Pennsylvania Department of Health
RIVER VIEW NURSING AND REHABILITATION 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 34 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 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 April 8, 2025, it was determined that Riverview Nursing and Rehabilitation Center was not in compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(c)(3), 416.54(c)(3), 418.113(c)(3), 441.184(c)(3), 482.15(c)(3), 483.475(c)(3), 483.73(c)(3), 484.102(c)(3), 485.542(c)(3), 485.625(c)(3), 485.68(c)(3), 485.727(c)(3), 485.920(c)(3), 486.360(c)(3), 491.12(c)(3), 494.62(c)(3) STANDARD Primary/Alternate Means for Communication:

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.

§403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3).

[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:

(3) Primary and alternate means for communicating with the following:
(i) [Facility] staff.
(ii) Federal, State, tribal, regional, and local emergency management agencies.

*[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies.

Observations:
Name: - Component: -- - Tag: 0032

Based on documentation review and interview, it was determined the facility failed to maintain the emergency preparedness plan in one instance, affecting three of three floors.

Findings include:

1. Observation on April 8, 2025, at 12:50 pm, revealed the facility lacked an updated Delegation of Authority succession plan, last dated 8/2020. Many of the names on the contact list did not match the current staff roster when provided by the Administrator.

Exit interview on April 8, 2025, at 1:15 pm, with the Facility Administrator and Facilities Manager, confirmed the emergency preparedness deficiency.

Plan of Correction - To be completed: 05/28/2025

1.Facility has updated the Delegation of Authority succession Plan.

2. The facility Delegation of Authority will be reviewed and updated as needed.

3. NHA will educate the Receptionist to ensure the Delegation of Authority is completed as needed.

4. Facility Delegation of Authority will be audited weekly x4 then monthly x3 by NHA/Designee to ensure the plan is up to date. Audits will be reviewed at QAPI for further recommendations.

Initial comments:Name: REPLACEMENT BUILDING - Component: 10 - Tag: 0000

Facility ID# 220102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 8, 2025, it was determined that River 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 unused attic spaces, that is fully sprinklered

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

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: REPLACEMENT BUILDING - Component: 10 - Tag: 0211

Based on observation and interview, it was determined the facility failed to ensure that exit access was being maintained readily accessible in one location, on one of three floors.

Findings include:

1. Observation on April 8, 2025, at 12:11 pm, 3rd floor Pine Ridge, C-Tower exit had a wheelchair being stored in the corridor blocking access to the exit door.

Exit interview with the Facility Administrator and Facilities Manager on April 8, 2025, at 1:15 pm, confirmed the wheelchair blocking the exit door.

Plan of Correction - To be completed: 05/28/2025

1.The wheelchair on the 3rd floor Pine Ridge C- Tower exit was removed upon discovery.

2.Education will be provided to all staff by the Maintenance Director/Designee on ensuring wheelchairs are not stored blocking access to the exit doors.

3.The Maintenance director or designee will audit weeklyx4 then monthly x3 to ensure wheelchairs are not stored blocking access to the exit doors.

4.Monthly audits will be reviewed at QAPI for further 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: REPLACEMENT BUILDING - Component: 10 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain three hazardous area enclosures, affecting two of three floors.

Findings include:

1. Observation on April 8, 2025, between 11:15 am, and 12:06 pm, revealed the following:

a. At 11:15 am, 1st floor, Holding Room door failed to latch into frame when tested.
b. At 11:29 am, 1st floor, Elevator machine room had 6 plastic folding tables being stored within the room.
c. At 12:06 pm, 3rd floor Sycamore, Soiled Linen, had unsealed penetrations of the wall due to the wall being damaged.

Exit interview with the Facility Administrator and Facilities Manager on April 8, 2025, at 1:15 pm, confirmed the hazardous area enclosure deficiencies.

Plan of Correction - To be completed: 05/28/2025

1. The first floor holding room door mechanism has been repaired. The 6 plastic folding tables have been removed from the first-floor elevator machine room . Third floor Sycamore Soiled Linen penetration has been sealed and repaired.

2. NHA will in-service Maintenance Director on maintaining enclosed areas free of hazards and penetrations.

3. Maintenance Director /designee will complete a random weekly audit x 4 then monthly x3.

4. Audits will be reported to QAPI for further recommendations.

NFPA 101 STANDARD Sprinkler System - Supervisory Signals:

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.

Sprinkler System - Supervisory Signals
Automatic sprinkler system supervisory attachments are installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and provide a signal that sounds and is displayed at a continuously attended location or approved remote facility when sprinkler operation is impaired.
9.7.2.1, NFPA 72

Observations:
Name: REPLACEMENT BUILDING - Component: 10 - Tag: 0352

Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler in one instance, affecting three of three floors.

Findings include:

1. Observation on April 8, 2025, at 11:37 am, revealed a supervisory signal on the fire alarm panel for fire pump loss of power. Facility stated they have a new fire pump on site but it has not been installed. Fire alarm testing on 4/1/2025 found no deficiencies.

Exit interview with the Facility Administrator and Facilities Manager on April 8, 2025, at 1:15 pm, confirmed the sprinkler supervisory signal.

Plan of Correction - To be completed: 05/28/2025

1. The facility has contracted with Beach Lake Sprinkler to replace the fire pump panel on the week of May 5, 2025.

2.The facility fire pump controller will be reviewed and updated as needed.

3.NHA will educate the Maintenance Director, to assure the fire pump is updated as needed.

4.Fire pump will be audited weekly x4 then monthly x3 by Maintenance Director/Designee to ensure fire alarm pump is up to date. Audits will be reviewed at QAPI for further recommendations.

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: REPLACEMENT BUILDING - Component: 10 - Tag: 0353

Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler in two instances, affecting three of three floors.

Findings include:

1. Observation on April 8, 2025, at 10:55 am, revealed a quarterly sprinkler inspection report from 2/4/2025, stated the fire pump still works as it should, control panel nonresponsive, Emergency stop used to shut down pump.
At the time of the survey, this condition remains.

Exit interview on April 8, 2025, at 1:15 pm., with the Facility Administrator and the Facilities Manager, confirmed the fire pump deficiency.

2. Observation on April 8, 2025, between 11:10 am, and 12:28 pm, revealed the following:
a. At 11:19 am, Laundry, had an unsealed penetration of a ceiling tile, washer side. b. At 11:25 am, Dietary, had (5) sprinkler heads loaded with dust. c. At 12:28 pm, 2nd floor Birch, unsealed penetration in a corridor ceiling tile near the nurse's station.
Exit interview on April 8, 2025, at 1:15 pm., with the Facility Administrator and the Facilities Manager, confirmed the sprinkler system defciencies.

Plan of Correction - To be completed: 05/28/2025

1. The facilities fire pump panel will be replaced the week of May 5th 2025 with Beach Lake Sprinkler company. Maintenance has sealed the penetrations located in the laundry area. The five Dietary Sprinkler heads have been replaced. The second floor Birch penetration near the nurses' station has been sealed.

2. Maintenance Director /Designee will check the ceiling in the laundry from any additional penetrations, and seal if needed. Maintenance Director/Designee will check all sprinkler heads in the dietary for dust, and replace if needed. Maintenance/designee will inspect the Birch unit for penetrations, and seal if needed.

3.Maintenance Director /designee will complete audit x4 weeks, then monthlyx3.

4.Maintenance Director will report to QAPI audits and findings.

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: REPLACEMENT BUILDING - Component: 10 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain three corridor openings, affecting two of three floors.

Findings include:

1. Observation on April 8, 2025, between 11:27 am, and 12:32 pm, revealed the following:

a. At 11:27 am, Dietary, Food Service Room door required adjustment to fully latch into frame.
b. At 12:24 pm, 2nd floor, Personal Laundry Room door failed to latch into frame due to the strike plate being taped over.
c. At 12:32 pm, 2nd floor Aspen, Resident Room 202 door failed to latch into frame.

Exit interview with the Facility Administrator and Facilities Manager on April 8, 2025, at 1:15 pm, confirmed the corridor opening deficiencies.

Plan of Correction - To be completed: 05/28/2025

1. The food service door latch has been adjusted to ensure latching; the Personal Laundry Room door latch has been replaced, Aspen Resident Room 202 latch has been adjusted to ensure latching.

2. Dietary doors will be checked to ensure they latch into their frame . Resident room doors in Aspen will be checked to ensure they latch into their frames.

3. NHA/Designee will in-service Maintenance Director on assuring self-closure doors latch correctly.

4. Maintenance/Designee will audit weeklyx4, then monthly x3. Audits will be reported to QAPI, for further recommendations.

NFPA 101 STANDARD Smoking Regulations:

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: REPLACEMENT BUILDING - Component: 10 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain smoking regulations, affecting one of three floors.

Findings include:

1. Observation on April 8, 2025, at 11:50 am, revealed discarded cigarette butts within the exterior mulch bed, outside the main entrance.

Exit interview with the Facility Administrator and Facilities Manager on April 8, 2025, at 1:15 pm, confirmed the smoking regulations deficiency.

Plan of Correction - To be completed: 05/28/2025

1. Cigarette butts have been removed from the exterior mulch bed, outside the main entrance.

2. Cigarette butts have been removed from all exterior mulch beds.

3. Maintenance/Designee will provide education to all staff on the facility non- smoking policy.

4. Maintenance will complete audits x4 weeks and then monthly x3. Audits will be reviewed at QAPI .

NFPA 101 STANDARD Electrical Equipment - Other:

Electrical Equipment - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 10 (NFPA 99)

Observations:
Name: REPLACEMENT BUILDING - Component: 10 - Tag: 0919

Based on observation and interview, it was determined the facility failed to maintain the electrical system in one location, affecting one of three floors.

Findings include:

1. Observation on April 8, 2025, at 12:02 pm, 3rd floor Storage room near the nurse's station, revealed the storage of items with 36 inches of electrical components, within the room.

Exit interview with the Facility Administrator and Facilities Manager on April 8, 2025, at 1:15 pm, confirmed the electrical systems deficiency.

Plan of Correction - To be completed: 05/28/2025

1. Storage items have been moved away from all electrical panel's components in third floor storage room near the nurses' station.

2. Items have been moved to at least 36 inches of electrical components in facility storage rooms.

3. Maintenance/Designee will educate all staff about maintaining a 3 foot clearance from all electrical panels.

4. Maintenance/Designee will complete audits weekly x4, then monthly x3. Audits will be reported to QAPI.

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