Pennsylvania Department of Health
BELLE TERRACE
Building Inspection Results

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BELLE TERRACE
Inspection Results For:

There are  39 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.
BELLE TERRACE - 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 January 17, 2024, it was determined that Belle Terrace, was not in compliance with the requirements of 42 CFR 483.73.





 Plan of Correction:


403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually: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.
§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.
Observations:
Name: - Component: -- - Tag: 0004

Based on document review and interview, it was determined that the facility failed to develop and maintain an Emergency Preparedness Plan that must be reviewed and updated at least annually, for one of one plan.

Findings include:

Document review on January 17, 2024, at 10:00 a.m., revealed the facility lacked documentation indicating annual review of the Emergency Preparedness Plan.

Exit Interview with the Administrator and Maintenance Director on January 17, 2024, at 12:15 p.m., confirmed the missing annual update.





 Plan of Correction - To be completed: 03/15/2024

EPP has been reviewed and updated. NHA will audit annually. All staff to be educated on the EPP. Findings to be reviewed at QAPI.
403.748(a)(1)-(2), 416.54(a)(1)-(2), 418.113(a)(1)-(2), 441.184(a)(1)-(2), 482.15(a)(1)-(2), 483.475(a)(1)-(2), 483.73(a)(1)-(2), 484.102(a)(1)-(2), 485.542(a)(1)-(2), 485.625(a)(1)-(2), 485.68(a)(1)-(2), 485.727(a)(1)-(2), 485.920(a)(1)-(2), 486.360(a)(1)-(2), 491.12(a)(1)-(2), 494.62(a)(1)-(2) STANDARD Plan Based on All Hazards Risk Assessment: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.
§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)

[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*

(2) Include strategies for addressing emergency events identified by the risk assessment.

* [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.

*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.
Observations:
Name: - Component: -- - Tag: 0006

Based on document review and interview, the facility failed to maintain emergency Preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

Document review on January 17, 2024, at 11:00 a.m., revealed the facility failed to establish and maintain a comprehensive Emergency Preparedness Plan that was based on and includes a documented Facility-based and community-based risk assessment, utilizing an all-hazards approach. Risk assessment was not available at time of survey.

Exit Interview with the Administrator and Maintenance Director on January 17, 2024, at 12:15 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 03/15/2024

Risk assessment has been completed and is included in the EPP, and all staff educated. NHA will audit annually. Findings to be reviewed at QAPI.
483.475(c)(8), 483.73(c)(8) STANDARD LTC and ICF/IID Sharing Plan with Patients: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.
§483.73(c)(8); §483.475(c)(8)

*[For LTC Facilities at §483.73(c):]
[(c) The LTC facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually. The communication plan must include all of the following:]

*[For ICF/IIDs at §483.475(c):]
[(c) The ICF/IID must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years. The communication plan must include all of the following:]

(8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.
Observations:
Name: - Component: -- - Tag: 0035

Based on document review and interview, the facility failed to maintain emergency Preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

Document review on January 17, 2024, at 10:00 a.m., revealed the facility lacked a written Emergency Preparedness Plan to include sharing facility emergency preparedness plans and policies with family members and resident representatives.

Exit Interview with the Administrator and Maintenance Director on January 17, 2024, at 12:15 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 03/15/2024

Plan to notify residents and their families has been included in the EPP. All staff to be educated, findings will be reviewed at QAPI.
Initial comments:Name: MAIN BUILDING 01 (ORIGINAL & PERSONAL CARE) - Component: 01 - Tag: 0000


Facility ID# 024302
Component 01
Original Building & Personal Care

Based on a Medicare/Medicaid Recertification Survey completed on January 17, 2024, it was determined that Belle Terrace 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 two story, Type V (000), unprotected, wood-frame building, with a basement, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 (ORIGINAL & PERSONAL CARE) - Component: 01 - Tag: 0161

Based on observation, document review and interview, it was determined the facility failed to maintain building construction requirements, affecting two of two floors within the component.

Findings include:

Observation and document review on January 17, 2024, between 9:30 a.m. and 11:00 a.m., revealed the building was classified as a two story, unprotected wood frame building, that is fully sprinklered. This type of construction is not permitted to be over one story in height.

Exit Interview with the Administrator and Maintenance Director on January 17, 2024, at 12:15 p.m., confirmed the building construction exceeded the maximum allowable story height.






 Plan of Correction - To be completed: 03/15/2024

The facility wishes to have DOH conduct a new FSES under Life Safety Code.
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 (ORIGINAL & PERSONAL CARE) - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain stair tower doors, affecting one of three levels.

Findings include:

Observation on January 17, 2024, at 10:40 a.m., revealed the basement stair tower door to boiler room rated door fire resistive labeling was rusted through and illegible.

Exit Interview with the Administrator and Maintenance Director on January 17, 2024, at 12:15 p.m., confirmed the illegible fire resistive labeling.





 Plan of Correction - To be completed: 03/15/2024

Reached out to vendor to see if they can rate the door, if not it will be replaced. Audit done on all doors to stairway enclosures with no issues. Maintenance Director to be educated. Weekly audits x4 and monthly x2. Findings to be reviewed at QAPI.
Initial comments:Name: BUILDING 02 (A WING) - Component: 02 - Tag: 0000


Facility ID# 024302
Building 02
A Wing

Based on a Medicare/Medicaid Recertification Survey completed on January 17, 2024, it was determined that Belle Terrace 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 one story, Type II (000), unprotected, non-combustible building, with a partial lower level and crawl space, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Emergency Lighting: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.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: BUILDING 02 (A WING) - Component: 02 - Tag: 0291

Based on observation and interview, it was determined the facility failed to ensure battery back-up lighting was maintained in operable condition, affecting one of two levels.

Findings include:

Observation on January 17, 2024, at 11:45 a.m., revealed, in A-wing basement generator room, the battery back-up light remained constantly on due to wiring condition.

Exit Interview with the Administrator and Maintenance Director on January 17, 2024, at 12:15 p.m., confirmed the battery back-up light condition.





 Plan of Correction - To be completed: 03/15/2024

Light to be replaced and rewired to turn on only as a backup. Maintenance director educated. Audit done for all emergency backup lighting monthly x3. Findings to be reviewed at QAPI.
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: BUILDING 02 (A WING) - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting one of two levels.

Findings include:

Observation on January 17, 2024, at 11:50 a.m., revealed, in basement new boiler room, a sprinkler was obstructed by an insulated pipe installed directly adjacent to the sprinkler.

Exit Interview with the Administrator and Maintenance Director on January 17, 2024, at 12:15 p.m., confirmed the obstructed sprinkler.




 Plan of Correction - To be completed: 03/15/2024

Reached out to vendor to un-obstruct sprinkler. Maintenance director educated. Audit done on all sprinklers. Findings to be reviewed at QAPI.
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: BUILDING 02 (A WING) - Component: 02 - Tag: 0923

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

Findings include:

Observation on January 17, 2024, at 11:15 a.m., revealed an unsecured oxygen cylinder, in the first floor clean utility room.

Exit Interview with the Administrator and Maintenance Director on January 17, 2024, at 12:15 p.m., confirmed the unsecured oxygen cylinder.




 Plan of Correction - To be completed: 03/15/2024

Unsecured oxygen cylinder was immediately secured. Nursing staff to be educated. Audits done weekly x3 and monthly x2. Findings to be reviewed at QAPI.
Initial comments:Name: BUILDING 03 (B WING) - Component: 03 - Tag: 0000


Facility ID# 024302
Component 03
B Wing

Based on a Medicare/Medicaid Recertification Survey completed on January 17, 2024, it was determined that Belle Terrace 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 two story, Type II (000), unprotected, non-combustible building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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: BUILDING 03 (B WING) - Component: 03 - Tag: 0353

Based on document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting two of two levels.

Findings include:

Document review on January 17, 2024, at 9:30 a.m., revealed the September 27, 2023, sprinkler inspection report listed a flow-test timing deficiency, evidence of corrective action and retest was not available at time of survey:

Exit Interview with the Administrator and Maintenance Director on January 17, 2024, at 12:15 p.m., confirmed the sprinkler system deficiency.




 Plan of Correction - To be completed: 03/15/2024

Reached out to vendor to correct and retest flow-test timing. Maintenance Director educated. NHA will Audit next 3 sprinkler inspections and will review findings at QAPI.



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