Pennsylvania Department of Health
RIDGEVIEW HEALTHCARE & REHAB CENTER
Building Inspection Results

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RIDGEVIEW HEALTHCARE & REHAB CENTER
Inspection Results For:

There are  49 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.
RIDGEVIEW HEALTHCARE & REHAB 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 January 31, 2024, at Ridgeview Healthcare and Rehab 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# 152502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 31, 2024, it was determined that Ridgeview Healthcare and Rehab Center, LLC, 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 483.70(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 Corridors - Construction of Walls: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.
Corridors - Construction of Walls
2012 EXISTING
Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code.
Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames.
If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area.
19.3.6.2, 19.3.6.2.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0362

Based on observation and interview, it was determined the facility failed to maintain corridors in two locations, affecting two of floors.

Findings include:

1. Observation on January 31, 2024, between 10:40 a.m., and 11:33 a.m., revealed the following:

a. 10:40 a.m., numerous penetrations of the basement-level, exit access corridor system ceiling.
b. 11:33 a.m., a pipe penetration of the second floor, ceiling corridor system, located closest to the Resident Room 202.

Exit interview on January 31, 2024, between 12:15 p.m., and 12:30 p.m., with the Facilities Manager, and the Facility Administrator, confirmed the corridor deficiencies.




 Plan of Correction - To be completed: 03/15/2024

A. New ceiling tile will be added to the problem areas on both floors and then sealed with 3M Intumescent Fire Barrier Sealant which is red in color.
B. All maintenance staff will be educated on the importance of sealing all corridor walls and ceiling in accordance with NFPA 101
C. Weekly audits for 4 weeks, and monthly audits for 3 months will be completed by the Facilities Director to ensure compliance.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor openings in five locations, affecting two of four floors.

Findings include:

1. Observation on January 31, 2024, between 10:50 a.m., and 11:38 a.m., revealed the following:

a. 10:50 a.m., the basement-level, Dietary Storage Room door was held open by unapproved means (tape);
b. 10:52 a.m., a small penetration of the basement-level, Dietary Office door.
c. 10:54 a.m., the Dry Storage Room door was held open by unapproved means (propped open).
d. 10:58 a.m., the basement-level, Dish Room door required adjustment to fully latch.
e. 11:38 a.m., the second floor, Room 204 door was not smoke-tight.


Exit interview on January 31, 2024, between 12:15 p.m., and 12:30 p.m., with the Facilities Manager, and the Facility Administrator, confirmed the corridor opening deficiencies.



 Plan of Correction - To be completed: 03/15/2024

A. All door props were immediately removed, new hardware will be installed to properly seal penetrations, all doors will be adjusted for proper closure and smoke tightness.
B. All maintenance staff will be educated on the importance of doors closing properly, penetrations, props, and smoke tightness in accordance with NFPA 101 Corridor Doors
C. Weekly audits for 4 weeks, and monthly audits for 3 months will be conducted by the Facilities Director to ensure compliance.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
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 four floors.

Findings include:

1. Observation on January 31, 2024, at 11:40 a.m., revealed the second floor, smoke barrier separation door did not close upon release of the magnetic hold-open device.

Exit interview on January 31, 2024, between 12:15 p.m., and 12:30 p.m., with the Facilities Manager, and the Facility Administrator, confirmed the smoke barrier separation door deficiency.



 Plan of Correction - To be completed: 03/15/2024

A. The second floor smoke barrier doors will be adjusted for proper closure.
B. All maintenance staff will be educated on the importance of smoke doors closing properly in accordance with NFPA 101 Smoke Barrier Doors
C. Weekly audits for 4 weeks , and monthly audits for 3 months will be conducted by the Facilities Director to ensure compliance.

NFPA 101 STANDARD HVAC: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.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on observation and interview, it was determined the facility failed to maintain heating, ventilation, and air conditioning in one location, affecting one of four floors.

Findings include:

1. Observation on January 31, 2024, at 11:11 a.m., revealed exhaust duct work within the first floor, Therapy, exhausted into interstitial spaces.

Exit interview on January 31, 2024, between 12:15 p.m., and 12:30 p.m., with the Facilities Manager, and the Facility Administrator, confirmed the HVAC deficiency.



 Plan of Correction - To be completed: 03/15/2024

A. The flexible exhaust hose will be reattached to the ductwork and clamped in place to ensure it doesn't fall off again
B. All maintenance staff will be educated on the importance of keeping all exhaust vents and ductwork intact.
C. Weekly audits for 4 weeks, and monthly audits for 3 months will be conducted by the Facilities Director to ensure compliance.


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