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

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ROOSEVELT REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

There are  44 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.
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 29, 2025, 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 29, 2025, 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 Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on observation and interview, it was determined the facility failed to maintain smoke detectors within a smoke tight assembly, affecting one of five levels.

Findings include:

Observation on April 29, 2025, at 12:05 p.m., revealed a large ceiling penetration directly next to a smoke detector, room 242 bathroom, on the second floor.

Exit Interview with the Director of Nursing and Maintenance Director on April 29, 2025, at 1:40 p.m., confirmed the smoke detector deficiency.





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

1.Facility corrected the ceiling penetration in room 242 bathroom by the smoke detector, using a fire-rated product 3M FIRE BARRIER SEALANT CP 25WB+ INTUMESCENT to seal the penetration.
2.The facility conducted a full house audit to ensure no ceiling penetration.
3.NHA re-educated the maintenance department to ensure the ceiling in the facility does not have any areas of penetration
4.The maintenance director or designee will conduct audits weekly x4 and monthly x2 to ensure no areas of the ceiling are penetrated. Results will be submitted to QAPI for review and recommendations as needed.

NFPA 101 STANDARD Utilities - Gas and Electric: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.
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0511

Based on observation and interview, it was determined facility failed to maintain protection of electrical systems, affecting four of five levels.

Findings include:

Observations on April 29, 2025, revealed the following electrical system deficiencies:

a. 10:50 a.m., in the basement, the corridor by central supply- duplex missing its cover.
b. 11:00 a.m., in the basement, the boiler room- EM-1 panel missing internal cover plate.
c. 11:05 a.m., in the basement, the construction room- damaged duplex receptacle.
d. 11:20 a.m., on the fourth floor, by room 409- damaged duplex receptacle.
e. 11:43 a.m., on the third floor, above doors by room 302- exposed wires by exit sign.
f. 12:45 p.m., on the first floor, the lobby behind desk- duplex missing its cover.

Exit Interview with the Director of Nursing and Maintenance Director on April 29, 2025, at 1:40 p.m., confirmed the electrical deficiencies.








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

1.
a. Facility replaced duplex in central supply, construction room
b. Facility replaced missing panel plate cover in the basement boiler room
c. Facility relaced damaged duplex receptable
d. Facility replaced damaged duplex receptable on the fourth floor.
e. Facility ensured no exposed wires on the third floor by 302
f. Facility replaced missing duplex cover.
2. Maintenance director or designee conducted full house audit to ensure duplexes are in in good standing order, EM panels are in place, and no exposed wires with exit signs.
3.NHA re-educated the maintenance department on duplex, panels, and ensuring no exposed wires throughout the facility.
4. Maintenance director or designee will conduct audits weekly x4 and monthly x2. Results will be submitted to QAPI for review and recommendations as needed.

NFPA 101 STANDARD HVAC: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.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on observation and interview, it was determined the facility failed to maintain Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting one of five levels

Findings include:

Observation on April 29, 2025, at 11:55 a.m., revealed on the second floor, in the South Unit Managers Office, the duct penetrating the 2-hour shaft wall lacked a fire damper.

Exit Interview with the Director of Nursing and Maintenance Director on April 29, 2025, at 1:40 p.m., confirmed the missing damper.






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

1.A rated fire damper will be installed between the barrier walls on 2 south unit manager's office.
2.The maintenance director or designee conducted full house audit to ensure all fire dampers are in place.
3.NHA or designee re-educated maintenance department on fire dampers.
4.The maintenance director or designee will conduct audits x4 weeks and monthly x2. Results will be submitted to QAPI for review and recommendations are needed.

NFPA 101 STANDARD Maintenance, Inspection & Testing - 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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to maintain fire doors, affecting 16 of 60 fire doors.

Findings include:

Document review on April 29, 2025, at 8:30 a.m., revealed 16 fire doors failed their annual inspection. Documentation could not be provided showing repairs were completed.

Exit Interview with the Director of Nursing and Maintenance Director on April 29, 2025, at 1:40 p.m., confirmed the missing documentation.





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

1.The Facility is requesting a Time-limited Waiver to replace several rated fire doors due to manufacturer delays.
2.The facility will replace and/or repair 16 fire doors. The annual fire door inspection was completed the day before the LS inspection.
3.Facility conducted full house inspection on all fire doors to ensure no other repairs were needed.
4.NHA/designee re-educated maintennce department on fire doors must be in working order.
5.The maintenance director/designee will conduct audits weekly x4 and monthly x2. Results will be submitted to QAPI for review and recommendations are needed.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
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 prohibit the unauthorized use of electrical devices, affecting one of five levels.

Findings include:

Observations on April 29, 2025, revealed the following electrical deficiencies:

a. 11:50 a.m., on the second floor, South Social Services office- fridge and microwave into outlet multiplier;
b. 12:00 p.m., on the second floor, North Unit Manager office- microwave into power strip.

Exit Interview with the Director of Nursing and Maintenance Director on April 29, 2025, at 1:40 p.m., confirmed the unauthorized electrical devices.





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

1.Facility removed outlet multiplier from social services office and power strip on the 2nd floor unit manager office.
2.The maintenance director/designee conducted a full house audit of all offices to ensure power strips and multipliers are not in use.
3.NHA or designee re-educated unit managers and department staff on unauthorized electrical devices.
4.The maintenance director/designee will conduct audits weekly x4 and monthly x2. Results will be submitted to QAPI for review and recommendations are needed.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain storage of oxygen cylinders, affecting three of five levels.

Findings include:

Observation on April 29, 2025, from 11:30 a.m. to 12:35 p.m., revealed oxygen storage deficiencies at the following locations:

a. 11:30 a.m., two unsecured oxygen cylinders, North Oxygen Storage Room, on the fourth floor;
b. 11:45 a.m., one unsecured oxygen cylinder, Dialysis Room 242, on the second floor;
c. 12:35 p.m., oxygen cylinders stored in a room missing a self-closer and full/empty signage, inside the physical therapy soiled holding room, on the first floor.

Exit interview with the Director of Nursing and Maintenance Director on April 29, 2025, at 1:40 p.m., confirmed the oxygen storage deficiencies.








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

1.Facility secured oxygen tanks in 4 North oxygen rooms, and dialysis room 242. Facility placed a self-closer and full/empty sign in the soiled holding room in the therapy gym.
2.The maintenance director or designee conducted a full house audit to ensure no free standing oxygen, all oxygen rooms have self-closers and full/emptied signs in place
3.NHA/designee re-educated staff on free standing 02 tanks, self-closing doors and full/empty signage placement.
4.Maintenance director or designee conducted audits daily x4, weekly x4 and monthly x2. Results will be submitted to QAPI for review and recommendations are needed.


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