Pennsylvania Department of Health
CONCORDIA AT THE CEDARS
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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CONCORDIA AT THE CEDARS - 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 3, 2025, at Concordia at the Cedars, 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# 062502
Component 01
Main building

Based on a Medicare/Medicaid Recertification Survey completed on March 3, 2025, it was determined that Concordia at the Cedars 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 three-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

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 3, 2025, at 9:15 a.m., revealed the door to room 320 on the third floor failed to latch when tested.

Interview with the Facility Administrator and Maintenance Director on March 3, 2025, at 10:30 a.m., confirmed the corridor door deficiency

Plan of Correction - To be completed: 03/24/2025

1. Room 320 on the third floor is now latching in accordance with K 0363.

2. Current residents have the potential to be affected. Maintenance Director and or designee will audit doors to validate doors latch in accordance with K 0363. Any identified doors during the audit not adhering to the K 0363 regulation will have corrective action.

3. Administrator and or designee will educate Maintenance Department on Life Safety regulation K 0363.

4. The Maintenance Director will complete audits on doors weekly x4 weeks then monthly thereafter for 3 months to validate doors are closing properly according to the K 0363 regulation. Results of this audit will be reported to the Quality Assessment and Assurance Committee.

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