Pennsylvania Department of Health
BONHAM NURSING AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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BONHAM NURSING 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 August 13, 2024, at Bonham Nursing 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: BUILDING 03 - Component: 03 - Tag: 0000

Facility ID# 022802
Component 03
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on August 13, 2024, it was determined that Bonham Nursing 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 483.70(a).

This is a one story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Emergency Lighting:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

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 03 - Component: 03 - Tag: 0291

Based on observation and interview, the facility failed to provide functional emergency lighting in one location, of the facility.

Findings include:

1. Observations on August 13, 2024, at 10:28 a.m., revealed the Fire Pump House, emergency lights, failed to illuminate when tested.

Exit interview with the Facility Administrator and the Facilities Manager on August 13, 2024, at 11:15 a.m., confirmed the lighting failure.

Plan of Correction - To be completed: 09/10/2024

1. New batteries and bulbs will be installed to the emergency lighting system in the Fire Pump House.
2. The Maintenance Supervisor will complete an audit on emergency lighting to ensure proper functioning
3. Maintenance staff will be re-educated on need to maintain proper functioning of emergency lighting.
4. The Maintenance Supervisor/Designee will complete weekly quality monitors for 3 weeks and monthly for 4 months to ensure proper functioning of emergency lighting. Results will be submitted to the QAPI Committee for review and recommendations as needed.

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