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

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
OAK HILL CENTER FOR REHABILITATION AND NURSING
Inspection Results For:

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OAK HILL CENTER FOR REHABILITATION AND NURSING - 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 January 8, 2024, it was determined that Oak Hill Center for Rehabilitation and Nursing had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.



 Plan of Correction:


403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

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

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

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

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

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

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

Based on document review and interview, it was determined the facility failed to provide documentation verifying the emergency preparedness plan had been reviewed within the previous twelve months, affecting the entire component.

Findings include:

1. Review of documentation on January 8, 2024, at 9:00 AM, revealed the facility failed to provide documentation verifying the emergency preparedness plan had been reviewed since April 12, 2018.

Interview with the Director of Facilities on January 8, 2024, at 9:00 AM, confirmed the lack of documentation verifying the emergency preparedness plan had been reviewed within the previous twelve months.





 Plan of Correction - To be completed: 03/15/2024

1. QAPI Committee will systematically review the Emergency Preparedness Plan and make necessary revisions and updates to ensure optimal safety protocol is in place for the protection of residents and staff.

2. This review will be completed on or before February 28th, 2024.

3. QAPI will add Emergency Plan to annual review of operational and dietary policies and procedures to ensure this does not recur. This review should begin in the fourth quarter annually to be completed in January.

4. An audit is not appropriate for this plan of correction

5. QAPI will review as needed and annually.
Initial comments:Name: LINCOLN - Component: 01 - Tag: 0000


Facility ID #062102
Component 01
Lincoln Building

Based on a Medicare/Medicaid Recertification Survey completed on January 8, 2024, it was determined that Oak Hill Center for Rehabilitation and Nursing was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type II (000), unprotected noncombustible structure, without a basement, which 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: LINCOLN - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of building separating common walls, affecting one of three smoke compartments within the component.

Findings include:

1. Observation on January 8, 2024, at 10:13 AM, revealed the leaf of the double fire doors separating the 01 and the 05 components, closest to the Oxygen Storage Room, failed to positively latch within the door frame.

Interview with the Director of Facilities on January 8, 2024, at 10:13 AM, confirmed the door failed to latch within the frame.


 Plan of Correction - To be completed: 03/08/2024

1. Work order was entered into the system on 1/8/2024 to complete any work required that ensures doors on right are latching in accordance with regulatory requirements.

2. The work was completed 01/08/2024.

3. Routine Door latching added to work order system for each latching door with quarterly frequency.

4. Audit of doors will take place for these and other doors X 10 doors randomly once weekly for 4 weeks, then monthly for 4 weeks.

5. Audit findings will be reported to QAPI Committee monthly.


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


Facility ID #062102
Component 02
Roosevelt Building

Based on a Medicare/Medicaid Recertification Survey completed on January 8, 2024, it was determined that Oak Hill Center for Rehabilitation and Nursing was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.



 Plan of Correction:


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: ROOSEVELT - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of hazardous area enclosures, affecting one of three smoke compartments within the component.

Findings include:

1. Observation on January 8, 2024, at 11:21 AM, revealed the door to the Buchanan Hall Soiled Utility Room was obstructed from closing and latching by a paper towel occupying the cavity within the strike plate of the door frame.

Interview with the Director of Facilities on January 8, 2024, at 11:21 AM, confirmed the door did not automatically close and latch within the frame.


 Plan of Correction - To be completed: 03/08/2024

1. The obstruction to the soiled utility door was removed immediately and the door latched appropriately.

2. Facility doors were audited to ensure no other doors were failing to latch due to obstruction.

3. Education will be provided to facility staff on ensuring that there are no obstructions placed. Routine visual audits will be conducted of facility doors to ensure that no obstructions are present causing doors not latch.

4. Audit of doors will take place rotating hallways weekly for 8 weeks.

5. Audit findings will be reported to QAPI Committee monthly.
NFPA 101 STANDARD Corridors - Construction of Walls: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.
Corridors - Construction of Walls
2012 EXISTING
Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code.
Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames.
If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area.
19.3.6.2, 19.3.6.2.7
Observations:
Name: ROOSEVELT - Component: 02 - Tag: 0362

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of corridor walls, affecting one of three smoke compartments within the component.

Findings include:

1. Observation on January 8, 2024, at 11:10 AM, revealed four unprotected penetrations of the first floor corridor wall, between the East Unit Manager's Office and the Utility Room.

Interview with the Director of Facilities on January 8, 2024, at 11:10 AM, confirmed the unprotected penetrations of the corridor wall.


 Plan of Correction - To be completed: 03/08/2024

1. Drywall patching and caulking material was applied to the unprotected penetrations in first floor corridor wall between East Unit Managers Office and Utility Room.

2. The work was completed 01/08/2024.

3. Routine inspections of walls will be implemented to prevent recurrence.

4. Routine inspection of walls in SNF will occur rotating areas once weekly for 4 weeks, then monthly.

5. Audit findings will be reported to QAPI Committee monthly.
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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 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: ROOSEVELT - Component: 02 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of surge suppressors, affecting one of three smoke compartments within the component.

Findings include:

1. Observation on January 8, 2024, at 11:03 AM, revealed a surge suppressor supplying electrical power to a coffee machine within the East Unit Manager's Office.

Interview with the Director of Facilities on January 8, 2024, at 11:03 AM, confirmed the high draw appliance was plugged into a surge suppressor.


 Plan of Correction - To be completed: 03/08/2024

1. Power was immediately removed from surge protector.

2. The work was completed 01/08/2024.

3. Routine monitoring for surge protectors being appropriately used will be implemented.

4. Audit of surge protectors will take place weekly for 4 weeks then monthly.

5. Audit findings will be reported to QAPI Committee monthly.
Initial comments:Name: TOWER - Component: 04 - Tag: 0000


Facility ID #062102
Component 04
Tower Building

Based on a Medicare/Medicaid Recertification Survey completed on January 8, 2024, it was determined that Oak Hill Center for Rehabilitation and Nursing was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is an eight-story, Type II (222), fire resistive structure, with a basement, which 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: TOWER - Component: 04 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of building separating common walls, affecting one of nine levels within the component.

Findings include:

1. Observation on January 8, 2024, at 10:40 AM, revealed the leaf of the double doors
separating the 04 component from the Personal Care Building, closest to the Culinary Services Department, failed to positively latch within the door frame.

Interview with the Director of Facilities on January 8, 2024, at 10:40 AM, confirmed the door failed to latch within the frame.


 Plan of Correction - To be completed: 03/08/2024

1. Work order was entered into the system on 1/8/2024 to complete any work required that ensures doors are latching in accordance with regulatory requirements.

2. The work was completed 01/08/2024.

3. Routine Door latching added to work order system for each latching door with quarterly frequency.

4. Audit of doors will take place for these and other doors X 10 doors randomly once weekly for 4 weeks, then monthly.

5. Audit findings will be reported to QAPI Committee monthly.
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: TOWER - Component: 04 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the spacing of sprinkler heads, affecting one of nine levels within the component.

Findings include:

1. Observation on January 8, 2024, at 10:50 AM, revealed the sprinkler heads protecting the first floor Mail Room were spaced less than six feet apart from each other. The heads were approximately four feet apart.

Interview with the Director of Facilities on January 8, 2024, at 10:50 AM, confirmed the sprinkler heads were not a minimum of six feet apart from each other.


 Plan of Correction - To be completed: 03/08/2024

1. Work order was entered into the system on 1/8/2024 to have work scheduled to move sprinkler heads to meet regulatory requirements.

2. The work was scheduled for completion the by Johnson Controls between 01/22/2024 and 01/30/2024.

3. This is identified as an isolated area of non-compliance.

4. No further audits required.

5. Completed work will be reported to QAPI Committee monthly.
Initial comments:Name: PT/OT ADDITION - Component: 05 - Tag: 0000


Facility ID #062102
Component 05
P T Addition

Based on a Medicare/Medicaid Recertification Survey completed on January 8, 2024, at Oak Hill Center for Rehabilitation and Nursing, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.



 Plan of Correction:



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