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

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WESTGATE HILLS REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  45 surveys for this facility. Please select a date to view the survey results.

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WESTGATE HILLS REHABILITATION AND NURSING 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 Westgate Hills Rehabilitation And Nursing 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# 081302
Component 01

Based on a Medicare/Medicaid Recertification Survey completed on January 10, 2024, it was determined that Westgate Hills Rehabilitation And Nursing Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 (222), fire resistive construction, with a basement, which 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 the fire resistance rating of vertical openings, affecting 1 of three levels.

Findings Include:

Observation made on January 10, 2024, at 12:15 p.m., revealed inside the Community room there was an opening in the stair wall exposing a steel beam, across from the activities office.

Exit Interview with the Facility Administrator, Director of Maintenance and the Regional Director of Facilities on January 10, 2024, at 2:15 p.m., confirmed the vertical opening.










 Plan of Correction - To be completed: 03/10/2024

1. The opening in the stair wall exposing a steel beam inside the Community Room has been repaired with cement.
2. NHA/ Designee will in service the Director of Maintenance that all
3. The Director of Maintenance will complete weekly audits on 4 stairwells to ensure that they maintain the fire resistance rating of vertical openings.
4. Director of Maintenance will report finds to monthly QAPI meetings x 3 months.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to maintain fire alarm system components in operable condition, affecting 1 of two sprinkler control valves.

Findings Include:

Documentation review made on January 10, 2024, between 8:30 a.m. and 11:30 a.m., revealed the Fire alarm report dated December 20, 2023 identified the following deficiency:

"The devices in the pit did not function at the time of inspection 11/14 22 through 12/20/23. The modules are resistored out due to the water level in the pit. This needs to be resolved."

Exit Interview with the Facility Administrator, Director of Maintenance and the Regional Director of Facilities on January 10, 2024, at 2:15 p.m., confirmed the above deficiency had not been repaired at the time of this inspection.









 Plan of Correction - To be completed: 03/10/2024

1. The Sprinkler company was called to make the necessary repairs.
2. NHA/ Designee will inservice the Maintenance Director on getting any finding addresses in a timely manner.
3. Director of Maintenance will complete weekly audits on fire Pitt to ensure that the system is in operable condition.
4. Director of Maintenance will report findings to the monthly QAPI meetings x 3 months.


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 document review and interview, it was determined the facility failed to maintain sprinkler system components in operable condition, affecting 1 of two sprinkler control valves.

Findings Include:

Documentation review made on January 10, 2024, between 8:30 a.m. and 11:30 a.m., revealed the quarterly Sprinkler report dated December 20, 2023 identified the following deficiency:

The tampers on the OS&Y Valves in the pit did not report to the fire alarm panel 5/16/23 through 12/20/23, due to the continued water accumulation and corrosion in the pit. The device is resistored out. The tampers need to be replaced. The valves were sealed in the open position on departure.

Exit Interview with the Facility Administrator, Director of Maintenance and the Regional Director of Facilities on January 10, 2024, at 2:15 p.m., confirmed the above deficiency had not been repaired at the time of this inspection.








 Plan of Correction - To be completed: 03/10/2024

1. The Fire Alarm company was called to make the necessary repairs.
2. NHA/ Designee will inservice the Maintenance Director on getting and finding addressed in a timely manner.
3. Director of Maintenance will complete weekly audits on water levels and corrosion in the fire Pitt to ensure that the system is in operable condition.
4. Director of Maintenance will report findings to the monthly QAPI meetings x 3 months.


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 smoke tight resistance and positive latching of corridor doors, affecting 2 of five smoke compartments.

Findings Include:

Observation made on January 10, 2024, between 1:20 p.m. and 1:40 p.m., revealed the following corridor door deficiencies:

a. door 140 latch stuck in place when tested;
b. door 241 rubs the frame when closing.

Exit Interview with the Facility Administrator, Director of Maintenance and the Regional Director of Facilities on January 10, 2024, at 2:15 p.m., confirmed the corridor doors required adjustment.









 Plan of Correction - To be completed: 03/10/2024

1. Door in Room 140 and Door in Room 241 were repaired.
2. NHA/ Designee will in-service the Director of Maintenance
3. Director /Designee will randomly audit resident room doors weekly x 4 weeks and monthly.
X 3 .
4. Director of Maintenance will report findings to monthly QAPI meeting x 3 months.

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 Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier partitions with the proper fire resistance rating, affecting 1 of two smoke barriers.

Findings Include:

Observation made on January 10, 2024, at 12:28 p.m., revealed a pipe penetration through the smoke barrier wall outside room 21, 1st floor.

Exit Interview with the Facility Administrator, Director of Maintenance and the Regional Director of Facilities on January 10, 2024, at 2:15 p.m., confirmed the opening in the smoke barrier.









 Plan of Correction - To be completed: 03/10/2024

1. The pipe penetration through the smoke barrier wall outside room 121 was repaired utilizing 3M Fire Barrier Sealant CP 25WBt.
2. NHA / Designee will inservice Maintenance Director that facility must maintain smoke barrier partitions with the proper fire resistance rating .
3. Director of Maintenace /Designee will audit random smoke barrier walls weekly x4 and monthly x 3.
4. Director of Maintenance will report findings to monthly QAPI meetings x 3 months.

NFPA 101 STANDARD Smoking Regulations: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.
Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain smoking regulations, affecting 1 of three levels.

Findings Include:

Observation made on January 10, 2024, at 12:02 p.m., revealed the facility smoking policy did not identify designated smoking areas. The first floor patio was being used as a smoking location.

Exit Interview with the Facility Administrator, Director of Maintenance and the Regional Director of Facilities on January 10, 2024, at 2:15 p.m., confirmed the current location used for smoking.









 Plan of Correction - To be completed: 03/10/2024

1. The Smoking Policy was revised to include the First Floor Patio and Center Dining Room Patio as designated smoking areas.
2. Director of Maintenance / Designee will in-service staff that location of Smoking Areas will be included on Smoking policy.
3. Director of Maintenace to randomly audit Emergency Preparedness Binders for The revised Smoking Policy weekly x 4 and Monthly x3
4. Director of Maintenace will report findings to monthly QAPI meetings x3 months

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain protection of cylinder and container storage areas, affecting 1 of three levels.

Findings Include:

Observation made on January 10, 2024, at 11:55 a.m., revealed there was an exterior wood shed used for oxygen storage against the building. Sprinkler protection was not provided at this location. In addition, the cylinders were not protected from the elements.

Exit Interview with the Facility Administrator, Director of Maintenance and the Regional Director of Facilities on January 10, 2024, at 2:15 p.m., confirmed the current location of oxygen storage.





 Plan of Correction - To be completed: 03/10/2024

1. Oxygen storage space has been relocated away from the exterior wooden shed and is protected from the elements .
2. NHA/Designee will in-service Director of Maintenace regarding storage of oxygen must be relocated away from wooden sheds and protected from the elements.
3. Director of Maintenance to randomly audit that oxygen will be located away from wooden shed and protected from the elements.
4. Director of Maintenace will report findings to monthly QAPI meetings x3 month.



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