Pennsylvania Department of Health
RIDGEVIEW HEALTHCARE & REHAB 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 & 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 May 29, 2025, at Ridgeview Healthcare & 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 May 29, 2025, it was determined that Ridgeview Healthcare & Rehab 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 483.70(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 Stairways and Smokeproof Enclosures:

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.

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain one exit stair tower enclosure, affecting one of four floors.

Findings include:

1. Observation on May 29, 2025, at 11:33 a.m., revealed several items were located within the second floor portion of the west stair tower enclosure.

Exit interview on May 29, 2025, between 12:30 p.m., and 12:35 p.m., with the Facility Administrator and the Facilities Manager, confirmed the stair tower enclosure deficiency.

Plan of Correction - To be completed: 07/08/2025

1. All items were immediately removed from the stairtower.
2. All Maintenance staff will be educated on the importance of keeping stairtowers and smokeproof enclosures clutter free in accordance with NFPA 101 Stairways and Smokeproof Enclosures.
3. Weekly audits for 4 weeks will be completed by the Facilities Director to ensure compliance.

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 one hazardous area enclosure, affecting one of four floors.

Findings include:

1. Observation on May 29, 2025, at 11:44 a.m., revealed the basement-level, Pot and pan Storage Room door was held open by unapproved means.

Exit interview on May 29, 2025, between 12:30 p.m., and 12:35 p.m., with the Facility Administrator and the Facilities Manager, confirmed the hazardous area enclosure deficiency.

Plan of Correction - To be completed: 07/08/2025

1. All door props were immediately removed
2. All maintenance and kitchen staff will be educated on the importance of not propping open doors in accordance with NFPA 101 Hazardous Areas-Enclosures
3. Weekly audits for 4 weeks will be conducted by the Facilities Director to ensure compliance.

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 one location, affecting one of four floors.

Findings include:

1. Observation on May 29, 2025, at 11:03 a.m., revealed an "egg crate-style" ceiling tile, located within the third floor, Kitchenette.

Exit interview on May 29, 2025, between 12:30 p.m., and 12:35 p.m., with the Facility Administrator and the Facilities Manager, confirmed the automatic sprinkler deficiency.

Plan of Correction - To be completed: 07/08/2025

1. The egg crate style ceiling tile was removed immediately and replaced with a 5/8" Armstrong Fine Fissured fire rated ceiling tile.
2. All maintenance staff will be educated on the importance of installing and maintaining the proper ceiling tile in accordance with NFPA 101 Sprinkler Systems
3. Weekly Audits for 4 weeks will be conducted by the facilities Director to ensure compliance.

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