Pennsylvania Department of Health
MEADOWCREST REHABILITATION & HEALTHCARE CENTER
Building Inspection Results

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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.

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MEADOWCREST REHABILITATION & 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 Meadowcrest 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#280302
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 29, 2025, it was determined that Meadowcrest Healthcare 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 one-story, Type III (200), unprotected ordinary building, with a basement, that is fully sprinklered.

Plan of Correction:

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: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors in two instances, affecting two of four smoke compartments.

Findings include:

1. Observation on April 29, 2025, revealed the following corridor door deficiencies:

a) 9:00 a.m., the door to room 18 failed to latch when tested;
b) 9:30 a.m., the door to room 6 failed to latch when tested.

Interview with the Facility Administrator and Maintenance Director on April 29, 2025, at 10:30 a.m., confirmed the corridor door deficiencies.

Plan of Correction - To be completed: 05/26/2025

Room 18 and 6 were adjusted to latch when closed

Random audits to be completed on doors to ensure latching when closed weekly x2 weeks and monthly x1 month

Findings will be summarized and reviewed by the Quality Assurance Performance Improvement committee. The committee will determine the need for further audits and/or action plans at least monthly

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 documentation review and interview, it was determined the facility failed to perform emergency generator maintenance testing in one instance, affecting the entire facility.

Findings include:

1. Review of documentation on April 29, 2025, at 8:45 a.m., revealed the facility lacked documentation for an annual fuel quality test for the emergency generator.

Interview with the Facility Administrator and Maintenance Director on April 29, 2025, at 8:45 a.m., confirmed the required annual fuel quality testing documentation was unavailable at the time of the survey.

Plan of Correction - To be completed: 05/26/2025

Fuel Quality test was completed on 7/15/24.
Findings were obtained and added for documentation.

Facility will ensure that the test is completed and documentation is obtained and stored appropriately

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