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

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
COMPLETE CARE AT BERKSHIRE LLC
Inspection Results For:

There are  37 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.
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 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 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 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the stairtower doors, to be within the allowed gap margins, affecting one of six smoke compartments within the component.

Findings include:

1. Observation on December 21, 2023, at 10:50 AM, revealed the 2nd floor North Stairtower door exceeded the minimum gap margin, of 1/8 inch at the top.

Interview at the time of the exit conference with the Administrator and Maintenance Supervisor on December 21, 2023, at 1:30 PM, confirmed the stairtower door exceeded the allowable gap margin.



 Plan of Correction - To be completed: 02/19/2024

Gap 90 guard by National Guard products has been ordered and will be installed on the 2nd floor North stair tower door to maintain the proper door gap.

The maintenance director or designee will inspect all stairtower doors weekly x4, then monthly x2, then quarterly. Findings will be reported at the facility QAPI meeting.

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.



 Plan of Correction - To be completed: 02/19/2024

Gap 90 guards by National Guard products were ordered and will be installed on:

- Top of the 1st floor Storage Room door (by Maintenance Office)
- Top of the 1st floor Oxygen storage room door
- Top and latch side of the Dietary Storage door #1
- Top of the Dietary Storage door #2
- Top and latch side of the 1st floor Soiled Utility Room door #1
- Top and latch side of the 1st floor Soiled Utility Room door #2

A self-closure mechanism has been installed on the 1st floor Dietary Storage Room door #2 to allow it to self-close and latch properly into the frame.

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.


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 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the sprinkler piping system, to be free of extraneous weight, and sprinkler heads, to be free of dust and debris, affecting three of six smoke compartments within the component.

Findings include:

1. Observation on December 21, 2023, between 11:10 AM and 11:30 AM, revealed items were being supported by the sprinkler piping system, at the following locations:

a. 11:10 AM, Nurses' Station #1, 1st floor, above ceiling, various wires and flex conduit;
b. 11:30 AM, Main Lobby, 1st floor, above ceiling, by front windows, flex conduit.

Interview at the time of the exit conference with the Administrator and Maintenance Supervisor on December 21, 2023, at 1:30 PM, confirmed various items supported by the sprinkler pipe system.


2. Observation on December 21, 2023, between 12:10 PM and 12:14 PM, revealed sprinkler heads covered with debris, at the following locations:

a. 12:10 PM, 1st floor, Laundry Room, Dryer Chase Room, 2 sprinkler heads;
b. 12:14 PM, 1st floor, Laundry Room, 4 sprinkler heads.

Interview at the time of the exit conference with the Administrator and Maintenance Supervisor on December 21, 2023, at 1:30 PM, confirmed debris was covering the sprinkler heads.



 Plan of Correction - To be completed: 02/19/2024

Wires and flex conduit have been moved and supported away from the sprinkler piping system at the following locations: 1st floor Nurses' Station, above ceiling; 1st floor Main Lobby, above ceiling by front windows.

Sprinkler heads have been cleaned of debris in the 1st floor Laundry Room and Laundry Dryer Chase Room.

The maintenance director or designee will inspect the facility sprinkler pipes to be free of wires or conduit, inspect facility sprinkler heads to free of debris monthly, and report the findings at the facility QAPI meeting.


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