Pennsylvania Department of Health
SAPPHIRE CARE AND REHAB CENTER
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 47 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.


SAPPHIRE CARE AND 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 June 30, 2026, at Sapphire Care 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# 194002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 30, 2026, it was determined that Sapphire Care and 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 483.90(a).

This is a three story, Type III (211), protected, ordinary building, with basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

Least serious 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 has the potential for causing no more than a minor negative impact on the resident.

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, affecting four of four floors.

Findings include:

1. Observation on June 30, 2026, between 11:00 am, and 12:00 pm, revealed the building exceeded the maximum allowable story height for the type of construction by one story.

Exit interview on June 30, 2026, between 12:05 p.m., and 12:10 p.m., with the Facility Administrator and the Facilities Manager, confirmed the building construction deficiency.

Plan of Correction - To be completed: 08/11/2026

● Immediate Correction: The facility has submitted a request to the Pennsylvania Department of Health, Division of Life Safety, to complete a Fire Safety Evaluation System (FSES) review. Completed FSES documentation will be filed in the facility's Life Safety binder upon receipt.
● Systemic Measure: The Maintenance Director has been educated on the proper completion, documentation, and filing of FSES paperwork within the Life Safety binder.
● Monitoring: The Executive Director will review FSES documentation and request an FSES review on an annual basis. Compliance with FSES documentation requirements will be reported at the monthly QAPI meeting.

NFPA 101 STANDARD Vertical Openings - Enclosure:

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.

Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain vertical openings in one location, affecting two of four floor.

Findings include:

1. Observation on June 30, 2026, at 10:44 a.m., revealed a vertical pipe penetration of the floor slab assembly, located between the second and third floor, within the Therapy Gym Office.

Exit interview on June 30, 2026, between 12:05 p.m., and 12:10 p.m., with the Facility Administrator and the Facilities Manager, confirmed the vertical penetration deficiency.

Plan of Correction - To be completed: 08/11/2026

● Immediate Correction: The vertical pipe penetration in the floor slab assembly between the second and third floors within the therapy gym was sealed with approved fire-rated caulk.
● Identification of Other Areas: The Maintenance Director conducted a facility-wide inspection of ceilings and floor/wall penetrations to identify any additional unsealed openings; none were found.
● Systemic Measure: The Maintenance Director was educated on requirements for maintaining the integrity of vertical opening enclosures.
● Monitoring: The Maintenance Director will audit ceilings and penetrations monthly for three months to ensure no new openings exist. Results will be reported at the monthly QAPI meeting.

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 floor.

Findings include:

1. Observation on June 30, 2026, at 11:22 a.m., revealed the basement-level Laundry Room door required adjustment in order to fully latch.

Exit interview on June 30, 2026, between 12:05 p.m., and 12:10 p.m., with the Facility Administrator and the Facilities Manager, confirmed the hazardous area enclosure deficiency.

Plan of Correction - To be completed: 08/11/2026

● Immediate Correction: The laundry room doors were adjusted to fully latch and remain closed.
● Identification of Other Areas: All hazardous area doors throughout the facility were checked to confirm proper latching and closure.
● Systemic Measure: The Maintenance Director was educated on requirements for ensuring hazardous area doors latch and remain closed.
● Monitoring: The Maintenance Director will audit hazardous area doors monthly for three months to confirm doors close and latch properly. Results will be reported at the monthly QAPI meeting.

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 corridor openings in three locations, affecting two of four floors.

Findings include:

1. Observation on June 30, 2026, between 10:30 a.m., and 11:02 a.m., revealed the following doors lacked smoke-tight integrity:

a. 10:30 a.m., Resident Room 204.
b. 10:32 a.m., Resident Laundry.
c. 11:02 a.m., Nurse's Station (third floor).

Exit interview on June 30, 2026, between 12:05 p.m., and 12:10 p.m., with the Facility Administrator and the Facilities Manager, confirmed the corridor opening deficiencies.

Plan of Correction - To be completed: 08/11/2026

● Immediate Correction: The identified corridor doors were adjusted to achieve a smoke-tight closure.
● Identification of Other Areas: Corridor doors throughout the facility were checked to confirm each fully closes and forms a smoke-tight seal.
● Systemic Measure: The Maintenance Director was educated on requirements for ensuring corridor doors fully close and maintain a smoke-tight closure.
● Monitoring: The Maintenance Director will audit corridor doors monthly for three months to confirm proper closure. Results will be reported at the monthly QAPI meeting.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu:

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.

Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain one linen chute door, affecting one of four floors.

Findings include:

1. Observation on June 30, 2026, at 11:16 a.m., revealed the third floor, Linen Chute access door, located within the exit access corridor system, was unlocked.

Exit interview on June 30, 2026, between 12:05 p.m., and 12:10 p.m., with the Facility Administrator and the Facilities Manager, confirmed the linen chute deficiency.

Plan of Correction - To be completed: 08/11/2026

● Immediate Correction: The identified laundry chute door was locked. This is the only laundry chute in the building.
● Systemic Measure: Nursing staff were educated on the regulatory requirement to keep the laundry chute door locked at all times.
● Monitoring: The Maintenance Director will conduct random audits monthly for three months to ensure the laundry chute door remains locked. Results will be reported at the monthly QAPI meeting.

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 maintain electrical apparatus in one location, affecting one of four floors.

Findings include:

1. Observation on June 30, 2026, at 10:22 a.m., revealed an extension cord in use at the first floor, Nurse's Station.

Exit interview on June 30, 2026, between 12:05 p.m., and 12:10 p.m., with the Facility Administrator and the Facilities Manager, confirmed the extension cord deficiency.

Plan of Correction - To be completed: 08/11/2026

● Immediate Correction: The identified power cord was removed from the area.
● Identification of Other Areas: A facility-wide check was conducted to identify any additional improper use of power cords.
● Systemic Measure: The Maintenance Director was educated on regulatory requirements governing the use of electrical power cords.
● Monitoring: Audits will be conducted monthly for three months to ensure ongoing compliance. Results will be reported at the monthly QAPI meeting.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright � 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement