Pennsylvania Department of Health
ROBERT PACKER HOSPITAL SKILLED CARE AND REHABILITATIONCENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 42 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.


ROBERT PACKER HOSPITAL SKILLED CARE AND REHABILITATIONCENTER - 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 February 20, 2025, at Robert Packer Hospital Skilled Care 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: BUILDING 02 - Component: 01 - Tag: 0000

Facility ID# 650202
Component 01
Building 02

Based on a Medicare/Medicaid Recertification Survey completed on February 20, 2025, it was determined that Robert Packer Skilled Care 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 two story, Type II (222), fire resistive building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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: BUILDING 02 - Component: 01 - Tag: 0353

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

Findings include:

1. Observation on February 20, 2025, at 12:10 p.m., revealed the facility lacked current five-year sprinkler gauge replacement (or recalibration) data.

Exit interview on February 20, 2025, between 12:45 p.m., and 12:50 p.m., with the Facility Administrator and the Facilities Manager, confirmed the automatic sprinkler system deficiency.

Plan of Correction - To be completed: 03/11/2025

Five-year sprinkler gauge replacement/recalibration completed 03/30/2022
Education provided to Maintenance Department on requirement
Five-year sprinkler gauge replacement/recalibration will review in QAPI

NFPA 101 STANDARD Corridor - Doors:

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.

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: BUILDING 02 - Component: 01 - Tag: 0363

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

Findings include:

1. Observation on February 20, 2025, at 11:40 a.m., revealed the distance between the Physical Therapy doors exceeded one-eighth-inch.

Exit interview on February 20, 2025, between 12:45 p.m., and 12:50 p.m., with the Facility Administrator and the Facilities Manager, confirmed the corridor opening deficiency.

Plan of Correction - To be completed: 03/11/2025

The Physical Therapy doors that exceeded one-eighth inch have been adjusted to be less than one-eighth inch

Audit completed of other doors to determine any other areas that might be affected

Education provided to Maintenance department on requirement

Audits to be completed monthly x 3 months

Audits to be reviewed in QAPI

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: BUILDING 02 - Component: 01 - Tag: 0761

Based on documentation review and interview, it was determined the facility failed to maintain fire doors, affecting two of two floors.

Findings include:

1. Observation on February 20, 2025, at 12:00 p.m., revealed the facility lacked current fire door annual inspection data.

Exit interview on February 20, 2025, between 12:45 p.m., and 12:50 p.m., with the Facility Administrator and the Facilities Manager, confirmed the fire door deficiency.

Plan of Correction - To be completed: 03/11/2025

Current fire door annual inspection completed

Facility will continue to complete the annual fire door inspection annually as required

Education provided on the requirement

Annual fire door inspection will be reviewed in QAPI annually

Initial comments:Name: BUILDING 03 - Component: 02 - Tag: 0000

Facility ID# 650202
Component 02
Building 03

Based on a Medicare/Medicaid Recertification Survey completed on February 20, 2025, it was determined that Robert Packer Skilled Care 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 two story, Type II (222), fire resistive building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Corridor - Doors:

Observations:
Name: BUILDING 03 - Component: 02 - Tag: 0363

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

Findings include:

1. Observation on February 20, 2025, between 11:06 a.m., and 11:12 a.m., revealed the following:

a. 11:06 a.m., the basement-level Conference Room door was not smoke-tight.
b. 11:12 a.m., the basement-level Nurse Family Partnership Suite door required adjustment to fully latch.

Exit interview on February 20, 2025, between 12:45 p.m., and 12:50 p.m., with the Facility Administrator and the Facilities Manager, confirmed the corridor opening deficiencies.

Plan of Correction - To be completed: 03/11/2025

The basement-level Conference Room door is now smoke-tight.

The basement-level Nurse Family Partnership Suite door has been adjusted to fully
latch.

Audit completed to determine any other doors that might be affected.

Education provided to Maintenance department on requirement

Monthly audit to be completed and reviewed at QAPI

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