Pennsylvania Department of Health
 EMBASSY OF HEARTHSIDE
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 HEARTHSIDE
Inspection Results For:

There are  64 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 HEARTHSIDE - 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 February 9, 2026, at Embassy of Hearthside, 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 #940502
Component 01
Main Building 01

Based on a Medicare/Medicaid Recertification Survey completed on February 9, 2026, it was determined Embassy of Hearthside 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 483.70(a).

This is a two story, Type III (211) protected, ordinary building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on observation and interview, it was determined the following item(s) did not meet the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the facility.

Findings include:

1. Observation on February 9, 2025, at 1:30 p.m., revealed the facility failed to request an occupancy inspection for the installation of the diesel generator set (drawing number H-25-0918).

Exit interview on February 9, 2026, between 1:45 p.m., and 2:00 p.m., with the Director of Nursing and the Facilities Manager, confirmed the above deficiency.







 Plan of Correction - To be completed: 03/30/2026

The occupancy inspection is scheduled for 3/6/2026.
Records will be maintained on file in the Maintenance Department.
Subsequent inspections will be scheduled and monitored via TELS preventive maintenance system.
Results will be shared at the next monthly QAPI meeting.

NFPA 101 STANDARD Multiple Occupancies: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.
Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain one common wall, affecting one of two floors.

Findings include:

1. Observation on February 9, 2026, at 11:37 a.m., revealed the distance between the second floor common wall doors with the 02 Component exceeded one-eighth-inch.

Exit interview on February 9, 2026, between 1:45 p.m., and 2:00 p.m., with the Facility Director of Nursing and the Facilities Manager, confirmed the common wall deficiency.




 Plan of Correction - To be completed: 03/30/2026

The common wall door gap was reduced to less than 1/8 inch by adjusting the door latch.
Subsequent inspections will be scheduled and monitored via TELS preventive maintenance system.
Results will be shared at the next monthly QAPI meeting.

NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in four locations, affecting two of two floors.

Findings include:

1. Observation on February 9, 2026, between 11:31 a.m., and 12:08 p.m., revealed the following:

a. 11:31 a.m., a damaged ceiling tile within the first floor Conference Room.
b. 11:39 a.m., a cut-out penetration of the rated ceiling assembly within the Dining Room.
c. 11:40 a.m., a penetration of the rated ceiling assembly, closest to the fireplace.
d. 12:08 a.m., an opening within the first floor, maintenance Office closet.

Exit interview on February 9, 2026, between 1:45 p.m., and 2:00 p.m., with the Facility Director of Nursing and the Facilities Manager, confirmed the building construction deficiencies.





 Plan of Correction - To be completed: 03/30/2026

The damaged ceiling in the conference room, dining room, fireplace area and first floor maintenance office closet were repaired with 5/8 inch firecode drywall and sealed.
Maintenance will monitor ceiling assemblies for unsealed / open penetrations made by contractors, etc and will promptly repair.
Maintenance will report any non compliance at the monthly QAPI meeting.

NFPA 101 STANDARD Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain means of egress in several locations, affecting one of two floors.

Findings include:

1. Observation on February 9, 2026, between 12:13 p.m., and 12:17 p.m., revealed illuminated exit signage, located within the first floor exit access corridor system, was installed at six feet, two inches from finished floor level in several locations.

Exit interview on February 9, 2026, between 1:45 p.m., and 2:00 p.m., with the Facility Director of Nursing and the Facilities Manager, confirmed the means of egress deficiencies.




 Plan of Correction - To be completed: 03/30/2026

The first floor exit signs were relocated to walls so as not to impede travel.
Maintenance will ensure that proper placement of exit signs in all locations and that they remain lit at all times.
Maintenance will report any non compliance at the monthly QAPI meeting.

NFPA 101 STANDARD Emergency Lighting: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.
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 documentation review and interview, it was determined the facility failed to maintain emergency lighting, affecting two of two floors.

Findings include:

1. Observation on February 9, 2026, at 1:40 p.m., revealed the facility lacked annual, ninety-minute, "bleed" or "drain" testing data of emergency lighting fixtures.

Exit interview on February 9, 2026, between 1:45 p.m., and 2:00 p.m., with the Facility Director of Nursing and the Facilities Manager, confirmed the emergency lighting deficiency.




 Plan of Correction - To be completed: 03/30/2026

On 2/25/2026 the annual 90 minute drain test was conducted on both emergency light fixtures and results were recorded.
Subsequent tests / inspections are entered into the facilities preventive maintenance system TELS.
Results of such inspections will be shared at subsequent QAPI meetings.

NFPA 101 STANDARD Vertical Openings - Enclosure: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.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain vertical openings in one location, affecting two of two floors.

Findings include:

1. Observation on February 9, 2026, at 12:02 p.m., revealed a vertical penetration of the floor slab assembly, located within the second floor, Heirloom Clean Linen Room.

Exit interview on February 9, 2026, between 1:45 p.m., and 2:00 p.m., with the Facility Director of Nursing and the Facilities Manager, confirmed the vertical opening deficiency.




 Plan of Correction - To be completed: 03/30/2026

The vertical penetration in the floor slab was sealed using 3M Fire Barrier Sealant CP 25WB+, tested in accordance with ASTM E 814 (UL1479) and ASTM E 84 (UL723).
Maintenance will monitor for unsealed / open penetrations made by contractors, etc and will promptly seal / repair.
Maintenance will report any non compliance at the monthly QAPI meeting.

NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain two hazardous area enclosures, affecting one of two floors.

Findings include:

1. Observation on February 9, 2026, between 11:35 a.m., and 12:01 p.m., revealed the following:

a. 11:35 a.m., the second floor, Soiled Utility Room door was not smoke-tight.
b. 12:01 p.m., the Four Seasons Room housed storage and lacked a self-closing device.

Exit interview on February 9, 2026, between 1:45 p.m., and 2:00 p.m., with the Facility Director of Nursing and the Facilities Manager, confirmed the hazardous area enclosure deficiencies.




 Plan of Correction - To be completed: 03/30/2026

The soiled utility room door gap was reduced to less than 1/8 inch by adjusting the door latch and adding foam weather strip.
A self closing device was added to the Four Seasons Room.
Maintenance will monitor door gaps / compliance on all smoke doors and will report any non-compliance at the monthly QAPI meeting.

NFPA 101 STANDARD Sprinkler System - Installation: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.
Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0351

Based on observation and interview, it was determined the facility failed to install automatic sprinkler protection in one location, affecting one of two floors.

Findings include:

1. Observation on February 9, 2026, at 12:38 p.m., revealed the Staff Lounge locker area lacked automatic sprinkler protection.

Exit interview on February 9, 2026, between 1:45 p.m., and 2:00 p.m., with the Facility Director of Nursing and the Facilities Manager, confirmed the automatic sprinkler system deficiency.




 Plan of Correction - To be completed: 03/30/2026

On 2/24/2026 a sprinkler head was located in the staff lounge locker area.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in three locations, affecting one of two floors.

Findings include:

1. Observation on February 9, 2026, between 11:33 a.m., and 11:50 a.m., revealed the following:

a. 11:33 a.m., a corroded sprinkler head assembly at the Main Entrance area.
b. 11:36 a.m., an escutcheon plate was missing within the Beaver Med Room.
c. 11;50 a.m., an escutcheon plate was missing within the TV Room.

Exit interview on February 9, 2026, between 1:45 p.m., and 2:00 p.m., with the Facility Director of Nursing and the Facilities Manager, confirmed the automatic sprinkler system deficiencies.





 Plan of Correction - To be completed: 03/30/2026

On 3/3/2026 Liberty Fire been contracted to replace the corroded sprinkler head assembly in the Main Entrance area, install escutcheon plates in the Beaver Med room and the TV room.
Maintenance will, in conjunction with subsequent sprinkler system inspections, monitor compliance and will report findings to QAPI.

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 observation and interview, it was determined the facility failed to maintain portable fire extinguishers in five locations, affecting two of two floors.

Findings include:

1. Observation on February 9, 2026, between 11:34 a.m., and 1:22 p.m., revealed the following:

a. 11:34 a.m., the fire extinguisher cabinet bulb, located closest to Resident Room 204, was not illuminated.
b. 11:38 a.m., a fire extinguisher was located on the floor within the Beaver Med Room.
c. 11:48 a.m., the fire extinguisher cabinet bulb, located within the Heirloom Dining Hall, was not illuminated.
d. 12:09 p.m., the fire extinguisher located within the Activities Office, had not been inspected past 11/2025.
e. 12:27 p.m., the fire extinguisher located closest to Human resources had not been inspected past 11/2025

Exit interview on February 9, 2026, between 1:45 p.m., and 2:00 p.m., with the Facility Director of Nursing and the Facilities Manager, confirmed the portable fire extinguisher deficiencies.





 Plan of Correction - To be completed: 03/30/2026

Fire extinguisher light bulbs were replaced above the cabinet closest to room 204 and the Heirloom Dining Hall.
Extinguishers in Activities Office and Human Resources were inspected and passed inspection. Monthly inspection of fire extinguishers is in the facilities preventive maintenance system, TELS.
The extinguisher on the floor in the Bever Med room was mounted on a hanger.

NFPA 101 STANDARD Corridor - 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.
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 openings in two locations, affecting two of two floors.

Findings include:

1. Observation on February 9, 2026, between 11:40 a.m., and 1:10 p.m., revealed the following:

a. 11:40 a.m., the Nourishment Center door, located within Beaver, was held open by unapproved means.
c. 1:10 p.m., the Dietary door was held open by unapproved means.

Exit interview on February 9, 2026, between 1:45 p.m., and 2:00 p.m., with the Facility Director of Nursing and the Facilities Manager, confirmed the corridor opening deficiencies.






 Plan of Correction - To be completed: 03/30/2026

Maintenance cleared both the Nourishment Center door and the Dietary door of unapproved means of held open.
Dietary staff were educated on no holding doors open by unapproved means.
Maintenance will continue to monitor and will report findings to QAPI.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain one smoke barrier separation door, affecting one of two floors.

Findings include:

1. Observation on February 9, 2026, at 11:59 a.m., revealed the Heirloom smoke barrier separation door exhibited damaged hardware.

Exit interview on February 9, 2026, between 1:45 p.m., and 2:00 p.m., with the Facility Director of Nursing and the Facilities Manager, confirmed the smoke barrier separation door deficiency.




 Plan of Correction - To be completed: 03/30/2026

The damaged hardware on the Heirloom Smoke Barrier door was replaced on 2/18/2026.
Maintenance will continue to monitor during annual door inspections and will report findings to QAPI.

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 documentation review and interview, it was determined the facility failed to maintain fire door testing, affecting two of two floors.

Findings include:

1. Observation on February 9, 2026, at 1:35 p.m., revealed the facility lacked required annual fire door functional and visual testing data.

Exit interview on February 9, 2026, between 1:45 p.m., and 2:00 p.m., with the Facility Director of Nursing and the Facilities Manager, confirmed the fire door deficiencies.





 Plan of Correction - To be completed: 03/30/2026

On 2/27/2026 the maintenance director was trained on proper inspection of fire door functional and visual testing.
Forms for inspection of each door will be maintained in maintenance.
Annual testing of fire door functional and visual testing has been scheduled in the facilities preventive maintenance system, TELS.
Maintenance will report findings at QAPI.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000


Facility ID #940502
Component 02
Building 02

Based on a Medicare/Medicaid Recertification Survey completed on February 9, 2026, it was determined Embassy of Hearthside 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 483.70(a).

This is a two story, Type II (222), fire resistive building, that is fully sprinklered.




 Plan of Correction:


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: BUILDING 02 - Component: 02 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers in one location, affecting one of two floors.

Findings include:

1. Observation on February 9, 2026, at 1:22 p.m., revealed the portable fire extinguisher, located within the first floor, Laundry Soiled, had not been checked past 11/2025.

Exit interview on February 9, 2026, between 1:45 p.m., and 2:00 p.m., with the Facility Director of Nursing and the Facilities Manager, confirmed the portable fire extinguisher deficiency.





 Plan of Correction - To be completed: 03/30/2026

Extinguisher in first floor soiled laundry area was inspected and tagged.
Monthly inspection of fire extinguishers is scheduled and monitored via the preventive maintenance system, TELS.
Maintenance will continue to monitor and report findings to monthly QAPI meetings.

NFPA 101 STANDARD Corridor - 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.
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: BUILDING 02 - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor openings in one location, affecting one of two floors.

Findings include:

1. Observation on February 9, 2026, at 11:58 a.m., revealed the Resident Laundry required adjustment to fully latch.

Exit interview on February 9, 2026, between 1:45 p.m., and 2:00 p.m., with the Facility Director of Nursing and the Facilities Manager, confirmed the corridor opening deficiency.




 Plan of Correction - To be completed: 03/30/2026

On 2/25/2026 the latch on the resident laundry room was adjusted to ensure positive latch.
Maintenance will monitor all appropriate doors for self latching via TELS preventive maintenance system.
Results will be reported at Monthly QAPI 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