Pennsylvania Department of Health
RIVER'S EDGE REHABILITATION & HEALTHCARE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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RIVER'S EDGE REHABILITATION & HEALTHCARE 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 June 11, 2024, at River's Edge Rehabilitation and Healthcare 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 #183502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 11, 2024, it was determined Rivers Edge Rehabilitation & Healthcare Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 two-story, Type II (222), fire resistive building, 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 doors in the means of egress free of obstructions, affecting one of two levels.

Findings Include:

Observation on June 11, 2024, at 12:55 p.m., revealed, on the first floor, the East stair emergency exit door was difficult to open due to sticking on the threshold.

Exit Interview with the Administrator and Maintenance Director on June 11, 2024, at 12:15 p.m., confirmed the egress door obstruction.

Plan of Correction - To be completed: 08/10/2024

1. There was no negative outcome due to the emergency exit door being difficult to open.
2. All residents have the potential to be affected by the deficient practice.
3. The facility contracted with an outside company to install a new door.
4. The Maintenance Director or designee will audit the emergency exit doors twice a month to ensure the means of egress remain unimpeded X 90 days. The finding will be reported to the QAPI committee on a monthly basis X 3 months.

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to maintain its emergency lighting, affecting one of two floors.

Findings include:

Document review on June 11, 2024, at 9:00 a.m., revealed the facility lacked documentation showing annual 90-minute testing of battery back-up lighting.

Exit Interview with the Administrator and Maintenance Director on June 11, 2024, at 12:15 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 06/28/2024

1. There was no negative outcome noted by there not being any documentation in place for the annual 90-minute testing of battery back-up lighting.
2. All residents have the potential to be affected by the deficient practice.
3. Maintenance reached out to the facility's vendor to obtain documentation of the 90-minute testing of the battery backup lighting.
4. The Maintenance Director will audit the Life Safety book weekly x 90 days to ensure that there is no documentation that is missing. The findings will be reported to the QAPI committee on a monthly basis x 3 months.

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 that the facility failed to maintain hazardous areas, affecting one of two levels.

Findings include:

Observation on June 11, 2024, at 10:30 a.m., revealed the kitchen electrical transformer room had multiple items stored within the room.

Exit Interview with the Administrator and Maintenance Director on June 11, 2024, at 12:15 p.m., confirmed the storage in the hazardous electrical room.

Plan of Correction - To be completed: 06/28/2024

1. The kitchen electrical transformer room was immediately cleared of all the items stored in the room.

2. All residents have the potential to be affected by the deficient practice.

3. The kitchen electrical transformer room was immediately cleared of all the items stored in the room.
4. The Maintenance Director or designee will audit the electrical transformer room twice a month to ensure that there are no items being stored in there X 90 days. The finding will be reported to the QAPI committee on a monthly basis X 3 months.

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 ensure that corridor doors were maintained to resist the passage of smoke, affecting one of two levels.

Findings include:

Observation on June 11, 2024, at 11:05 a.m., revealed, on the first floor, the room 110 corridor door failed to close and latch when tested.

Exit Interview with the Administrator and Maintenance Director on June 11, 2024, at 12:15 p.m., confirmed the corridor door failed to latch.

Plan of Correction - To be completed: 06/28/2024

1. There was no negative outcome noted by the fact that the door dragged on the floor and was difficult to open and close.

2. All residents have the potential to be affected by the deficient practice of the door not closing properly.

3. Door identified on the first floor was adjusted and latching properly.

4. The Maintenance Director or designee will audit all door hinges twice a month to ensure that all doors are positively latching x 90 days. The findings will be reported to the QAPI committee on a monthly basis x 3 months.

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 smoke barrier walls free of unsealed penetrations, affecting one of two levels.

Findings include:

Observation on June 11, 2024, at 11:30 a.m., revealed, above smoke doors by resident room 128, an unsealed penetration around a new copper pipe.

Exit Interview with the Administrator and Maintenance Director on June 11, 2024, at 12:15 p.m., confirmed the penetration.

Plan of Correction - To be completed: 07/05/2024

1. No negative outcome was noted due to the open penetration around the new copper pipe above the smoke doors outside room 128.

2. All residents have the potential to be affected by the deficient practice.

3. Maintenance sealed the open penetration around the new copper pipe above the smoke doors outside room 128 on the first floor. All penetrations were sealed using an UL approved stop gap penetration system.

4. The Maintenance Director or designee will conduct a monthly audit during environmental rounds to ensure there are no areas of open penetration within the facility x 90 days. The findings will be reported to the QAPI committee on a monthly basis x 3 months.

NFPA 101 STANDARD Utilities - Gas and Electric:

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting one of two levels.

Findings include:

Observation on June 11, 2024, at 11:50 a.m., revealed, on the first floor, in Nurse Station Med Room, a non-GFCI outlet located within 6 feet of a sink. Per NFPA 70 210.8(B)5, a GFCI outlet is required where receptacles are installed within 6 ft of the outside edge of the sink.

Exit Interview with the Administrator and Maintenance Director on June 11, 2024, at 12:15 p.m., confirmed the outlet.

Plan of Correction - To be completed: 06/28/2024

1. There was no negative outcome noted due to the outlet not being a ground fault circuit interrupter outlet.

2. All residents have the potential to be affected by the deficient practice.

3. Maintenance immediately changed the outlet to a ground fault circuit interrupter outlet.

4. The Maintenance Director or designee will audit all the outlets that require a ground fault circuit protecter outlet twice a month x 90 days, to ensure that the proper outlets are in place. The findings will be reported to the QAPI committee on a monthly basis x 3 months.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to properly conduct the required annual fire door inspection, for one required inspection.

Findings include:

Document review on June 11, 2024, at 9:00 a.m., revealed the facility lacked documentation showing that a complete annual fire door inspection was performed as required per NFPA 80.

Exit Interview with the Administrator and Maintenance Director on June 11, 2024, at 12:15 p.m., confirmed the incomplete documentation.

Plan of Correction - To be completed: 07/05/2024

1. No negative outcome was noted due to not having the documentation showing the complete annual fire door inspection as required per NFPA 80.

2. All residents have the potential to be affected by the deficient practice.

3. The Maintenance Director inspected all the fire doors to ensure they are working properly and documented completely that the inspection was performed properly as per NFPA 80.

4. The Maintenance Director or designee will inspect all fire doors monthly for 3 months to ensure they are completely working as required per NFPA 80. The findings will be reported to the QAPI committee.

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 prohibit the improper and unauthorized use of electrical devices, affecting one of two levels.

Findings include:

Observation on June 11, 2024, at 10:45 a.m., revealed a fridge plugged into an extension cord, on the first floor, the Administrator's Office.

Exit Interview with the Administrator and Maintenance Director on June 11, 2024, at 12:15 p.m., confirmed the unauthorized electrical device.

Plan of Correction - To be completed: 06/28/2024

1. No negative outcome was noted due to having the fridge plugged into the extension cord.
2. All residents have the potential to be affected by the deficient practice.
3. The refrigerator in the administrator's office was immediately disconnected from the extension cord.
4. The Maintenance Director or designee will audit all electrical devices weekly X 1 month and then monthly thereafter for 3 months to ensure that there are no electrical devices that are plugged into an extension cord or surge protector. The findings will be reported to the QAPI committee.

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