Pennsylvania Department of Health
 CORNER VIEW NURSING AND REHABILITATION CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
CORNER VIEW NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  60 surveys for this facility. Please select a date to view the survey results.

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CORNER VIEW 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 March 12, 2024, at Corner View 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# 060402
Component 01
Main Building-East Wing

Based on a Medicare/Medicaid Recertification Survey completed on March 11-12, 2024, it was determined that Corner View 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 six-story, Type II (222), fire resistive building, with 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, it was determined the facility failed to maintain emergency lighting in one instance, affecting the entire facility.

Findings include:

1.Documentation review on March 11, 2024, at 9:00 a.m., revealed the facility lacked documentation for an annual 90-minute test for the emergency lights.

Interview with the Facility Administrator and Maintenance Director on March 12, 2024, at 9:00 a.m. confirmed the facility lacked documentation for the annual 90-minute test for the emergency lights at the time of survey.





 Plan of Correction - To be completed: 04/18/2024

Audit created for annual 90-minute emergency light inspection. Maintenance Director or designee will complete audit annually in 2024 and annual thereafter. Results reported to Quality Assurance and Process Improvement meeting.
NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
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 self-closing devices on doors to hazardous areas in one instance, affecting one of thirteen smoke compartments.

Findings include:

1. Observation on March 11, 2024, at 9:20 a.m., revealed the door to the soiled utility room on the sixth floor, failed to latch due to paper towels stuffed into the door jamb.


Interview with the Facility Administrator and Maintenance Director on March 12, 2024, at 10:30 a.m., confirmed the door would not latch.


 Plan of Correction - To be completed: 04/18/2024

March 11th 2024 towels removed from soiled utility door on 6 East. Audit created for monitor soiled utility door on 6 East. Maintenance director or designee will audit 6 East soiled utility door to ensure no towels are impeding the closure of the door from latching 3 times a week for 4 weeks. Results will be reported to the Quality Assurance and Process Improvement meeting.
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 documentation review and interview, it was determined the facility failed to maintain the fire alarm system, in three instances, affecting the entire facility

Findings Include:

1. Review of documentation on March 11, 2024, at 8:30 a.m., revealed the facility lacked documentation for the semi-annual fire alarm inspection.

Interview with the Facility Maintenance Director on March 11, 2024, at 8:30 a.m., confirmed the missing fire alarm system documentation.

2. Observation on March 11, 2024, revealed the following rooms had smoke detector hangers present, but no smoke detectors:

a) 9:40 a.m., in the storage closet on the third floor;
b) 10:05 a.m., in the storage closet on the second floor.

Interview with the Facility Administrator and Maintenance Director on March 12, 2024, at 10:30 a.m., confirmed the missing smoke detectors.




 Plan of Correction - To be completed: 04/18/2024

Audit created for visual inspection of the fire alarm system on a semi-annual basis. 2nd and 3rd floor smoke detectors will be replaced. Maintenance Director or designee complete visual inspection on a semi-annual fire alarm basis. Results will be reported to the Quality Assurance and Process Improvement meeting.
NFPA 101 STANDARD Corridor - Doors: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.
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 corridor doors in one instance, affecting one of thirteen smoke compartments.

Findings include:

1. Observation on March 11, 2024, at 9:50 a.m., revealed the door to room 4022 on the fourth floor failed to latch when tested.


Interview with the Facility Administrator and Maintenance Director on March 12, 2024, at 10:30 a.m., confirmed the corridor door deficiency.





 Plan of Correction - To be completed: 04/18/2024

Room 4022 latch was fixed. . Maintenance director or designee will audit the door monthly. Results will be reported to the Quality Assurance and Process Improvement meeting.
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 1 of 12 required fire drills, affecting the entire facility.

Findings include:

1. Review of documentation on March 11, 2024, at 8:25 a.m., revealed the facility lacked documentation for the third shift fire drill, for the fourth quarter.

Interview with the Facility Administrator and Maintenance Director on March 12, 2024, at 8:25 a.m., confirmed the facility lacked documentation for a fire drill between October and December in 2023.





 Plan of Correction - To be completed: 04/18/2024

Education of ¼ fire drills given to Maintenance department. Maintenance Director or designee will audit ¼ fire drills for accuracy and compliance. Results will be reported to Quality Assurance and Process Improvement meeting.
Initial comments:Name: WEST WING - Component: 02 - Tag: 0000

Facility ID# 060402
Component 02
Main Building-West Wing

Based on a Medicare/Medicaid Recertification Survey completed on March 11-12, 2024, it was determined that Corner View 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 six-story, Type II (222), fire resistive building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies: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.
Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623
Observations:
Name: WEST WING - Component: 02 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain a two-hour fire resistance rating to separate the health care occupancy from other occupancies between the east wing and the west wing on one of six floors

Findings include:

1. Observation on March 11, 2024, at 9:35 a.m., revealed the door to the west wing on the fifth floor failed to latch in its frame when tested.

Interview with the Facility Administrator and Maintenance Director on March 12, 2024, at 10:30 a.m., confirmed the deficiency with the doors in the two-hour rated occupancy separation wall.




 Plan of Correction - To be completed: 04/18/2024

5 west door closures were adjusted to latch securely. Maintenance director or designee will audit fire door on 5 west monthly for latching securely. Results will be reported to Quality Assurance and Process Improvement meeting.
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: WEST WING - Component: 02 - Tag: 0291

Based on document review and interview, it was determined the facility failed to maintain emergency lighting in one instance, affecting the entire facility.

Findings include:

1.Documentation review on March 11, 2024, at 9:00 a.m., revealed the facility lacked documentation for an annual 90-minute test for the emergency lights.

Interview with the Facility Administrator and Maintenance Director on March 12, 2024, at 9:00 a.m. confirmed the facility lacked documentation for the annual 90-minute test for the emergency lights at the time of survey.



 Plan of Correction - To be completed: 04/18/2024

Audit created for annual 90-minute emergency light inspection. Maintenance Director or designee will complete audit annually in 2024 and annual thereafter. Results reported to Quality Assurance and Process Improvement meeting.
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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 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: WEST WING - Component: 02 - Tag: 0345

Based on documentation review and interview, it was determined the facility failed to maintain the fire alarm system, in two instances, affecting the entire facility

Findings Include:

1. Review of documentation on March 11, 2024, at 8:30 a.m., revealed the facility lacked documentation for the semi-annual fire alarm inspection.

Interview with the Facility Maintenance Director on March 11, 2024, at 8:30 a.m., confirmed the missing fire alarm system documentation.





 Plan of Correction - To be completed: 04/18/2024

Audit created for visual inspection of the fire alarm system on a semi-annual basis. Maintenance Director or designee complete visual inspection on a semi-annual fire alarm basis. Results will be reported to the Quality Assurance and Process Improvement meeting.
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: WEST WING - Component: 02 - Tag: 0353
Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting the one of six smoke compartments.

Findings include:

1. Observation on March 11, 2024, at 9:10 a.m., revealed the ceiling of the sixth-floor storage closet collapsed and left an opening greater than an 8th of an inch.

Interview with the Facility Administrator and Maintenance Director on March 12, 2024, at 10:30 a.m., confirmed the automatic sprinkler system deficiency.



 Plan of Correction - To be completed: 04/18/2024

Ceiling in dining room closet was repaired. Maintenance director or designee will audit the closet to ensure ceiling is intact. Results will be reported to Quality Assurance and Process Improvement meeting.
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: WEST WING - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors in one instance, affecting one of six smoke compartments.

Findings include:

1. Observation on March 12, 2024, at 8:35 a.m., revealed the door to room 1108 on the first floor failed to latch when tested.


Interview with the Facility Administrator and Maintenance Director on March 12, 2024, at 10:30 a.m., confirmed the corridor door deficiency





 Plan of Correction - To be completed: 04/18/2024

Room 1108 in dietary was fixed. Maintenance director or designee will audit the door monthly. Results will be reported to the Quality Assurance and Process Improvement meeting.
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: WEST WING - Component: 02 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform 1 of 12 required fire drills, affecting the entire facility.

Findings include:

1. Review of documentation on March 11, 2024, at 8:25 a.m., revealed the facility lacked documentation for the third shift fire drill, for the fourth quarter.

Interview with the Facility Administrator and Maintenance Director on March 12, 2024, at 8:25 a.m., confirmed the facility lacked documentation for a fire drill between October and December in 2023.





 Plan of Correction - To be completed: 04/18/2024

Education of ¼ fire drills given to Maintenance department. Maintenance Director or designee will audit ¼ fire drills for accuracy and compliance. Results will be reported to Quality Assurance and Process Improvement meeting.
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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 Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: WEST WING - Component: 02 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in two instances, affecting one of six smoke compartments.

Findings include:
1. Observation on March 11, 2024, revealed the following electrical equipment deficiencies:
a) 10:58 a.m., there was a microwave plugged into a surge protector in the DON 's office on the second floor;
b) 11:03 a.m., there was a refrigerator plugged into a surge protector in the DON 's office on the second floor.

Interview with the Facility Administrator and Maintenance Director on March 12, 2023, at 10:30 a.m., confirmed the misuse of electrical wiring.





 Plan of Correction - To be completed: 04/18/2024

Surge proctor removed from office. Maintenance director or designee will audit office for compliance weekly for 4 weeks. Results will be reported to the Quality Assurance and Process Improvement meeting.

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