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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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GREENERY CENTER FOR REHAB AND NURSING - 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 May 12, 2025, at Greenery Center for Rehab and Nursing, 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# 135602
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 12, 2025, it was determined that Greenery Center for Rehab and Nursing 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 II (000), unprotected non-combustible building, without a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

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.

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain an unobstructed means of egress in one instance, affecting one of six smoke compartments.

Findings include:

1. Observation on May 12, 2025, at 10:45 a.m., revealed the 100 hallway was overcrowded with wheelchairs and other miscellaneous storage on both sides of the hallway, which would impede the exit egress routes from resident rooms.

Interview with the Facility Administrator and the Maintenance Director on May 12, 2025, at 1:00 p.m., confirmed the listed means of egress deficiency.

Plan of Correction - To be completed: 06/25/2025

Items stored in the hallway have been positioned to just one side of the hallway. Staff will be educated on means of egress and storage in the hallway not being there for longer than 30 minutes, by 07/15/2025. The maintenance directly will complete weekly audits of hallways to ensure compliance for 4 weeks and then weekly for one month. Findings will be submitted to QAPI for review and further action if needed.

NFPA 101 STANDARD Doors with Self-Closing Devices:

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, it was determined the facility failed to maintain self-closing doors in one instance, affecting one of six smoke compartments.

Findings include:

1. Observation on May 12, 2025, at 10:35 a.m., revealed a self-closing device was removed from the door to the Housekeeping Supervisor's office.

Interview with the Facility Administrator and Maintenance Director on May 12, 2025, at 1:00 p.m.,confirmed the self-closing door deficiency.

Plan of Correction - To be completed: 06/25/2025

The maintenance director has installed a self closing device to the housekeeping supervisors door. The maintenance director completed an audit on facility doors to verify that they have self-closing devices. The maintenance director will audit self-closing devices on the six smoke compartments monthly for 3 months. Findings will be submitted to QAPI for review and further action if needed.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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 hazardous area enclosures in one instance, affecting one of six smoke compartments.

Findings include:

1. Observation on May 13, 2025, at 10:50 a.m., revealed the door to the generator room failed to latch when tested.

Interview with the Facility Administrator and the Maintenance Director on May 12, 2025, at 1:00 p.m., confirmed the door failed to latch at the time of the survey.

Plan of Correction - To be completed: 06/25/2025

The maintenance director has scheduled for a semi annual fire suppression system inspection and for a semiannual hood cleaning to be completed for June 5th 2025. The NHA or designee has educated the maintenance director on NFPA code for Cooking Facilities. The NHA or designee will audit that semi annual inspections are conducted timely for 6 months and yearly going forward. Findings will be submitted to QAPI for review and further action if needed.

NFPA 101 STANDARD Cooking Facilities:

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on documentation review, observation, and interview, it was determined the facility failed to maintain the kitchen hoods in two instances, affecting one of six smoke compartments.

Findings include:

1. Document review and observation on May 12, 2025, revealed the facility lacked the following documentation for maintaining the facility's kitchen hoods:

a) 8:25 a.m., there was only documentation for one of two required semiannual fire suppression system inspections;
b) 8:29 a.m., there was only documentation for one of the two required semiannual hood cleanings.

Interview with the Facility Administrator and Maintenance Director on May 12, 2025, at 1:00 p.m., confirmed the facility lacked the above listed kitchen hood maintenance documentation performed in the last 12 months.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 four instances, affecting four of six smoke compartments.

Findings include:

1. Observation on May 12, 2025, revealed the following automatic sprinkler system deficiencies:

a) 10:30 a.m., there were multiple missing ceiling tiles in the basement Mechanical room/Fire alarm panel room, which would allow the passage of heat and smoke, and may affect operation of the automatic sprinkler system;
b) 10:40 a.m., there was a ceiling tile that had an excessive gap over 1/8 inch in the storage room of the large conference room;
c) 11:00 a.m., there was insulation laying on a sprinkler branch line above the ceiling tile, next to the Physical Therapy room;
d) 11:25 a.m., a sprinkler head was missing an escutcheon plate above the Nurse's station in the 100 hallway.

Interview with the Facility Administrator and Maintenance Director on May 12, 2025, at 1:00 p.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 06/25/2025

The maintenance director has made sure that the ceiling tiles in the mechanical/fire alarm panel room have been placed according to code. The insulation that was laying on the branch line above the ceiling tile has been removed and the sprinkler plate that was missing above the nurses station of the 100 hall has been placed and ceiling tiles replaced . The maintenance director will audit 2X a week for 4 weeks that the sprinkler system is maintained. Findings will be submitted to QAPI for review and further action if needed.

NFPA 101 STANDARD Portable Fire Extinguishers:

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.

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on documentation review and interview, it was determined the facility failed to maintain portable fire extinguisher inspections in one instance, affecting the entire facility. In accordance with NFPA 10, 7.1.2.1.

Findings include:

1. Review of documentation on May 12, 2025, at 9:25 a.m., revealed the facility is unable to confirm if the person/persons who performed the annual portable fire extinguisher inspection are certified to inspect portable fire extinguishers.

Interview with the Facility Administrator and the Maintenance Director on May 12, 2025, at 1:00 p.m., confirmed a certificate of training for the fire extinguisher inspector that performed the annual inspection, was not available at the time of the survey.

Plan of Correction - To be completed: 06/25/2025

The facility will obtain the person who completed the portable fire extinguisher inspection certification. The maintenance director will obtain certification prior to services being provide going forward and maintain a binder with documentation to ensure compliance. Findings will be submitted to QAPI for review and further action if needed.

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 corridor doors in two instances, affecting two of six smoke compartments.

Findings include:

1. Observation on May 12, 2025, revealed the following corridor door deficiencies:

a) 10:05 a.m., the door to resident room 114 would not close and latch because the resident's bed was blocking the door from closing;
b) 10:20 a.m., the door to the conference room had a large divot caused by a heavy magnet hitting the door repeatedly, affecting the integrity of the door.

Interview with the Facility Administrator and Maintenance Director on May 12, 2025, at 1:00 p.m., confirmed the corridor door deficiencies.

Plan of Correction - To be completed: 06/25/2025

The bed in resident room 114 has been adjusted to not block the door. The door to the conference room will be replaced. The maintenance director/designee will educate staff regarding doors not being blocked from closing. Findings will be submitted to QAPI for review and further action if needed.

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 smoke barrier doors in one instance, affecting two of six smoke compartments.

Findings include:

1. Observation on May 12, 2025, at 9:55 a.m., revealed the smoke barrier doors in the 200 hallway were blocked by a hoyer lift and would not close.

Interview with the Facility Administrator and the Maintenance Director on May 12, 2025, at 1:00 p.m., confirmed the listed smoke barrier door deficiency.

Plan of Correction - To be completed: 06/25/2025

Items blocking the smoke barrier doors in the 200 hall were removed. The maintenance director/designee will educate staff that items are not to be stored in front of smoke barrier doors. The maintenance/designee will audit 2x weekly for 4 weeks that items are not stored in front of smoke barrier doors in hallways. Findings will be submitted to QAPI for review and further action if needed.

NFPA 101 STANDARD Fire Drills:

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 May 12, 2025, at 8:50 a.m., revealed the facility lacked documentation for a first shift fire drill, in the second quarter.

Interview with the Facility Administrator and Maintenance Director on May 12, 2025, at 1:00 p.m., confirmed the facility lacked documentation for the required fire drill in the last twelve months.

Plan of Correction - To be completed: 06/25/2025

A fire drill was completed on 05/14/2025 on first shift. The NHA/Designee has educated the maintenance director on Fire Drills being done monthly. The NHA/Designee will audit that fire drills are completed monthly for 3 months. Findings will be submitted to QAPI for review and further action if needed.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

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: MAIN BUILDING 01 - Component: 01 - 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 May 12, 2025, revealed the following electrical equipment deficiencies:

a) 9:15 a.m., there was a refrigerator, coffee pot, and small heater, plugged into a power strip in the Billing Office on the first floor;
b) 9:20 a.m., there was a refrigerator plugged into a power strip in the ADON office on the first floor.

Interview with the Facility Administrator and Maintenance Director on May 12, 2025, at 1:00 p.m., confirmed the misuse of electrical wiring.

Plan of Correction - To be completed: 06/25/2025

All heating or cooling devices have been plugged in properly. The maintenance director completed an audit to confirm no other power strips were being used with heating and cooling devices. The Maintenance director will audit 2 rooms a week for 4 weeks to verify that power strips are not being used to connect power to heating and cooling devices. Findings will be submitted to QAPI for review and further action if needed.

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