Pennsylvania Department of Health
 RIVER'S BEND HEALTH & REHAB CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
RIVER'S BEND HEALTH & REHAB CENTER
Inspection Results For:

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RIVER'S BEND HEALTH & REHAB 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 March 30, 2026, at River's Bend Health &; Rehab 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 - Component: 01 - Tag: 0000
Facility ID #640202Component 01Main BuildingBased on a Medicare/Medicare Recertification Survey completed on March 30, 2026, it was determined that River's Bend Health &; Rehab 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 (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.
 Plan of Correction:


NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintain the smoke barrier doors of hazardous area enclosures to positively latch, affecting three of eight smoke compartments within the component. Findings include: 1. Observation on March 30, 2026, between 11:10 AM and 11:40 AM, revealed the doors to the following Soiled Utility Rooms failed to automatically positively latch within the door frames: a. "C" Hall, by the Central Bath; b. next to Resident Room G11 (glove inside the strike plate); c. by Resident Room F13.. Interview with the Facility Representative on March 30, 2026, at 11:40 AM, confirmed the compromised smoke resistance of the hazardous area enclosures.
 Plan of Correction - To be completed: 04/17/2026

The doors to "C" Hall, by the Central Bath now latch positively.

The doors next to Resident Room G11 (glove inside the strike plate) now latch positively and glove was removed.

The doors by Resident Room F13 now latch positively.

All hazardous area enclosures positively latch.

Maintenance Director and/or designee have been reducated on proper positively latching smoke compartments.

Maintenance Director and/or designee will audit the facility monthly for proper latching and results will be brought to QAPI for recommendations.
NFPA 101 STANDARD Corridors - Construction of Walls: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.
Corridors - Construction of Walls
2012 EXISTING
Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code.
Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames.
If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area.
19.3.6.2, 19.3.6.2.7
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0362 Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of corridor walls, affecting one of eight smoke compartments within the component. Findings include: 1. Observation on March 30, 2026, at 11:00 AM, revealed an unprotected penetration of the corridor wall, below the ceiling, beside the time clock across from the Scheduling Office. Interview with the Facility Representative on March 30, 2026, at 11:00 AM, confirmed the compromised smoke resistance of the corridor wall.
 Plan of Correction - To be completed: 04/17/2026

The penetration of the corridor wall, below the ceiling, beside the time clock across from the Scheduling office was repaired.

The facility was checked for other areas with penetrations and proper smoke resistance of corridor walls.

Maintenance Director was inserviced on the importance of proper penetration prevention of corridor walls.

Maintenance Director and/or designee will audit facility monthly to ensure that there is proper smoke resistance protection. Results of the audits will be brought to QAPI for further recommendations.
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 - Component: 01 - Tag: 0363 Based on observation and interview, it was determined the facility failed to maintain the positive latching of corridor doors, affecting one of eight smoke compartments within the component. Findings include: 1. Observation on March 30, 2026, at 10:44 AM, revealed the door to the Dietary Department, by the ice machine, failed to positively latch within the door frame, due to a paper towel within the strike plate. Interview with the Facility Representative on March 30, 2026, at 10:44 AM, confirmed the corridor door did not latch within the frame.
 Plan of Correction - To be completed: 04/17/2026


The door to the Dietary Department, by the ice machine, now positively latches within the door frame and paper towel was removed from within strike plate.

The Maintenance Director and/or designee has checked the facility to ensure that all corridor doors latch within the frame.

The Maintenance Director and/or designee have been inserviced on proper latching doors within the door frame.

The Maintenance Director and/or designee will complete monthly audits of the facility doors to ensure they latch properly. Results will be brought to QAPI for recommendations and review.
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 - Component: 01 - Tag: 0511
Based on observation and interview, it was determined the facility failed to maintain components of electrical hardware, affecting one of eight smoke compartments within the component.

Findings include:



1. Observation on March 30, 2026, at 11:31 AM, revealed an open electrical junction box, located above the suspended ceiling, by Elevator #1, on the 2nd floor.
Interview with the Facility Representative on March 30, 2026, at 11:31 AM, confirmed the exposed electrical wiring.




 Plan of Correction - To be completed: 04/17/2026

Open electrical junction box, located above the suspended ceiling, by Elevator #1, on the 2nd floor, has been repaired so that components are maintained properly.

Areas throughout the facility where junction boxes may have been exposed have been checked and properly maintained.

Maintenance Director and/or designee were re-educated on the need to have electrical junction boxes covered.

Maintenance Director and/or designee will perform random audits to areas where junction boxes are placed to ensure wiring is not exposed. Results of these audits will be brought to QAPI for further review and recommendation.


NFPA 101 STANDARD Gas Equipment - Precautions for Handling Oxyg: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 - Precautions for Handling Oxygen Cylinders and Manifolds
Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99)
11.6.2 (NFPA 99)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0929 Based on observation and interview, it was determined the facility failed to maintain portable oxygen cylinders to be secured at all times, affecting one of eight smoke compartments within the component. Findings include: 1. Observation on March 30, 2026, at 11:07 AM, revealed an unsecured portable oxygen "E" cylinder, located by the water dispenser, at Nurses' Station #1. Interview with the Facility Representative on March 30, 2026, at 11:07 AM, confirmed the unsecured oxygen cylinder.
 Plan of Correction - To be completed: 04/17/2026

The unsecured portable oxygen "E" cylinder located by the water dispenser at Nurses' Station #1 has been secured.

Maintenance Director and/or designee will do an all house sweep to ensure that oxygen cylinders are properly contained.

The Maintenance Director/designee has educated nursing staff on proper oxygen cylinder storage.

Maintenance Director/designee will complete weekly floor checks throughout the facility for proper oxygen storage. Monitoring will be done on an on-going basis and results will be brought to QAPI for review and recommendations.




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