deficiencies.

Plan of Correction - To be completed: 05/17/2025

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

1. Maintenance Director removed the duct tape and added a cover plate to the first floor inside kitchen deep well electrical box. Maintenance Director resecured the surface mounted duplex with new anchors. Maintenance Director closed the 2 open junction boxes above the ceiling grid with 1900 cover plates.

2. Maintenance Director completed an initial audit to ensure that all deep well electrical boxes, surface mounted duplexes, and junction boxes are in good condition.

3. Maintenance Director was in-serviced on proper electrical system maintenance of deep well electrical boxes, surface mounted duplexes, and junction boxes.

4. Maintenance Director or designee will randomly audit deep well electrical boxes, surface mounted duplexes, and junction boxes for proper system maintenance weekly x 4 and then monthly x 4. Results will be reviewed in QAPI.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of electrical devices affecting one of three levels.

Findings include:

Observations on March 31, 2025, revealed the following electrical deficiencies:

a) 11:30 a.m., on the first floor, RNAC office-fridge and microwave plugged into power strip.
b). 11:45 a.m., on the first floor, unit manager-fridge and microwave plugged into power strip.

Exit Interview with the Administrator and Maintenance Director on March 31, 2025, at 2:00 p.m., confirmed the unauthorized electrical devices.

Plan of Correction - To be completed: 05/17/2025

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

1. There were no adverse effects to residents or staff. The power strip in the RNAC office and the power strip in the first-floor unit manager office were removed.

2. Department Managers' offices were audited to ensure there were no unauthorized electrical devices in use.

3. Department managers were in-serviced on not using unauthorized electrical devices.

4. Maintenance Director/designee will randomly audit department managers' offices to ensure no unauthorized electrical devices are being used weekly x 4 and then monthly x 4. Results will be reviewed in QAPI.

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