Nursing Investigation Results -

Pennsylvania Department of Health
BALA NURSING AND RETIREMENT CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
BALA NURSING AND RETIREMENT CENTER
Inspection Results For:

There are  32 surveys for this facility. Please select a date to view the survey results.

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BALA NURSING AND RETIREMENT 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 30, 2019, it was determined that Bala Nursing And Retirement Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.



 Plan of Correction:


483.73(b)(1) REQUIREMENT Subsistence Needs for Staff and 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.
[(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.] At a minimum, the policies and procedures must address the following:

(1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following:
(i) Food, water, medical and pharmaceutical supplies
(ii) Alternate sources of energy to maintain the following:
(A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(B) Emergency lighting.
(C) Fire detection, extinguishing, and alarm systems.
(D) Sewage and waste disposal.

*[For Inpatient Hospice at 418.113(b)(6)(iii):] Policies and procedures.
(6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following:
(iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following:
(A) Food, water, medical, and pharmaceutical supplies.
(B) Alternate sources of energy to maintain the following:
(1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(2) Emergency lighting.
(3) Fire detection, extinguishing, and alarm systems.
(C) Sewage and waste disposal.
Observations:
Name: - Component: -- - Tag: 0015

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness (EP) plan that included policies and procedures that include subsistence needs for staff and residents during an emergency, affecting the entire facility.

Findings Include:

1. Documentation reviewed on April 30, 2019, between 8:30 a.m. and 3:00 p.m., revealed the Emergency Preparedness plan did not include policies and procedures for provisions for subsistence needs for staff and residents, for the following:

a. Safety and sanitary storage of provisions;
b. Waste disposal.

Interview with the Facility Administrator, Assistance Administrator, and the Director of Maintenance on April 30, 2019, at the 3:00 pm exit conference, confirmed the EP plan did not include all required provisions to be used in the event of an emergency.








 Plan of Correction - To be completed: 06/29/2019

A Policy has been developed to cover both "Safety and Sanitary storage & Waste disposal" and placed in the Emergency Preparedness Manual.

All policies will be reviewed annually and as needed
The Administrator shall be responsible ongoing compliance.
483.73(e) REQUIREMENT Hospital CAH and LTC Emergency Power: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.
(e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section.

483.73(e), 485.625(e)
(e) Emergency and standby power systems. The [LTC facility and the CAH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section.

482.15(e)(1), 483.73(e)(1), 485.625(e)(1)
Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated.

482.15(e)(2), 483.73(e)(2), 485.625(e)(2)
Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and maintenance requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code.

482.15(e)(3), 483.73(e)(3), 485.625(e)(3)
Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates.

*[For hospitals at 482.15(h), LTC at 483.73(g), and CAHs 485.625(g):]
The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.
If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes.
(1) National Fire Protection Association, 1 Batterymarch Park,
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
(i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011.
(ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011.
(iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
(iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
(v) TIA 12-5 to NFPA 99, issued August 1, 2013.
(vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
(vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011.
(viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
(ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
(x) TIA 12-3 to NFPA 101, issued October 22, 2013.
(xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
(xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.
Observations:
Name: - Component: -- - Tag: 0041

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness (EP) plan with policies and procedures to maintain the Essential Electrical System operational for the duration of emergencies, affecting the entire facility.

Findings Include:

1. Documentation reviewed on April 30, 2019, between 8:30 a.m. and 3:00 p.m., revealed the Emergency Preparedness plan did not include policies and procedures to have emergency power systems, or plans in place, to maintain safe operations while sheltering in place, including onsite fuel source.

Interview with the Facility Administrator, Assistance Administrator, and the Director of Maintenance on April 30, 2019, at the 3:00 pm exit conference, confirmed the EP plan did not include a means of maintaining emergency power systems, in the event of an emergency.








 Plan of Correction - To be completed: 06/29/2019

Our existing policy has been revised on maintaining safe operation while sheltering in place as well as the location of our fuel source for the facility

All policies will be reviewed annually and as needed
The administrator shall be responsible for
ongoing compliance.
Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 041402
Component 01
Building 01

Based on a Medicare/Medicaid Recertification Survey completed on April 30, 2019, it was determined that Bala Nursing And Retirement 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 483.70(a)

This is a two-story, Type III (200), unprotected ordinary construction, with a basement, which is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
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 - Component: 01 - Tag: 0161

Based on observation, document review and interview, it was determined the facility failed to maintain building construction requirements and maintain a smoke tight ceiling assembly, affecting 2 of three levels.

Findings Include:

1. Observation made and documentation reviewed on April 30, 2019, between 8:30 a.m. and 3:00 p.m., revealed unprotected structural steel columns and beams above the suspended ceiling assemblies, and pan-style ceiling diffusers at the ceiling level lacked full "blanket" protection, resulting in a classification of unprotected ordinary construction. The building has been classified as two stories. The story height exceeds the maximum height allowed for unprotected ordinary construction by one story.

Interview with the Facility Administrator, Assistance Administrator, and the Director of Maintenance on April 30, 2019, at the 3:00 pm exit conference, confirmed the building construction.


2. Observations made on April 30, 2019, between 9:45 am and 10:32 am, revealed ceiling tiles had holes, gaps or were broken, in the following locations:

A. Ceiling tile had hole inside the nurse station closet on 2 East; sprinkler head not sealed in tile;
B. Ceiling tile was missing above central supply, next to stair tower 3 oxygen room.

Interview with the Facility Administrator, Assistance Administrator, and the Director of Maintenance on April 30, 2019, at the 3:00 pm exit conference, confirmed the missing/broken ceiling tiles.

















 Plan of Correction - To be completed: 06/29/2019

An FSES has been completed for the facility by an outside engineer is on file. a waiver is not required for the facility construction type.

Ceiling Tiles on 2 east nurses' closet was replaced and penetrations were sealed with through penetration fire stop sealant. Spec Sealant SSS: UL R14288: as per manufacturer.

Ceiling tile missing in central supply by Stair Tower #3 was replaced.

Environmental rounds will be conducted regularly. Ceiling tiles will be replaced as needed. Maintenance Director
will monitor for compliance.
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 the facility failed to maintain the fire resistance rating of vertical openings, affecting two of three levels within this component.

Findings Include:

1. Observation made on April 30, 2019, between 11:00 a.m. and 2:15 p.m., revealed there were penetrations through vertical enclosures, at the following locations:

a. 12:12 pm, 2nd floor, above ceiling near elevator, unsealed penetration;
b. 12:30 pm, stairtower 3, no sealant around penetrations;
c. 2:14 pm, 1 East stairwell, pass through hole with no sealant;
d. 11:45am, 2 East smoke barrier, there was a partially sealed pipe and wiring.

Interview with the Facility Administrator, Assistance Administrator, and the Director of Maintenance on April 30, 2019, at the 3:00 pm exit conference, confirmed the unsealed penetrations in the above named locations.









 Plan of Correction - To be completed: 06/29/2019

All penetrations as listed, 2nd Fl. Above ceiling near elevator, stair tower 3, 1 East stairwell, 2 east smoke barrier have been sealed with an approved through penetration fire stop sealant. Spec Sealant SSS: UL R14288: as per manufacturer. Information will be kept on file
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 the fire resistance rating of smoke barrier partitions, affecting one of three levels within the facility.

Findings Include:

1. Observation on April 30, 2019, at 11:12 am to 11:15 am, revealed on the second floor; there loose door knobs, which would not resist the passage of smoke, in the following locations:

A. at room 244;
B. at room 228.

Interview with the Facility Administrator, Assistance Administrator, and the Director of Maintenance on April 30, 2019, at the 3:00 pm exit conference, confirmed the unsecured door knobs.






 Plan of Correction - To be completed: 06/29/2019

All residents doors were checked to make sure they were all tightened down and working

Loose doorknobs in rooms 244 and 228 have been fixed.

Environmental rounds will be conducted weekly times 5 weeks. Appropriate repairs will be made.
Results will be reported in monthly QAPI.


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