Pennsylvania Department of Health
BELAIR HEALTHCARE AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 43 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.


BELAIR HEALTHCARE AND REHABILITATION 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 May 15, 2024, at Belair Healthcare and Rehabilitation 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# 021002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 15, 2024, it was determined that Belair 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 two-story, Type II (222), fire resistive building, without a basement, 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 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: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in four instances, affecting three of five smoke compartments.

Findings include:

1. Observation on May 15, 2024, revealed the following automatic sprinkler deficiencies:

a) 8:30 a.m., there was an unsealed hole in the ceiling tile above the coffee machine in the employee break room in the south wing;
b) 8:40 a.m., there were multiple unsealed ceiling penetrations in the electrical room, located in the employee break room, in the south wing;
c) 8:45 a.m, there were multiple ceiling penetrations in the housekeeping closet, in the south wing;
d) 9:15 a.m., there were multiple ceiling penetrations in the kitchen storage closet in the employee hallway on the first floor.

Interview with the Facility Administrator and Maintenance Director on May 15, 2024, at 11:30 a.m., confirmed the listed automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 05/31/2024

Maintenance Director has repaired all 4 violations of K0353.

Maintenance Director, or designee, will monitor the automatic sprinkler system to ensure there are no further penetrations or holes in the ceiling bi-weekly x 1, weekly x 3 and monthly thereafter.

Maintenance Director will report all monitored finding to the QAPI team on the next scheduled meeting.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of five smoke compartments.

Findings include:
1. Observation on May 15, 2024, at 9:30 a.m., revealed that there was a microwave plugged in to a surge protector in the RNAC's office on the first floor.

Interview with the Facility Administrator and Maintenance Director on May 15, 2024, at 11:30 a.m., confirmed the misuse of electrical wiring.

Plan of Correction - To be completed: 05/31/2024

Maintenance Director, or designee, has inserviced all employees on the K 0920 citation by May 28, 2024.

Microwave and surge protector were immediately removed from the RNAC's office while surveyor was in the facility.

Maintenance Director, or designee, will monitor the facility to ensure there is no misuse of surge protectors and/or extension cords bi-weekly x 1, weekly x 3 and monthly thereafter.

All results of the monitoring will reported to the QAPI team on the next scheduled meeting.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID# 021002
Component 02
Physical Therapy Addition

Based on a Medicare/Medicaid Recertification Survey completed on May 15, 2024, at Belair Healthcare and Rehabilitation Center, it was determined there were no deficiencies identified under the 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 (211), protected ordinary building, without a basement, that is fully sprinklered.

Plan of Correction:

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