Pennsylvania Department of Health
HILLTOP HEALTHCARE AND REHABILITATION CENTER
Building Inspection Results

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HILLTOP HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  34 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.
HILLTOP HEALTHCARE 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 30, 2024, it was determined that Hilltop Healthcare and Rehabilitation was not in compliance with the requirements of 42 CFR 483.73.


 Plan of Correction:


482.15(e), 483.73(e), 485.542(e), 485.625(e) STANDARD Hospital CAH and LTC Emergency Power:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§482.15(e) Condition for Participation:
(e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section.

§483.73(e), §485.625(e), §485.542(e)
(e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section.

§482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1)
Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated.

482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2)
Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code.

482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2)
Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates.

*[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):]
The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.
If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes.
(1) National Fire Protection Association, 1 Batterymarch Park,
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
(i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011.
(ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011.
(iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
(iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
(v) TIA 12-5 to NFPA 99, issued August 1, 2013.
(vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
(vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011.
(viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
(ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
(x) TIA 12-3 to NFPA 101, issued October 22, 2013.
(xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
(xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009..
Observations:
Name: - Component: -- - Tag: 0041
Based on observation and interview, it was determined the facility failed to maintain the remote alarm annunciator for the emergency generator, affecting the entire facility.

Findings include:

1. Observation on January 30, 2024, at 9:55 a.m., revealed the remote generator annunciator panel located in the D-wing nurse station failed to function when tested. The alarm test function failed to operate when tested.


Interview with the Facility Administrator, Maintenance Supervisor, and Facility Staff on January 30, 2024, at 1:30 p.m., confirmed the listed emergency generator annunciator panel deficiency.




 Plan of Correction - To be completed: 02/23/2024

1. The Director of Maintenance contracted the fire panel service company to fix the emergency generators remote alarm annunciator in the D wing nurses station, it is now fixed and working properly.
2. The emergency generator annunciator panel was checked for any further malfunctions by the Director of Maintenance to ensure it is working order.
3. The Director of Maintenance or designee will test the annunciator monthly to confirm that it is alarming as required. The Director of Maintenance or designee will create and maintain a monthly record of performing a check of the emergency annunciator system to ensure integrity.
4. Results of the tests will be reviewed at the Quality Assurance Performance Improvement meeting
5. Date of compliance 2/23/2024

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




Facility ID# 341902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 30, 2024, it was determined that Hilltop Healthcare and Rehabilitation 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 V (000), unprotected wood frame building, with a basement, that is fully sprinklered.




 Plan of Correction:


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 opening enclosures in two instances, affecting two of eight smoke compartments.

Findings include:

1. Observation on January 30, 2024, revealed the following vertical opening enclosure deficiencies:

a) 9:30 a.m., the self-closing device was unhooked from the laundry chute room door in the basement laundry;
b) 9:32 a.m., there were multiple unsealed pipe penetrations in the laundry chute room in the basement.


Interview with the Facility Administrator, Maintenance Supervisor, and Facility Staff on January 30, 2024, at 1:30 p.m., confirmed the listed vertical opening enclosure deficiencies.




 Plan of Correction - To be completed: 02/23/2024

1. The self-closing fixture was hooked back up from the laundry chute room door in the basement and all unsealed pipe penetrations in the laundry chute room were repaired using the approved methods of fire rated caulking
2. A inspection of the basement and first floor ceilings has been completed and any penetrations were sealed using an approved construction method to keep the integrity of the fire rated walls/ceilings.
3.The Director of Maintenance or designee will perform a quarterly walkthrough of the facility to check that all vertical penetrations are properly sealed and that all self-closers are attached and functioning on all required doors. The Director of Maintenance/designee will maintain a quarterly record of any findings.
4. Results of these inspections will be reviewed during the Quality Assurance Performance Improvement meetings
Date of compliance 2/23/2024

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 one instance, affecting one of eight smoke compartments.

Findings include:

1. Observation on January 30, 2023, at 9:59 a.m., revealed the facility failed to maintain the required one-hour fire rating for hazardous area enclosures. There were two large holes in the D-wing soiled utility room door above the door handle.


Interview with the Facility Administrator, Maintenance Supervisor, and Facility Staff on January 30, 2024, at 1:30 p.m., confirmed the listed hazardous area enclosure deficiency.







 Plan of Correction - To be completed: 02/23/2024

1. The D wing soiled utility room door holes are being repaired using approved fire rated construction material.
2. An inspection of all hazardous area enclosures was completed and any holes were repaired using approved fire rated construction material.
3. The Director of Maintenance or designee will perform a quarterly walkthrough of the facility to check that all hazardous area enclosures are free from holes so to maintain the required 1-hour fire rating. Maintenance/designee will create and maintain a quarterly record of any findings.
4. Results of these inspections will be reviewed during the Quality Assurance Performance Improvement meetings
5. Date of compliance 2/23/2024

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 four instances, affecting four of seven smoke compartments.

Findings include:

1. Observation on January 30, 2024, at 10:33 a.m., revealed the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. There was a large section of ceiling missing in the beauty shop.

Interview with the Facility Administrator, Maintenance Supervisor, and Facility Staff on January 30, 2024, at 1:30 p.m., confirmed the listed automatic sprinkler system deficiency.



 Plan of Correction - To be completed: 02/23/2024

1. The ceiling in the beauty shop was repaired.
2. an inspection of the 1st floor ceiling was completed by the Director of Maintenance any other areas failing to meet code where repaired.
3. a quarterly walk-through of the facility will be completed by the Maintenance director/designee with any findings being repaired. Record of walk throughs will be recorded to ensure the facility does not fail to maintain the proper activation/operation of the automatic sprinkler system.
4. Results of these inspections will be reviewed during the Quality Assurance Performance Improvement meetings.
5. Date of compliance 2/23/2024

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 smoke barrier doors in one instance, affecting two of eight smoke compartments.
Findings include:
1. Observation on January 30, 2024, at 10:41 a.m., revealed the A-wing smoke barrier doors equipped with latching hardware would not self-close and latch in their frame when tested.
Interview with the Facility Administrator, Maintenance Supervisor, and Facility Staff on January 30, 2024, at 1:30 p.m., confirmed the listed smoke barrier door deficiency.



 Plan of Correction - To be completed: 02/23/2024

1. A wing smoke barrier doors were adjusted so that they latch in their frame when closed.
2. an inspection of all self-closing doors containing latches was completed. Any self-closing doors with latches not closing correctly were adjusted.
3. Monthly walk throughs of all self-closing doors with latches will be completed by the
Maintenance Director or designee will create a monthly record and maintain the findings from all walk throughs.
4. Results of these inspections will be reviewed during the Quality Assurance Performance Improvement meetings.
5. Date of compliance 2/23/2024

NFPA 101 STANDARD Electrical Systems - Other: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 - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911
Based on observation and interview, it was determined the facility failed to maintain electrical wiring in one instance, affecting one of eight smoke compartments. Installation shall be in accordance with NFPA 70, National Electric Code. 19.5.1.1, NFPA 101.

Findings include:

1. Observation on January 30, 2024, at 9:38 a.m., revealed an open electrical junction box on the side of water heater 1 in the boiler room.


Interview with the Facility Administrator, Maintenance Supervisor, and Facility Staff on January 30, 2024, at 1:30 p.m., confirmed the listed electrical wiring deficiencies.







 Plan of Correction - To be completed: 02/23/2024

1. The electrical junction box for water heater 1 was immediately put back on.
2. Inspection of junction boxes on all water heaters throughout the building was completed and no further missing covers observed.
3. monthly walk-throughs will be performed by the maintenance director or designee to ensure junction boxes are not removed from water heaters. Audits will be maintained and logged.
4. Results of these inspections will be reviewed during the Quality Assurance Performance Improvement meetings.
5. Date of compliance 2/23/2024

NFPA 101 STANDARD Electrical Systems - Receptacles: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 - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912
Based on observation and interview, it was determined the facility failed to maintain electrical receptacles in one instance, affecting one of eight smoke compartments.

Findings include:

1. Observation on January 30, 2024, at 9:25 a.m., revealed there was a broken electrical receptacle in the laundry room by the washing machines.


Interview with the Facility Administrator, Maintenance Supervisor, and Facility Staff on January 30, 2024, at 1:30 p.m., confirmed the listed electrical receptacle deficiency.





 Plan of Correction - To be completed: 02/23/2024

1. The broken electrical receptable was replaced.
2. Maintenance director preformed a walk through of the building to ensure no other cracked electrical receptacles were observed.
3. quarterly audits will be completed and documented by the maintenance director or designee monitoring for the integrity of all electrical receptacles.
4. audits will be reviewed during the Quality Assurance Performance Improvement meetings.
5. Date of compliance 2/23/2024

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Systems - Essential Electric System Alarm Annunciator
A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator.
6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0916
Based on observation and interview, it was determined the facility failed to maintain the remote alarm annunciator for the emergency generator, affecting the entire facility.

Findings include:

1. Observation on January 30, 2024, at 9:55 a.m., revealed the remote generator annunciator panel located in the D-wing nurse station failed to function when tested. The alarm test function failed to operate when tested.


Interview with the Facility Administrator, Maintenance Supervisor, and Facility Staff on January 30, 2024, at 1:30 p.m., confirmed the listed emergency generator annunciator panel deficiency.




 Plan of Correction - To be completed: 02/23/2024

1. The Director of Maintenance contracted the fire panel service company to repair the emergency generator annunciator panels faulty board in the D wing nurses station.
2. The emergency generator annunciator panel was checked for any further malfunctions by the Director of Maintenance to ensure it was functioning properly.
3. The Director of Maintenance or designee will test the annunciator monthly and confirm that it is alarming as required. The Director of Maintenance or designee will create and maintain the monthly record to perform a check of the emergency annunciator system to ensure integrity.
4. Results will be reviewed at the Quality Assurance Performance Improvement meeting
5. Date of compliance 2/23/2024


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