Pennsylvania Department of Health
 ROOSEVELT REHABILITATION AND HEALTHCARE 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

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ROOSEVELT REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

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.
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 July 17, 2024, 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 July 17, 2024, 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 Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined that the facility failed to maintain the fire-resistance rating of stair towers, affecting one of five levels.

Findings include:

Observation on July 17, 2024, at 11:45 a.m., revealed 3 North stair tower door had open holes where the hardware had been relocated.

Exit Interview with the Administrator and Maintenance Director on July 17, 2024, at 1:20 p.m., confirmed the stair tower door deficiency.





 Plan of Correction - To be completed: 08/01/2024

1. 3 North Stair tower door holes in the hardware were repaired.
2. Audit conducted of fire resistance rating stair tower doors to ensure no open holes.
3. NHA/designee re-educated maintenance on ensuring all fire rating doors not having open holes.
4. NHA/designee will conduct audits monthly x3 months. Results will be submitted to QAPI for review and recommendations as needed.

NFPA 101 STANDARD Smoke Detection: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.
Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0347

Based upon observation and interview, it was determined the facility failed to maintain smoke detectors, affecting two of five levels.

Findings include:

Observation on July 17, 2024, revealed smoke detectors detached from their housings, in the following locations:

a. 10:40 a.m., on the first floor, small RNAC Office, detached and above the ceiling.
b. 12:00 p.m., on the second floor, 2 North Soiled Room.
c. 12:50 a.m., on the first floor, Kitchen Office.

Exit Interview with the Administrator and Maintenance Director on July 17, 2024, at 1:20 p.m., confirmed the detached smoke detectors.





 Plan of Correction - To be completed: 08/01/2024

1. Smoke detector in the RNAC office, 2 N soiled room, and kitchen office were attached appropriately.
2. Audit conducted on all smoke detectors to ensure smoke detectors are attached.
3. NHA/designee re-educated maintenance on ensure all smoke detectors are secure and attached.
4. NHA/designee will conduct audits monthly x3 months. Results will be submitted to QAPI for review and recommendations as needed.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to ensure automatic sprinkler components were maintained, affecting one of five levels.

Findings Include:

Observation on July 17, 2024, at 11:30 a.m., revealed on the first floor, in the Kitchen Janitor Closet, a sprinkler was missing its escutcheon.

Exit Interview with the Administrator and Maintenance Director on July 17, 2024, at 1:20 p.m., confirmed the missing escutcheon.





 Plan of Correction - To be completed: 08/01/2024

1.Sprinker in the kitchen janitor closet escutcheon was replaced.
2. Audit conducted on all sprinklers to ensure escutcheons are intact.
3. NHA/designee re-educated maintenance on ensuring all sprinklers have attached escutcheons.
4.NHA/designee will conduct audits monthly x3 months. 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 July 17, 2024, revealed the following electrical system deficiencies:

a. 10:45 a.m., on the first floor, RNAC small office, above ceiling, 3 junction boxes missing covers.
b. 11:05 a.m., in the basement mechanical room, junction box missing cover.
c. 11:50 a.m., on the third floor, corridor by room 320, exposed wires protruding from MC cable.
d. 12:30 p.m., on the second floor, kitchen by ice machine, duplex receptacle missing cover.

Exit Interview with the Administrator and Maintenance Director on July 17, 2024, at 1:20 p.m., confirmed the electrical deficiencies.





 Plan of Correction - To be completed: 08/01/2024

1.Juction box covers in rnac office, basement mechanical room, corridor by room 320, and in kitchen were replaced.
2. Audit conducted to ensure all junction boxes have proper coverings.
3. NHA/designee re-educated maintenance on junction boxes having proper coverings.
4.NHA/designee will conduct audits monthly x3 months. 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:

Document review on July 17, 2024, at 10:50 a.m., revealed a portable AC unit was vented directly above the suspended ceiling, on the first floor, RNAC small office.

Exit Interview with the Administrator and Maintenance Director on July 17, 2024, at 1:20 p.m., confirmed the venting.




 Plan of Correction - To be completed: 08/01/2024

1.AC unit vented directly above the suspended ceiling was removed in the RNAC office and vented according to manufacturers specifications.
2. Audit conducted to ensure all AC units are properly vented.
3. NHA/designee re-educated maintenance on the appropriately way to vent an AC unit.
4. NHA/designee will conduct audits monthly x3 months. Results will be submitted to QAPI for review and recommendations as needed.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain required testing of emergency generator components, affecting one generator.

Findings Include:

Document review on July 17, 2024, at 9:00 a.m., revealed the facility lacked verifying documentation of the following emergency generator maintenance item:

a. monthly testing of battery electrolyte specific gravity or conductance testing.

Exit Interview with the Administrator and Maintenance Director on July 17, 2024, at 1:20 p.m., confirmed the missing documentation.





 Plan of Correction - To be completed: 08/01/2024

1.Facililty conducted a monthly generator test.
2. Audit conducted to ensure previous 6 month look back no other monthly test were missed on any other emergency generator.
3.NHA/designee re-educated maintenance on testing emergency generators monthly.
4. NHA/designee will conduct audits monthly x3 months. Results will be submitted to QAPI for review and recommendations as 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 two of five levels.

Findings include:

Observations on July 17, 2024, revealed the following electrical deficiencies:

a. 11:00 a.m.. in the basement, medical records- fridge plugged into power strip and extension cord.
b. 11:55 a.m., on the second floor, Social Services office- fridge plugged into an outlet multiplier.

Exit Interview with the Administrator and Maintenance Director on July 17, 2024, at 1:20 p.m., confirmed the unauthorized electrical devices.





 Plan of Correction - To be completed: 08/01/2024

1.Powerstrip and extension cord was removed from medical records. Outlet multiplier was removed from social services office in the second floor.
2. Audit conducted on all offices to ensure the absence of powerstrips, extension cords and/or outlet multipliers.
3. NHA/designee re-educated maintenance and department management on approved electrical devices.
4. NHA/designee will conduct audits monthly x3 months. Results will be submitted to QAPI for review and recommendations as 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 the fire resistance rating of medical gas rooms, in sprinklered locations, affecting one of five levels.

Findings include:

Observation on July 17, 2024, at 11:05 a.m., revealed in the basement floor Oxygen Storage Room door failed to self-close and latch when tested.

Exit Interview with the Administrator and Maintenance Director on July 17, 2024, at 1:20 p.m., confirmed the oxygen storage deficiency.





 Plan of Correction - To be completed: 08/01/2024

1.Oxygen storage room in the basement latched was fixed.
2. Audit conducted on all oxygen rooms to ensure self-closing doors latch.
3. NHA/designee re-educated maintenance on ensuring self-closing doors latch.
4. NHA/designee will conduct audits monthly x3 months. Results will be submitted to QAPI for review and recommendations as needed.


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
Visit the PA Power Port