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

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RIVER'S EDGE REHABILITATION & HEALTHCARE CENTER
Inspection Results For:

There are  38 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.
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 March 31, 2025, 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 March 31, 2025, 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 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 that the facility failed to maintain the fire-resistance rating of stair towers, affecting one of two levels.

Findings include:

1. Observation on March 31, 2025, at 11:40 am, revealed 1st floor center stair tower door had an open hole above the handle.

Exit Interview with the Administrator and Maintenance Director on March 31, 2025, at 12:00 pm, confirmed the stair tower door deficiency.




 Plan of Correction - To be completed: 05/05/2025


1. There was no negative outcome due to the 1st floor center stair tower door having an open hole above the handle.
2. All residents have the potential to be affected by the deficient practice.
3. The facility immediately installed a steel fastener that completely seals the hole above the handle.
4. The Maintenance Director or designee will audit all stairwell doors weekly x1 month and monthly X2 thereafter to ensure the there are no open enclosures. The findings will be reported to the QAPI committee on a quarterly basis X2.

NFPA 101 STANDARD Alcohol Based Hand Rub Dispenser (ABHR):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.
Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0325

Based on observation and interview, it was determined the facility failed to protect Alcohol Based Hand Rub Dispenser (ABHR), affecting one of two levels.

Findings include:

1. Observation on March 31, 2025, at 11:35 am, revealed an ABHR was installed directly above a duplex electrical outlet, 2nd floor east by the resident weight-scale.

Exit Interview with the Administrator and Maintenance Director on March 31, 2025, at 12:00 pm, confirmed the ABHR location.




 Plan of Correction - To be completed: 05/05/2025

1. There was no negative outcome due to an ABHR being placed above a duplex electrical outlet.
2. All residents have the potential to be affected by the deficient practice.
3. The facility Immediately moved the ABHR to the opposite side, on a wall with no outlet resulting in greater than 1" from any electrical outlet.
4. The Maintenance Director or designee will audit all ABHR weekly x1 month and monthly X2 thereafter to ensure the there are no ABHR above an electrical outlet. The findings will be reported to the QAPI committee on a quarterly basis X2.

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 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 March 31, 2025, at 11:05 am, revealed an unsealed penetration around data wires, 1st floor above smoke doors by room 117.

Exit Interview with the Administrator and Maintenance Director on March 31, 2025, at 12:00 pm, confirmed the penetration.




 Plan of Correction - To be completed: 05/05/2025

1. No negative outcome was noted due to the unsealed penetration around the data wires above the smoke doors by room 117.

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

3. Maintenance sealed the penetration around the data wire above the smoke doors outside room 117 on the first floor with STI SpecSeal Firestop Products #SSP100 System No. W-L-3090
F Ratings - 1 and 2 Hr
T Ratings - 1/2, 1 and 2 Hr
L Rating At Ambient - 8 CFM/sq ft
L Rating At 400 F - Less Than 1 CFM/sq ft
4. The Maintenance Director or designee will conduct a monthly audit 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 quarterly basis X2 quarters.



NFPA 101 STANDARD Utilities - Gas and Electric: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.
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 March 31, 2025, at 11:00 am, revealed, in 1st floor East Wing soiled 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 March 31, 2025, at 12:00 pm, confirmed the outlet.





 Plan of Correction - To be completed: 05/05/2025

1. There was no negative outcome noted due to the non-GFCI outlet located within 6 feet of a sink.

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 weekly X1 Month, and monthly X2 to ensure that the proper outlets are in place. The findings will be reported to the QAPI committee on a quarterly basis X2 quarters.


NFPA 101 STANDARD HVAC:This is a less serious (but not lowest level) 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 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.
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 document review and interview, it was determined the facility failed to maintain Heating, Ventilating, and Air Conditioning (HVAC) equipment, affecting the entire facility.

Findings include:

1. Document review on March 31, 2025, at 9:00 am, revealed the March 19, 2025, fire damper inspection report listed 16 dampers deficient. Evidence of corrective action was not available at time of survey.

Exit Interview with the Administrator and Maintenance Director on March 31, 2025, at 12:00 pm, confirmed the missing documentation.




 Plan of Correction - To be completed: 05/30/2025

1. There was no negative outcome noted due to the 16 deficient dampers having failed their test.

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

3. The facility has contracted an outside company to repair or replace all dampers that are currently not working.

4. The Maintenance Director or designee will audit all the dampers monthly to ensure that they are working properly x 90 days. The findings will be reported to the QAPI committee on a quarterly basis x 2 quarters.


NFPA 101 STANDARD Smoking Regulations: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.
Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain smoking areas, affecting one of two levels.

Findings include:

1. Observation on March 31, 2025, at 10:30 am, revealed the designated Employee Smoking area had numerous cigarette butts strewn on the ground adjacent to the designated smoking area and not in the provided ash receptacles.

Exit Interview with the Administrator and Maintenance Director on March 31, 2025, at 12:00 pm, confirmed the smoking deficiency.




 Plan of Correction - To be completed: 05/05/2025

1. There was no negative outcome noted due to the employee smoking area having numerous cigarette butts strewn on the ground and not in the provided cigarette receptacles.
2. All residents have the potential to be affected by the deficient practice.
3. Housekeeping immediately swept up all cigarette butts and all staff were in-serviced on proper cigarette disposal.
4. The Housekeeping Director or designee will audit the designated smoking area weekly X4 and Monthly X2 to ensure the area is free of cigarette butts. The findings will be reported to the QAPI committee on a quarterly basis x 2 quarters.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
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:

1. Observation on March 31, 2025, at 10:45 am, revealed a fridge plugged into a power strip, 1st floor kitchen office.

Exit Interview with the Administrator and Maintenance Director on March 31, 2025, at 12:00 pm, confirmed the unauthorized electrical device.




 Plan of Correction - To be completed: 05/05/2025

1. No negative outcome was noted due to having the fridge plugged into a power strip.
2. All residents have the potential to be affected by the deficient practice.
3. The refrigerator in the Kitchen office was immediately disconnected from the extension cord and switched to opposite side of room to be directly plugged into the wall.
4. The Maintenance Director or designee will audit all electrical devices weekly X 1 month and then monthly thereafter x2 months to ensure all electrical devices are plugged into a wall receptacle. The findings will be reported to the QAPI committee on a quarterly basis x 2 quarters


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