Pennsylvania Department of Health
ROSE VIEW NURSING AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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ROSE VIEW NURSING AND REHABILITATION 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 December 30, 2024, at Rose View Nursing and Rehabilitation 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# 185502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on December 30, 2024, 2023, it was determined that Rose View Nursing and Rehabilitation 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 483.90(a).

This is a three story, Type II (111), protected, noncombustible building, with an unused attic space, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

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.

Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in one location, affecting one of nine smoke compartments.

Findings include:

1. Observation on December 30, 2024, at 10:55 a.m., revealed the ceiling tiles lacking in two locations within the first floor, Maintenance Storage Room.

Exit interview with the Facility Administrator on December 30, 2024, between 11:35 a.m., and 11:40 a.m., confirmed the building construction deficiency.

Plan of Correction - To be completed: 02/05/2025

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.

1. Both ceiling tiles were replaced with a rated ceiling tile.
2. Other ceiling tiles will be checked to ensure they are in place.
3. Maintenance will be re-educated on ensuring that ceiling tiles are in place.
4. Maintenance Director/ designee will conduct random audits to verify that ceiling tiles are in place weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at QAPI meeting for review and recommendations.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

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 three of three floors.

Findings include:

1. Observation on December 30, 2024, at 10:40 a.m., revealed the first floor, west stair tower enclosure exit discharge door, fire exit hardware, was missing an end cap.

Exit interview with the Facility Administrator on December 30, 2024, between 11:35 a.m., and 11:40 a.m., confirmed the stair tower enclosure deficiency.

Plan of Correction - To be completed: 02/05/2025

1. Missing end cap on the first floor west stair tower door was replaced.
2. Other stair tower door enclosures will be checked for missing end caps.
3. Maintenance will be re-educated on ensuring that door enclosures have end caps installed.
4. Maintenance Director/ designee will conduct random audits to verify that exit hardware end caps are in place weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at QAPI meeting for review and recommendations.

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 nine smoke compartments.

Findings include:

1. Observation on December 30, 2024, at 10:12 a.m., revealed the second floor, Soiled Utility Room door was not smoke-tight.

Exit interview with the Facility Administrator on December 30, 2024, between 11:35 a.m., and 11:40 a.m., confirmed the hazardous area enclosure deficiency.

Plan of Correction - To be completed: 02/05/2025

1. Soiled utility room door will be adjusted for smoke-tight gap.
2. Soiled utility room door gaps will be checked for smoke-tight gap.
3. Maintenance will be re-educated on ensuring that all doors are smoke-tight.
4. Maintenance Director/designee will conduct random audits to verify that doors are smoke-tight weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at QAPI meeting for review and recommendations.

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 one corridor opening, affecting one of nine smoke compartments.

Findings include:

1. Observation on December 30, 2024, at 11:01 a.m., revealed the first floor, Dietary door failed to close and latch, due to door drag.

Exit interview with the Facility Administrator on December 30, 2024, between 11:35 a.m., and 11:40 a.m., confirmed the corridor opening deficiency.

Plan of Correction - To be completed: 02/05/2025

1. Door will be replaced so it will close and latch properly.
2. Other doors enclosures will be checked to verify closing and latching.
3. Maintenance will be re-educated on ensuring that all door enclosures are closing and latching.
4. Maintenance Director/ designee will conduct random audits to verify that door enclosures are closing and latching weekly for 4 weeks and then monthly for 2 moths thereafter. Audits results will be presented at the QAPI meeting for review and recommendations.

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