Pennsylvania Department of Health
COMPLETE CARE AT BERKSHIRE LLC
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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COMPLETE CARE AT BERKSHIRE LLC - 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 December 21, 2023, at Complete Care at Berkshire Llc, 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 #044502
Component 01
Main Building

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on December 21, 2023, it was determined that Complete Care at Berkshire Llc 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 (111), protected noncombustible structure, 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 hazardous area doors to be within the allowed gap margins and to self-close, in two of six smoke zones within the component.

Findings include:

1. Observation on December 21, 2023, between 11:43 AM and 12:10 PM, revealed rated hazardous area doors had gaps, greater than 1/8 of an inch, at the following locations:

a. 11:43 AM, 1st floor, Storage Room door, by Maintenance Office, at the top;
b. 11:44 AM, 1st floor, Oxygen Room door, by, Maintenance Office, top;
c. 12:00 PM, 1st floor, Dietary Storage door #1, top and latch side;
d. 12:03 PM, 1st floor, Dietary Storage door #2, top;
e. 12:07 PM, 1st floor, Soiled Utility Room door #1, top and latch side;
f. 12:10 PM, 1st floor, Soiled Utility Room door #2, top and latch side.

Interview at the time of the exit conference with the Administrator and Maintenance Supervisor on December 21, 2023, at 1:30 PM, confirmed hazardous area doors exceeded the allowed gap margins.

2. Observation on December 21, 2023, at 12:04 PM, revealed the 1st floor Dietary Storage Room door #2 failed to self-close and latch in the frame.

Interview at the time of the exit conference with the Administrator and Maintenance Supervisor on December 21, 2023, at 1:30 PM, confirmed the door failed to self-close.
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*Observation on February 20, 2024, at 10:00 AM, revealed Item 1C, 1D, 1E and 1F had not been completed.

Interview at the time of the exit conference with the Administrator and Maintenance Supervisor on February 20, 2024, at 11:00 AM, confirmed item 1C, 1D, 1E and 1F was not completed.

Plan of Correction - To be completed: 03/04/2024

Gap 90 guards by National Guard products have be installed on:

c. 1st floor, Dietary Storage door #1, top Gap90 installed. Latch side frame has been adjusted to correct Gap.

d. 1st floor, Dietary Storage door #2, top Gap90 installed.

e. 1st floor, Soiled Utility Room door #1, top and latch side Gap90 installed.

f. 1st floor, Soiled Utility Room door #2, top and latch side Gap90 installed.

The maintenance director or designee will inspect the operation/gaps of all hazardous area doors weekly x4, then monthly x2, then quarterly. Findings will be presented at the facility QAPI meeting.

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