Pennsylvania Department of Health
ROOSEVELT REHABILITATION AND HEALTHCARE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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ROOSEVELT REHABILITATION AND 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 April 16, 2026, at Roosevelt 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# 210102

Component 01

Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 16, 2026, it was determined that Roosevelt Rehabilitation And 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 four-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

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.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0211 Based on observation and interview, it ws determined the facility failed to maintain paths of egress free from all obstructions, affecting the entire facility. Findings include: Observation on April 16, 2026, at 9:45 a.m. revealed, on the fourth floor, the staff did not know the code to open the exit stairwell door. This condition was noted throughout the facility. Exit interview with the Administrator and the Maintenance Director on April 16, 2026, at 10:30 a.m., confirmed the staff did not know the door code.

Plan of Correction - To be completed: 05/15/2026

1. Facility informed staff of the code to the exit stairwell on the fourth floor.
2. Facility did a full-house audit of all exit stairwell codes to inform staff of each stairwell
3. Maintenance Director/Designee re-educated nursing staff on codes for the exit stairwell
4. Maintenance Director/Designee conducted an audit to interview staff members weekly (x4) and monthly (x2) on knowing the code to the exit stairwell. Results of the audits will be reviewed during monthly QAPI meetings

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 Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374 Based on observation and interview, it was determined the facility failed to maintain the fire resistance of smoke barrier doors, affecting one of five levels in the facility. Findings include: 1. Observations on April 16, 2026, between 9:50 a.m., and 10:00 a.m., revealed, on the fourth floor, the following deficiencies: a. 9:50 a.m., Smoke barrier doors by resident room 402 failed to close together. b. 10:00 a.m., Smoke barrier doors by resident room 443 failed to close. Exit interview with the Administrator and the Maintenance Director on April 16, 2026, at 10:30 a.m., confirmed the above deficiencies.

Plan of Correction - To be completed: 05/15/2026

1. Repairs made to smoke doors to ensure the doors close and latch properly by resident rooms 402 and 443
2. Facility conducted full house audit on all smoke doors to ensure that all doors close and latch properly
3. Maintenance Director/Designee re-educated maintenance staff members on the importance and how to close and latch smoke doors properly.
4. Maintenance Director/ Designee conducted an audit consisting of checking 5 smoke doors weekly x 4 and monthly x 2 to ensure they latch and close properly. Results of the audits will be reviewed during monthly QAPI meetings

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