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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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RIDGEVIEW 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 18, 2025, at Ridgeview 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 #015002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on September 18, 2025, it was determined that Ridgeview 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 one-story, Type V (111), protected, wood frame building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

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 01 - Component: 01 - Tag: 0100

Based on observation, document review, and interview, the facility failed to maintain general requirements not addressed by the provided K-tags, but are deficient, affecting one of one building component.
Findings include:
Document review, observation, and interview on September 18, 2025, at 9:35 a.m., revealed the facility failed to provide a set of accurate, portable floor plans at the time of the survey. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site to be used during the Life Safety Code Survey.

The Life Safety Code Floor Plan failed to include the following:
a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls (two-hour walls);
c. Rated rooms (storage rooms, soiled utility rooms, and designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan;
e. Required exits shall be clearly noted.

Interview with the maintenance supervisor on September 18, 2025, at 9:35 a.m., confirmed the facility failed to provide a copy of accurate life safety plans.

Plan of Correction - To be completed: 10/14/2025

The facility located both sets of blueprints identifying smoke barrier walls, fire barrier walls, rated rooms and exits. A portable schematic will be created by the facility maintenance director and added to the facility emergency preparedness manual and each wing nurse's station for reference by 10/14/2025.

NFPA 101 STANDARD Doors with Self-Closing Devices:

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.

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, the facility failed to maintain doors with self-closing devices for one of three smoke compartments.
Findings include:
Observation and interview on September 18, 2025, at 11:22 a.m., revealed the therapy door was missing the self-closing device arm at the time of the survey.

Interview with the maintenance supervisor on September 18, 2025, at 11:22 a.m., confirmed the self-closing device was missing the arm.

Plan of Correction - To be completed: 10/14/2025

Self closure will be added to the therapy door on Walnut Hall smoke compartment and tested for functionality by 10/14/2025. The facility maintenance director or designee will check self closures during routine fire drills to ensure functionality with results reported to the facility quality assessment and assurance commmittee.

NFPA 101 STANDARD Electrical Systems - Receptacles:

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 - 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, the facility failed to maintain electrical receptacles throughout the entire facility.

Findings include:

1.Document review on September 18, 2025, at 10:40 a.m., revealed electrical receptacles in patient care rooms and at deep sedation bed locations were not tested at intervals not exceeding 12 months for non-hospital grade receptacles and hospital grade receptacles, based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:

a. Patient care rooms;
b. Visual inspection of physical integrity;
c. Correct polarity of the hot and neutral connections;
d. Retention force of the grounding blade (except locking-type receptacles) shall be not less than 115g (4 oz).

Interview with the maintenance supervisor on September 18, 2025, at 10:40 a.m., confirmed the lack of documentation.

2.Observation and interview on September 18, 2025, at 10:10 a.m., revealed the beauty shop had two outlets located within six feet of a water source that were not protected by a ground fault circuit interrupter.

Interview with the maintenance supervisor on September 18, 2025, at 10:10 a.m., confirmed the outlets were tested with a hairdryer and were not connected to a ground fault circuit interrupter at the time of the survey.

Plan of Correction - To be completed: 10/14/2025

Receptacle testing was completed in July 2024, noted to be scheduled for October 2025 in TELS. Receptacle testing will be completed by 10/14/2025 and annually, at least every 12 months, thereafter. Schedule in TELS will updated for annual testing.

The outlets identified in the facility beauty shop were replaced by the facility maintenance director with ground fault circuit interrupter outlets and tested for functionality upon installation.

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 01 - Component: 01 - Tag: 0918

Based on document review and interview, the facility failed to maintain the emergency generator, affecting the entire facility.

Findings include:

Document review on September 18, 2025, at 10:30 a.m., revealed the facility failed to provide documentation for the annual 90-minute load bank test.

Interview with the maintenance supervisor on September 18, 2025, at 10:30 a.m., confirmed the test was not completed.

Plan of Correction - To be completed: 10/14/2025

90-minute load bank testing is being completed on 10/6/2025 by PALCO. TELS will be updated to complete annual load bank testing on an annual basis, at least every 12 months.

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