Pennsylvania Department of Health
GREENWOOD CENTER FOR NURSING AND REHAB
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 52 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.


GREENWOOD CENTER FOR NURSING AND REHAB - 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 April 21, 2025, at Greenwood Nursing and Rehab, 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# 017902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 21, 2025, it was determined that Greenwood Center for Nursing and Rehab 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 (000), unprotected, wood frame building, that is fully sprinklered.

Plan of Correction:

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, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of one floor.

Findings include:

1. Observation on April 21, 2025, at 11:51 a.m., revealed the cables and BX wiring residing atop branch sprinkler piping, located closest to the west wing, smoke barrier separation wall doors.

Exit interview on April 21, 2025, between 12:50 p.m., and 1:00 p.m., with the Facility Administrator confirmed the automatic sprinkler system deficiency.

Plan of Correction - To be completed: 05/16/2025

1. The wiring on top of sprinkler piping on West Wing smoke barrier separation was repaired.
2. Facility completed baseline audit of sprinkler piping in smoke barrier areas and repaired as necessary.
3. NHA educated Maintenance dept. to ensure sprinkler pipes are free of wiring and on new system of adding monthly random checks to TELS.
4. Maintenance/designee will randomly audit these areas weekly for 4 weeks and then monthly for 2 months to ensure sprinkler piping is free of wiring.
5. Audits will be submitted to QAPI.

NFPA 101 STANDARD Corridor - Doors:

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 one corridor opening, affecting one of one floor.

Findings include:

1. Observation on April 21, 2025, at 11:42 a.m., revealed the west wing Pantry door was not smoke-tight.

Exit interview on April 21, 2025, between 12:50 p.m., and 1:00 p.m., with the Facility Administrator confirmed the corridor opening deficiency.

Plan of Correction - To be completed: 05/16/2025

1. Panty door on West wing was repaired.
2. Facility completed baseline audit of pantry doors and smoke barrier doors to ensure they are smoke tight.
3. NHA educated Maintenance dept to ensure that smoke barrier doors are smoke tight with no gaps and on new system of adding monthly random checks to TELS.
4. Maintenance/designee will randomly audit smoke barrier doors in facility to ensure they are smoke tight weekly for 4 weeks and then monthly for 2 months.
5. Audits will be submitted to QAPI.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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 two smoke barrier separation walls, affecting one of one floor.

Findings include:

1. Observation on April 21, 2025, between 12:03 p.m., and 12:12 p.m., revealed the following:

a. 12:03 p.m., two penetrations of the west main smoke barrier separation wall, located above the doors.
b. 12:12 p.m., a penetration of the east smoke barrier separation wall, located above the smoke barrier separation doors.

Exit interview on April 21, 2025, between 12:50 p.m., and 1:00 p.m., with the Facility Administrator confirmed the smoke barrier separation wall deficiencies.

Plan of Correction - To be completed: 05/16/2025

1. The penetrations on west main smoke barrier walls were repaired, separation of the east smoke separation wall was repaired.
2. Facility completed baseline audit of the smoke barrier walls on each wing to ensure that penetrations were repaired as necessary.
3. NHA educated maintenance dept. that smoke barrier walls cannot have penetrations and on new system of adding monthly random checks to TELS.
4. Maintenance/designee will randomly audit smoke barrier walls in facility to ensure there are no penetrations weekly for 4 weeks and then monthly for 2 months.
5. Audits will be submitted to QAPI for review.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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, it was determined the facility failed to maintain one smoke barrier separation door, affecting one of one floor.

Findings include:

1. Observation on April 21, 2025, at 12:02 p.m., revealed the west main smoke barrier separation door panic hardware was lacking an end cap.

Exit interview on April 21, 2025, between 12:50 p.m., and 1:00 p.m., with the Facility Administrator confirmed the smoke barrier door deficiency.

Plan of Correction - To be completed: 05/16/2025

1. The west main smoke Barrier door was repaired.
2. Facility completed baseline audit to ensure that smoke barrier separation doors have end caps in place.
3. NHA educated Maintenance dept that smoke barrier doors must have end caps in place that are secure and on new system of adding monthly random checks to TELS.
4. Maintenance/designee will randomly audit smoke barrier doors weekly for 4 weeks and then monthly for 2 months to ensure end caps are in place.
5. Audits will be submitted to QAPI for review.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

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 cylinder storage in one location, affecting one of one floor.

Findings include:

1. Observation on April 21, 2025, at 11:55 a.m., revealed three free-standing oxygen cylinders, located within the oxygen storage room.

Exit interview on April 21, 2025, between 12:50 p.m., and 1:00 p.m., with the Facility Administrator confirmed the cylinder storage deficiency.

Plan of Correction - To be completed: 05/16/2025

1. The three free standing O2 concentrators were immediately removed on 4/21/25.
2. Facility completed baseline audit in O2 room to ensure proper storage in place and organize O2 room.
3. NHA educated Maintenance dept. that O2 cylinders cannot be freestanding and on new system of adding weekly random checks to TELS.
4. Maintenance/designee will audit O2 room weekly for 4 weeks and then monthly for 2 month to ensure there is no free standing O2.
5. Audits will be submitted to QAPI for review.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID# 017902
Component 02
Therapy Addition

Based on a Medicare/Medicaid Recertification Survey completed on April 21, 2025, at Greenwood Center for Nursing and Rehab, it was determined there were no deficiencies identified under the 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, that is fully sprinklered.

Plan of Correction:

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