Pennsylvania Department of Health
HAMILTON ARMS CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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HAMILTON ARMS 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 September 10, 2025, it was determined that Hamilton Arms Center was not in compliance with 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 was reviewed within the previous twelve months, affecting the entire component. Findings include: 1. Review of documentation on September 10, 2025, at 10:30 AM, revealed the facility failed to provide documentation, verifying the emergency preparedness plan had been reviewed. Interview at the time of the exit conference with the Administrator and Assistant Maintenance Technician on September 10, 2025, at 2:00 PM, confirmed the lack of documentation, verifying the emergency preparedness plan had been reviewed, within the previous twelve months.

Plan of Correction - To be completed: 11/03/2025

1. The emergency preparedness plan will be reviewed annually within 12 months. Plan was reviewed on 10-1-25.
2. This requirement will be put into our maintenance tels system for monitoring and will be checked annually.
3. Education will be provided to the maintenance department on the 12 month requirement in addition to the QAPI committee.
4. The plan approval will be reviewed and reported to the QAPI committee.
5. Date certain is 11-3-25.

403.748(a)(1)-(2), 416.54(a)(1)-(2), 418.113(a)(1)-(2), 441.184(a)(1)-(2), 482.15(a)(1)-(2), 483.475(a)(1)-(2), 483.73(a)(1)-(2), 484.102(a)(1)-(2), 485.542(a)(1)-(2), 485.625(a)(1)-(2), 485.68(a)(1)-(2), 485.727(a)(1)-(2), 485.920(a)(1)-(2), 486.360(a)(1)-(2), 491.12(a)(1)-(2), 494.62(a)(1)-(2) STANDARD Plan Based on All Hazards Risk Assessment:

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.

§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)

[(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 the following:]

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*

(2) Include strategies for addressing emergency events identified by the risk assessment.

* [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

*[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. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.

*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.

Observations:
Name: - Component: -- - Tag: 0006 Based on document review and interview, it was determined the facility failed to provide an updated all hazards risk assessment for the facility, affecting the entire component. Findings include: 1. Review of documentation on September 10, 2025, at 10:30 AM, revealed the facility failed to provide an updated all hazards risk assessment for the facility. Interview at the time of the exit conference with theAdministrator and Assistant Maintenance Technician on September 10, 2025, at 2:00 PM, confirmed the facility could not provide an updated all hazards risk assessment.

Plan of Correction - To be completed: 11/03/2025

1. Facility will update and provide an all hazards risk assessment. Assessment will be completed in October with the QAPI committee and safety committee.
2. This requirement will be put into our maintenance tels system for monitoring and will be checked annually for completion.
3. Education will be provided to the QAPI committee and safety committee on the requirement for an annual hazards risk assessment.
4. The assessment will be reviewed and reported to the QAPI committee and safety committee.
5. Date certain is 11-3-25

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000
Facility ID #080202

Component 01

Main Building

Based on a Medicare/Medicaid Recertification Survey completed on September 10, 2025, it was determined that Hamilton Arms 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 III, (200), unprotected ordinary structure, with a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0100 28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE (a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met. 35 P.S. 448.808. Issuance of license. (a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met: (2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered. Based on document review and interview, it was determined the facility failed to meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component. Findings include: 1. Review of documentation on September 10, 2025, between 8:30 AM and 10:30 AM, revealed the facility's portable life safety drawings lacked compartment labeling, resident room capacities, fire wall boundaries, smoke wall boundaries, hazardous areas, length and width of zones and travel distances. This information is required by the active FSES used to meet compliance with NFPA 101A. Interview at the time of the exit conference with the Administrator and Assistant Maintenance Technician on September 10, 2025, at 2:00 PM, confirmed the portable life safety drawings lacked the required information for a facility with an active FSES.

Plan of Correction - To be completed: 11/03/2025

1. Life safety drawings will contain compartment labeling, resident room capacities, fire wall boundaries, smoke wall boundaries, hazardous areas, length and width of zones and travel distances.
2. Plans will be maintained at the facility. Floor plans will be reviewed on an annual basis and when projects are being approved by the governing body.
3. Education will be provided to the Maintenance department on the drawing requirements.
4. The drawings will be reviewed and reported to the QAPT committee.
5. Date certain is 11-3-25

NFPA 101 STANDARD Building Construction Type and Height:

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 - Component: 01 - Tag: 0161 Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire component. Findings include: 1. Observation on September 10, 2025, between 10:30 AM and 2:00 PM, revealed the component is a two-story, Type III (200), unprotected ordinary structure, with a basement, which is fully sprinklered. This facility exceeds the maximum allowable story height for this type of construction. Interview at the time of the exit conference with the Administrator and Assistant Maintenance Technician on September 10, 2025, at 2:00 PM, confirmed the construction type was not allowed.

Plan of Correction - To be completed: 11/03/2025

1. The facility requests DSI conduct the FSES survey.
2. The K0161 time limited waiver was sent to shosborne@pa.gov via e-mail.
3. The original letter was sent via mail to the central office.

NFPA 101 STANDARD Means of Egress - General:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is 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: MAIN BUILDING - Component: 01 - Tag: 0211 Based on observation and interview, it was determined the facility failed to maintain interior door clear width to be a minimum of 32 inches at all times, affecting two of five smoke compartments within the component. Findings include: 1. Observation on September 10, 2025, between 10:30 AM and 2:00 PM, revealed the doors to the Clean Linen Room, on both the 1st and 2nd floors, measured 26 inches, in width. Interview at the time of the exit conference with theAdministrator and Assistant Maintenance Technician on September 10, 2025, at 2:00 PM, confirmed the doors measured 26 inches.

Plan of Correction - To be completed: 11/03/2025

1. The doors to the clean linen room on both the 1st and 2nd floors will maintain an interior door clear width to be a minimum of 32 inches at all times. The clean linen room on first floor is 36" inches wide. The clean linen room on 2nd floor is 35 and a half inches wide.
2.Doors will be audited weekly for 2 months. Audits will be conducted by the maintenance director or designee.
3. Education will be provided to the maintenance department as to the width requirement of the doors and the QAPI committee.
4. Results of the fix will be reviewed and reported to the QAPI committee.
5. Date certain is 11-3-25

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 - Component: 01 - Tag: 0353 Based on document review and interview, it was determined the facility failed to perform 5-year dry sprinkler maintenance, affecting the entire component. Findings include: 1. Review of documentation on September 10, 2025, between 9:38 AM and 9:40 AM, revealed the facility failed to perform the following: a. 9:38 AM, 5-year gauge calibration/replacement dry system, last performed 4/2020; b. 9:40 AM, 5- year internal valve/pipe inspection dry system, last performed 4/2020. Interview at the time of the exit conference with theAdministrator and Assistant Maintenance Technician on September 10, 2025, at 2:00 PM, confirmed the facility failed to perform dry sprinkler system maintenance.

Plan of Correction - To be completed: 11/03/2025

1. The 5 year gauge calibration/replacement dry system will be performed along with the 5 year internal valve/pipe inspection dry system.
2. Audits for the 5 year internal inspection will be conducted annually to confirm the report is filed in the life safety book and to track the next scheduled 5 year inspection.
3. Education will be provided to the maintenance department as to the time frame requirements of these inspections.
4. Results of the audits will be reviewed and reported to the QAPI committee.
5. Date certain is 11-3-25

NFPA 101 STANDARD Electrical Systems - Maintenance and Testing:

Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0914 Based on document review and interview, it was determined the facility failed to inspect all electrical receptacles in resident care areas, affecting the entire component. Findings include: 1. Review of documentation on September 10, 2025, between 8:30 AM and 10:30 AM, revealed the facility failed to test electrical receptacles, in the last 12 months. Interview at the time of the exit conference with the Administrator and Assistant Maintenance Technician on September 10, 2025, at 2:00 PM, confirmed the receptacles were not tested, in the last 12 months.

Plan of Correction - To be completed: 11/03/2025

1. Electrical receptacles will be tested within patient care areas within every 12 months. Inspection will be completed in October.
2. The testing report will be placed in the life safety book.
3. Education will be provided to the maintenance department as to the 12 month requirement.
4. Results of the inspections will be reviewed and reported to the QAPI committee.
5. Date certain is 11-3-25

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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 - Component: 01 - Tag: 0918 Based on document review and interview, it was determined the facility failed to provide required maintenance and testing documentation for the emergency generator, which serves the entire component. Findings include: 1. Review of documentation on September 10, 2025, between 9:45 AM and 9:48 AM, revealed the facility lacked documentation for the following: a. 9:45 AM, one full year, weekly maintenance; b. 9:48 AM, one full year, monthly maintenance, 30-minute load with transfer switch. Interview at the time of the exit conference with theAdministrator and Assistant Maintenance Technician on September 10, 2025, at 2:00 PM, confirmed the lack of documentation for one full year emergency generator weekly and monthly maintenance.

Plan of Correction - To be completed: 11/03/2025

1. The generator will be inspected weekly and monthly beginning in October with a 30-minute load transfer switch.
2. This requirement will be met by weekly visual inspections and monthly runs.
3. Weekly audits will occur for 12 months to assure the weekly and monthly inspections have been completed. Audits will be conducted by the maintenance director or designee.
4. Education will be provided to the maintenance department as to the weekly and monthly requirements.
5. Audit results for the generator will be reviewed and reported to the QAPI committee.
6. Date certain is 11-3-25

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