Pennsylvania Department of Health
NORTH HILLS SKILLED NURSING AND REHABILITATION CENTER
Building Inspection Results

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NORTH HILLS SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  39 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.
NORTH HILLS SKILLED NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on January 10, 2024, at North Hills Skilled Nursing and Rehabilitation Center, 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# 127902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 10, 2024, it was determined that North Hills Skilled Nursing And Rehabilitation Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two-story, Type II (111), protected noncombustible building, without a basement, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Cooking Facilities:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324
Based on observation and interview, it was determined the facility failed to properly install and maintain equipment protected by the kitchen hood extinguishing system in one instance, affecting one of twelve smoke compartments.

Findings Include:

1. Observation on January 10, 2024, at 10:30 a.m., revealed a gas-fired oven on wheels, in the main kitchen, was not provided with an approved method that would ensure the appliance was returned to an approved design location after it had been moved for maintenance and cleaning, as required by section 12.1.2.3 and 12.1.2.3.1 of NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

Interview with the Facility Administrator and Maintenance Director on January 10, 2024, at 1:30 p.m., confirmed the gas-fired cooking appliance was not tethered in a way so it could not be moved from the ventilation hood and gas connection.




 Plan of Correction - To be completed: 02/26/2024

0324
Wheels on gas fired oven in the main kitchen to be replaced with legs. An initial audit will be completed by maintenance director or designee to ensure appliances in the kitchen are provided with approved methods to return them to approved design location after they have been moved for cleaning. Re-education will be provided by administrator or designee to maintenance department that appliances in the kitchen are provided with approved methods to return them to approved design location after they have been moved for cleaning. An audit will be completed by maintenance director or designee to ensure that appliances in the kitchen are provided with approved methods to return them to approved design location after they have been moved for cleaning weekly times 4 and monthly times 3 thereafter. The results of the audit will be brought to QAPI for discussion and review.

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 six instances, affecting the entire facility.

Findings include:

1. Observation on January 10, 2024, revealed the following automatic sprinkler system deficiencies:

a) 9:20 a.m., there were wires resting on the sprinkler line, near the smoke doors, next to the dining room;
b) 9:45 a.m., there were gaps in the ceiling tile greater than 1/8 " in the employee lounge on the first floor;
c) 10:10 a.m., there were wires resting on the sprinkler line next to resident room # 134;
d) 10:35 a.m., there were wires resting on the sprinkler line outside of Memory Care;
e) 10:55 a.m., there were gaps in the ceiling tile greater than 1/8" in the dishwashing room in the kitchen;
f) 11:30 a.m., there were gaps in the ceiling tile greater than 1/8" in the business office.

Interview with the Facility Administrator and the Maintenance Director on January 10, 2024, at 1:30 p.m., confirmed the automatic sprinkler system deficiencies.





 Plan of Correction - To be completed: 02/26/2024

353
Ceiling tile gaps sealed in the employee lounge on the first floor on 01/18/2024. Ceiling gap in the dish washing room in the kitchen sealed on 01/18/2024. Ceiling tile gap in business office sealed on 01/18/2024. An initial audit will be completed by maintenance director or designee of the facility ceiling to ensure there are no penetrations. Re-education will be provided by administrator or designee to maintenance department that there cannot be penetrations in the ceiling. An audit will be completed by maintenance director or designee of the ceiling in 10 rooms weekly times 4 and monthly times 3 thereafter. The results of the audit will be brought to QAPI for discussion and review.
Wires resting on sprinkler lines near the smoke doors, next to the dining room will be secured. Wires resting on sprinkler lines next to resident room #134 will be secured. Wires resting on sprinkler lines outside of memory care will be secured. An initial audit will be completed by maintenance director or designee of the facility ceiling to ensure wires resting on sprinkler lines are secured. Re-education will be provided by administrator or designee to maintenance department that there cannot be wires resting on sprinkler lines. An audit will be completed by maintenance director or designee of the sprinkler lines in 10 rooms weekly times 4 and monthly times 3 thereafter. The results of the audit will be brought to QAPI for discussion and review.

NFPA 101 STANDARD Fire Drills: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.
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 documentation review and interview, it was determined the facility failed to perform two of 12 required fire drills, affecting the entire facility.

Findings include:

1. Review of documentation on January 10, 2024, at 9:00 a.m., revealed the facility lacked fire drill documentation for the second shift, first quarter and the third shift, third quarter.

Interview with the Facility Administrator and Maintenance Director on January 10, 2024, at 1:30 p.m. confirmed the documentation for the above listed fire drills were not available at the time of survey.




 Plan of Correction - To be completed: 02/26/2024

0712
Monthly fire drills will be completed on all shifts. Re-education will be provided by administrator or designee to maintenance director that facility must perform monthly fire drills on all shifts. An audit will be completed by the maintenance director or designee to ensure monthly fire drills are completed on all shifts for 2024. The results of the audit will be brought to QAPI for discussion and review

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to perform emergency generator maintenance testing for 12 of the last 12 months, effecting the entire facility.

Findings include:

1. Review of documentation on January 10, 2024, at 9:30 a.m., revealed the facility lacked documentation verifying that the following items were performed in the last twelve months:

a) 9:30 a.m., the annual preventative maintenance;
b) 9:35 a.m., the annual 90 minute load bank;
c) 9:40 a.m., an annual fuel quality test;
d) 9:45 a.m., a four hour test, required every three years.

Interview with the Facility Administrator and Maintenance Director, on January 10, 2024, at 9:30 a.m., confirmed the required annual and three year generator testing documentation was not available at the time of the survey.






 Plan of Correction - To be completed: 02/26/2024

0918
Annual load bank test will be completed. Re-education will be provided by administrator or designee to maintenance director that facility must perform an annual load bank test of the emergency generator. An audit will be completed by the maintenance director or designee to ensure the annual load bank test of the emergency generator was completed for 2024. The results of the audit will be brought to QAPI for discussion and review.

Annual preventive maintenance will be completed. Re-education will be provided by administrator or designee to the maintenance director that facility must perform an annual preventive maintenance. An audit will be completed by the maintenance director or designee to ensure the annual preventive maintenance test of the emergency generator was completed for 2024. The results of the audit will be brought to QAPI for discussion and review.

Annual fuel quality test will be completed. Re-education will be provided by administrator or designee to maintenance director that facility must perform an annual fuel quality test of the emergency generator. An audit will be completed by the maintenance director or designee to ensure the annual fuel quality test of the emergency generator was completed for 2024. The results of the audit will be brought to QAPI for discussion and review.

A four hour test required every three years will be completed. Re-education will be provided by administrator or designee to maintenance director that facility must perform an four hour test required every three years of the emergency generator. An audit will be completed by the maintenance director or designee to ensure the four hour test of the emergency generator was completed for 2024. The results of the audit will be brought to QAPI for discussion and review.


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