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  58 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 April 10, 2024, at Embassy at 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 April 10, 2024, 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 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, in two instances, affecting one of two floors.

Findings include:

1. Observation on April 10, 2024, between 10:55 a.m., and 10:56 a.m., revealed the following:

10:55 a.m., the first floor, common wall door within the 02 Building, required adjustment to fully latch.
10:56 a.m., a penetration of the first floor common wall within the 02 Building, located above the common wall doors.

Exit interview on April 10, 2024, at 12:30 p.m., with the Facility Administrator and the Facilities Manager, confirmed the common wall deficiencies.



 Plan of Correction - To be completed: 05/14/2024

Adjusted the door mechanism to ensure that it fully latches when closed and verified that the door operates smoothly closed without any resistance or misalignment.
Filled the penetration hole above first floor common wall door with 3M Fire Barrier Sealant (CP25WB+).
2,. Verified remaining doors operate smoothly without any resistance or misalignment.
3. Educated the maintenance director was completed on the regulations

4. Monthly inspections will be performed to the doors to assure fully latches are closed and verified that the door operates smoothly without any resistance or misalignment.
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 one location, affecting one of two floors.

Findings include:

1. Observation on April 10, 2024, at 11:07 a.m., revealed the monolithic portion of the rated ceiling assembly was sealed in two locations with a vinyl-like material, located within the second floor Nurse's Station.

Exit interview on April 10, 2024, at 12:30 p.m., with the Facility Administrator and the Facilities Manager, confirmed the building construction deficiencies.



 Plan of Correction - To be completed: 05/14/2024

Removed the vinyl material used for sealing from the identified locations.
Replaced the removed vinyl material with appropriately sized drywall patches that match the surrounding ceiling assembly.
2.Review of other areas was performed to assure no vinyl like material was used for the ceiling
3. The maintenance director has been educated on the regulations regarding appropriate material for replacement for celling
4. The Maintenance Director or designee will audit weekly random areas to assure proper materials are used for sealed ceilings

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 one vertical opening, affecting one of two floors.

Findings include:

1. Observation on April 10, 2024, at 10:45 a.m., revealed the first floor, communicating stair door, was not fire-tight.

Exit interview on April 10, 2024, at 12:30 p.m., with the Facility Administrator and the Facilities Manager, confirmed the vertical opening deficiency.



 Plan of Correction - To be completed: 05/14/2024

Adjusted the hinges of the first-floor communicating stair door to ensure proper alignment and tight closure.
2. Verified that the adjustments made to the hinges stair doors in the facility resulted had a tight seal when the door is closed, preventing the passage of fire and smoke.
3. Provided training to maintenance staff on proper door maintenance techniques, including the adjustment of hinges to ensure fire safety compliance.
4. Continue conducting monthly fire door inspections as per standard protocol with integrated training provided on fire door maintenance and inspection techniques.


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 hazardous area enclosures, in three locations, affecting two of two floor.

Findings include:

1. Observation on April 10, 2024, between 10:41 a.m., and 11:25 a.m., revealed the following:

a. 10:41 a.m., the first floor, Housekeeping Storage Room door lacked a self-closing device.
b. 10:43 a.m., the first floor Activities Office/Storage Room door lacked a self-closing device and was not smoke-tight.
c. 11:25 a.m., the second floor, Beaver Soiled Utility Room door was not smoke-tight.

Exit interview on April 10, 2024, at 12:30 p.m., with the Facility Administrator and the Facilities Manager, confirmed the hazardous area enclosure deficiencies.




 Plan of Correction - To be completed: 05/14/2024

Cleared Room 132 of any stored items, including furniture, equipment, supplies, or materials not essential to its designated purpose.
2.Inspected and cleaned rooms on Nittany to ensure compliance with this regulation, items not stored in resident care areas.
2. Educated staff members and departments to prevent future misuse of Room 132 and similar spaces on Nittany units and occupied resident rooms
3. Maintenance will conduct weekly checks on Nittany units and unoccupied resident are areas to verify ongoing compliance, ensuring it remains free from unauthorized storage and is maintained in a clean and organized state.

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 three locations, affecting one of two floors

Findings include:

1. Observation on April 10, 2024, between 11:09 a.m., and 11:13 a.m., revealed the following:

a. 11:09 a.m., penetrations of the second floor, RR4 door.
b. 11:10 a.m., second floor, Nourishment door required adjustment to fully latch.
c. 11:13 a.m., second floor, ARNAC office door was not smoke-tight.

Exit interview on April 10, 2024, at 12:30 p.m., with the Facility Administrator and the Facilities Manager, confirmed the corridor opening deficiencies.




 Plan of Correction - To be completed: 05/14/2024

Adjusted the doors mechanism to ensure that they both fully latch when closed and verified that the doors operates smoothly without any resistance or misalignment.
Inspected other doors to assure they latched properly

2. Educated staff on how to identify issues with door latching mechanisms and take appropriate corrective action.
3. Monthly inspections will be performed to all doors to prevent recurrence of latch issues.

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


Facility ID #940502
Component 02
Main Building 02

Based on a Medicare/Medicaid Recertification Survey completed on April 10, 2024, 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 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: BUILDING 02 - Component: 02 - Tag: 0211

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

Findings include:

1. Observation on April 10, 2024, at 11:33 a.m., revealed the area between the University stair tower discharge location, and the common way, was compromised due to various carts, etc.

Exit interview on April 10, 2024, at 12:30 p.m., with the Facility Administrator and the Facilities Manager, confirmed the means of egress deficiency.



 Plan of Correction - To be completed: 05/14/2024

1. Cleared the area between the University stair tower discharge location and the common way of all carts, debris, and other obstructions .
2. Performed inspections on all discharge areas and promptly removed any obstructions and debris.
3. Educated staff on the importance of keeping exits free from any obstacles or debris.
4. Implemented weekly monitoring by maintenance to ensure compliance with the established guidelines.

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: BUILDING 02 - Component: 02 - Tag: 0321

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

Findings include:

1. Observation on April 10, 2024, at 11:23 a.m., revealed the 132 Resident Room is presently used as a storage room, and lacked a self-closing device.

Exit interview on April 10, 2024, at 12:30 p.m., with the Facility Administrator and the Facilities Manager, confirmed the hazardous area enclosure deficiency.




 Plan of Correction - To be completed: 05/14/2024

1. Cleared Room 132 of any stored items, including furniture, equipment, supplies, or materials not essential to its designated purpose.
2.Additionally, inspected and cleaned all resident rooms to ensure compliance with this regulation.
3. Educated staff members and departments to prevent future misuse of Room 132 and similar resident room spaces.
4. Maintenance will conduct weekly checks on resident rooms to verify ongoing compliance, ensuring it remains free from unauthorized storage and is maintained in a clean and organized state.


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 one corridor opening, affecting one of two floors.

Findings include:

1. Observation on April 10, 2024, at 11:20 a.m., revealed the second floor, Dining Room/Lounge door, required adjustment to fully latch.

Exit interview on April 10, 2024, at 12:30 p.m., with the Facility Administrator and the Facilities Manager, confirmed the corridor opening deficiency.



 Plan of Correction - To be completed: 05/14/2024

1. Adjusted the door mechanism to ensure that it fully latches when closed and verified that the door operates smoothly without any resistance or misalignment.
2.Inspected other doors and assured the latched and operated with a full latch
3 Educated staff on how to identify issues with door latching mechanisms and take appropriate corrective action.
4. Monthly inspections will be performed to all doors to prevent recurrence of latch issues.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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: BUILDING 02 - Component: 02 - Tag: 0918

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

Findings include:

1. Observation on April 10, 2024, at 11:31 a.m., revealed the remote annunciator was located at the first floor, unoccupied Nurse's Station.

Exit interview on April 10, 2024, at 12:30 p.m., with the Facility Administrator and the Facilities Manager, confirmed the emergency generator deficiency.



 Plan of Correction - To be completed: 05/14/2024

1. Coordinated with Alta Protection Services and scheduled a visit to quote the relocation of the remote annunciator.
2. Maintenance will oversee the installation of the remote annunciator at the University nurses station on the second floor ensuring that the annunciator will be installed in an area that is occupied 24/7.
3. Conduct thorough testing of the relocated annunciator to verify functionality and ensure it effectively communicates alerts and alarms.
4. Provide training to staff on the new location of the remote annunciator and how to respond to alerts and alarms effectively.
5. Weekly inspections will be performed to ensure the annunciator is functioning properly


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