Pennsylvania Department of Health
 CEDAR HILL HEALTHCARE AND REHABILITATION CENTER
Building Inspection Results

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CEDAR HILL HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  38 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.
CEDAR HILL 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 September 1, 2026, at Cedar Hill Healthcare 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 #232702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on September 1, 2026, it was determined that Cedar Hill Healthcare 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 (000), unprotected, non-combustible building, without a basement, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Emergency Lighting: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.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on document review and interview, the facility failed to maintain emergency light testing in one instance, affecting the entire facility.

Findings include:

Document review on September 1, 2026, at 8:25 a.m., revealed the facility lacked documentation for the required monthly 30-second emergency battery back-up lighting test.

Interview with the facility administrator and maintenance director on September 1, 2026, at 12:30 p.m., confirmed the lack of documentation at the time of the survey.






 Plan of Correction - To be completed: 09/25/2026

1.The maintenance director or designee completed an emergency light test, no issues noted.
2.The maintenance director or designee has audited all other testing requirements in for the emergency lightning to ensure none are missing, no issues noted.
3.The maintenance director or designee will add the 30 second emergency light testing to the annual testing checklist to ensure that it is being completed. All findings will be reported to QAPI.

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 observation and interview, the facility failed to maintain the fire alarm system in one instance, affecting one of seven smoke compartments.

Findings include:

Observation on September 1, 2026, at 10:25 a.m., revealed an accumulation of grease and dirt on the smoke detector near the kitchen stove.

Interview with the facility administrator and maintenance director on September 1, 2026, at 12:30 p.m., confirmed the fire alarm system deficiency.






 Plan of Correction - To be completed: 09/25/2026

1.The maintenance director or designee cleaned the smoke detector in the kitchen.
2.The maintenance director or designee has audited all other smoke detectors to ensure they are cleanly, no issues noted.
3.The maintenance director or designee will add a monthly audit to ensure all smoke detectors are cleanly. All findings will be reported to QAPI.

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, the facility failed to maintain the automatic sprinkler system in four instances, affecting three of seven smoke compartments.

Findings include:

Observation on September 1, 2026, revealed the following automatic sprinkler system deficiencies, which would allow the passage of heat and smoke, and may affect the operation of the automatic sprinkler system:

a) 9:30 a.m., There was was a gap in the ceiling tile of the sub-acute janitor closet;
b) 10:10 a.m., There was a gap greater than 1/8 inch in the ceiling tile of the dietary storage area of the kitchen;
c) 10:15 a.m., There was a sprinkler head next to the oven that was coated with grease;
d) 10:42 a.m., There were multiple gaps in the ceiling tile of the automatic transfer switch room.

Interview with the facility administrator and the maintenance director on September 1, 2026, at 12:30 p.m., confirmed the automatic sprinkler system deficiencies.






 Plan of Correction - To be completed: 09/25/2026

1. The maintenance director or designee has cleaned the sprinkler next to the oven.
2. The maintenance director or designee has fixed the ceiling tiles in the sub-acute janitor closet, dietary storage, and transfer switch room.
3.The maintenance director or designee has inspected all other ceiling tiles, no issues noted.
4.The maintenance director or designee will add these inspections to the annual testing checklist to ensure that they are completed. All findings will be reported to QAPI.

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, the facility failed to maintain corridor doors in five instances, affecting five of seven smoke compartments.

Findings include:

Observation on September 1, 2026, revealed the following corridor door deficiencies:

a) 10:10 a.m., The door to the office across from the visitor restroom would not close and latch, and the door had penetrations near the handle;
b) 10:25 a.m., The door to room 304 would not close and latch;
c) 10:40 a.m., The door to room 205 would not close and latch;
d) 10:50 a.m., The door to the tel/elec room north would not close and latch;
e) 11:05 a.m., The door to the transitional apartment would not close and latch.

Interview with the facility administrator and maintenance director on September 1, 2026, at 12:30 p.m., confirmed the corridor door deficiencies.











 Plan of Correction - To be completed: 09/25/2026

1.The maintenance director or designee has fixed the doors across from the visitor restroom, room 304, room 205, tel/elec room north, and transitional apartment and they all now self-close and latch properly.
2.The maintenance director or designee has inspected all other self-closing doors to ensure that they close and latch properly. No issues noted.
3.The maintenance director or designee will add checking self-closing doors to their quarterly safety checklist audit. All findings will be reported to QAPI.

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, the facility failed to maintain smoke barrier doors in one instance, affecting two of seven smoke compartments.

Findings include:

Observation on September 1, 2026, at 8:35 a.m., revealed the smoke barrier doors near room 229 were equipped with a self-latching device and failed to latch when tested.

Interview with the facility administrator and maintenance director on September 1, 2026, at 12:30 p.m., confirmed smoke barrier door deficiency.






 Plan of Correction - To be completed: 09/25/2026

1. The maintenance director or designee has fixed the door on room 229. The door now self-closes and latches properly.
2.The maintenance director or designee has inspected all other self-closing doors to ensure that they close and latch properly. No issues noted.
3.The maintenance director or designee will add checking self-closing doors to their quarterly safety checklist audit. All findings will be reported to QAPI.

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, the facility failed to properly store oxygen cylinders in one instance, affecting one of seven smoke compartments.

Findings include:

Observation on September 1, 2026, at 10:30 a.m., revealed oxygen cylinders were being stored in the south supply room without proper signage.

Interview with the facility administrator and maintenance director on September 1, 2026, at 12:30 p.m., confirmed the oxygen cylinder storage deficiency.






 Plan of Correction - To be completed: 09/25/2026

1.The maintenance director or designee has placed an oxygen signage outside the south supply room.
2.The maintenance or designee has inspected all other supply rooms to ensure that they have proper signage if they contain oxygen cylinders. No issues noted.
3.The maintenance director or designee has educated the nursing staff on ensuring that they are placing oxygen signage when appropriate.
4.The maintenance director or designee will add on monthly oxygen audit's to ensure that all rooms with oxygen have the appropriate signage.


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