Pennsylvania Department of Health
BEDFORD SKILLED 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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BEDFORD SKILLED 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 July 22, 2024, it was determined that Bedford Skilled Nursing and Rehabilitation had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

482.15(e), 483.73(e), 485.542(e), 485.625(e) STANDARD 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.

§482.15(e) Condition for Participation:
(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), §485.542(e)
(e) Emergency and standby power systems. The [LTC facility CAH and REH] 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), §485.542(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), §485.542(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),§485.542(e)(2)
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), REHs at §485.542(g), and 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 observation and interview, it was determined the facility failed to maintain the remote alarm annunciator for the emergency generator, affecting the entire facility.

Findings include:

1. Observation on July 22, 2024, at 11:48 a.m., revealed the remote generator annunciator panel failed to function when tested. The annunciator panel failed to function/alarm when the test/function switch was activated.

Interview with the Facility Administrator on July 22, 2024, at 1:00 p.m., confirmed the listed remote generator annunciator panel deficiency.

Plan of Correction - To be completed: 08/21/2024

Preparation and/or execution of this Plan of Correction does not constitute admission or agreement by the Provider of the truth or facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of federal and state law.
This Plan of Correction constitutes the facility's credible allegation of compliance.

Facility annunciator panel to be upgraded to show indicator light illuminates when generator is activated. Facility maintenance director/designee to monitor illumination weekly. Results will be documented and reported to facility Quality Assurance and Performance Improvement meetings.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID # 040402
Component 01
Main building

Based on a Medicare/Medicaid Recertification Survey completed on July 22, 2024, it was determined that Bedford Skilled Nursing and Rehabilitation was not in compliance with the following requirements of the Life Safety Code for an existing healthcare 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 V (000), unprotected wood frame building, with a basement, that 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 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in two instances, affecting one of seven smoke compartments.

Findings include:

1. Observation on July 22, 2024, revealed the following deficiencies with the required one-hour fire rating for the basement boiler room:

a) 11:22 a.m., the arm was unhooked from the self-closing device for the door;
b) 11:25 a.m., there were two unsealed pipe penetrations in the deck/ceiling above the storage cabinet.

Interview with the Facility Administrator on July 22, 2024, at 1:00 p.m., confirmed the listed hazardous are enclosure deficiencies.

Plan of Correction - To be completed: 08/21/2024

The arm to the self closing door was fixed immediately upon discovery. Facility Maintenance Director to seal pipe penetrations in deck/ceiling area above the storage cabinet. Maintenance Director/Designee to monitor monthly to ensure self closures and check/repair penetrations. Results will be documented and reported to facility Quality Assurance and Performance Improvement meetings.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on documentation review and interview, it was determined the facility failed to perform the required six-month battery replacement of the battery-operated smoke detectors in one instance, affecting four of seven smoke compartments.

Findings include:

1. Documentation review on July 22, 2024, at 9:45 a.m., revealed the facility failed to perform the required six-month replacement of batteries in the battery-operated smoke detectors.

Interview with the Facility Administrator on July 22, 2024, at 1:00 p.m., confirmed the listed battery-operated smoke detector deficiency.

Plan of Correction - To be completed: 08/21/2024

Facility Maintenance Director to document the six month replacement of batteries in battery operated smoke detectors and recorded in monthly checklist. Results to be documented and reported to facility Quality Assurance and Performance Improvement Meetings.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 five instances, affecting four of seven smoke compartments.

Findings include:

1. Observation on July 22, 2024, revealed the facility failed to maintain sprinkler heads and a smoke/heat resistive ceiling for proper activation /operation of the automatic sprinkler system in the following locations:

a) 11:00 a.m., in the maintenance office there were multiple unsealed penetrations;
b) 11:05 a.m., in the basement server room above the server;
c) 11:35 a.m., in the admissions office storage closet above the server;
d) 11:52 a.m., in the PT mechanical room above the water tank;
e) 12:31 p.m., there were multiple dirty sprinkler heads in the kitchen.

Interview with the Facility Administrator on July 22, 2024, at 1:00 p.m., confirmed the listed automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 08/21/2024

Facility Maintenance Director to caulk/seal penetrations in the maintenance office; basement server room above the server; admissions office storage room and the PT mechanical room. Sprinkler heads were immediately dusted upon observation. Maintenance Director/Designee to monitor monthly. Results to be documented and reported to facility Quality Assurance and Performance Improvement meetings.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined that the facility failed to maintain portable fire extinguishers in one instance, affecting one of seven smoke compartments.

Findings include:

1. Observation on July 22, 2024, at 11:02 a.m., revealed access to the fire extinguisher in the maintenance office was obstructed by miscellaneous storage.

Interview with the Facility Administrator on July 22, 2024, at 1:00 p.m., confirmed the listed portable fire extinguisher deficiencies.

Plan of Correction - To be completed: 08/21/2024

Miscellaneous storage obstructing fire extinguisher in the Maintenance Office was immediately removed upon notification. Maintenance Director/Designee to monitor obstruction weekly x1 month and monthly thereafter to ensure no obstruction. Results to be documented and reported to facility Quality Assurance and Performance Improvement Meetings.

NFPA 101 STANDARD Electrical Systems - Other:

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.

Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain the remote alarm annunciator for the emergency generator, affecting the entire facility.

Findings include:

1. Observation on July 22, 2024, at 11:48 a.m., revealed the remote generator annunciator panel failed to function when tested. The annunciator panel failed to function/alarm when the test/function switch was activated.

Interview with the Facility Administrator on July 22, 2024, at 1:00 p.m., confirmed the listed remote generator annunciator panel deficiency.

Plan of Correction - To be completed: 08/21/2024

Facility annunciator panel to be upgraded to show indicator light illuminates when generator is activated. Facility maintenance director/designee to monitor illumination weekly. Results will be documented and reported to facility Quality Assurance and Performance Improvement meetings.

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