Pennsylvania Department of Health
BALL PAVILION, THE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 44 surveys for this facility. Please select a date to view the survey results.

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BALL PAVILION, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Based on an Onsite Revisit to an Emergency Preparedness Survey completed on March 25, 2025, at The Ball Pavilion, 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 #540302
Component 01
Main Building

Based on an Onsite Revisit to a Medicare/Medicaid Recertification Survey completed on March 25, 2025, it was determined that The Ball Pavilion 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 one-story, Type V (111), protected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Cooking Facilities:

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.

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on document review and interview, the facility failed to maintain cooking equipment in one of one kitchen.

Findings include:

Document review on March 25, 2025, at 10:00 a.m., revealed the kitchen hood inspection, completed September 12, 2024, noted "The return air fans shut down upon system activation."

Interview with the maintenance supervisor on March 25, 2025, at 10:00 a.m., confirmed the cooking equipment deficiency.

****************

Interview with the administrator during an Onsite Revisit Survey conducted on May 21, 2025, at 11:00 a.m., revealed the facility was unable to provide documentation for the system repair at the time of the survey.
Interview with the administrator on May 21, 2025, at 11:00 a.m., confirmed the facility was unable to provide documentation at the time of the survey.

Plan of Correction - To be completed: 05/29/2025

The system's return air fan on the kitchen hood system was repaired by facility HVAC service provider. Facility's fire control company is scheduled to come out next week and will test the system for proper shut down. Documentation of results will be received immediately.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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, the facility failed to meet sprinkler system maintenance and testing requirements for one of three building components.

Findings include:

Observation on March 25, 2025, at 11:57 a.m., revealed the sprinkler heads in the kitchen dish room and the laundry room had build-up of material on the sprinkler heads.

Interview with the maintenance technician on March 25, 2025, at 11:57 a.m., confirmed the sprinkler deficiencies.

****************

Interview with the administrator during an Onsite Revisit Survey conducted on May 21, 2025, at 11:25 a.m., revealed the kitchen dishroom sprinkler heads had a build-up of material.
Interview with the administrator on May 21, 202,5 at 11:25 a.m., confirmed the kitchen dishroom sprinkler heads had a build-up of material.

Plan of Correction - To be completed: 06/16/2025

The kitchen dish room sprinkler heads were immediately replaced. Maintenance staff have been reeducated that sprinkler heads must be clean as well as rust free to meet sprinkler system maintenance and testing requirements.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

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.

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on document review and interview, the facility failed to meet door maintenance testing and inspection requirements for two of over five smoke barrier doors.

Findings include:

Document review on March 25, 2025, at 9:33 a.m., revealed the following fire doors listed on the March 12, 2025, report had door integrity compromised:
A. (9:33 a.m.) Main A corridor smoke barrier door;
B. (9:33 a.m.) Lakeside room.

Interview with the maintenance supervisor on March 25, 2025 at 9:33 a.m., confirmed the door deficiencies.

****************

Interview with the administrator during an Onsite Revisit Survey conducted on May 21, 2025, at 11:40 a.m., revealed the facility was unable to provide documentation for the door repair at the time of the survey.
Interview with the administrator on May 21, 2025, at 11:40 a.m., confirmed the facility was unable to provide documentation at the time of the survey.

Plan of Correction - To be completed: 06/16/2025

Documentation has been received from Builder's Hardware that the doors with compromised integrity have been repaired.

Initial comments:Name: D- WING - Component: 02 - Tag: 0000

Facility ID #540302
Component 02
D-Wing

Based on an Onsite Revisit to a Medicare/Medicaid Recertification Survey completed on March 25, 2025, it was determined that The Ball Pavilion was in substantial compliance with the requirements of the Life Safety Code for a new 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 V (111), protected, wood frame building, that is fully sprinklered.

Plan of Correction:

Initial comments:Name: THERAPY ADDITION - Component: 03 - Tag: 0000

Facility ID #540302
Component 03
Therapy Addition

Based on an Onsite Revisit to a Medicare/Medicaid Recertification Survey completed on March 25, 2025, it was determined that The Ball Pavilion was in substantial compliance with the requirements of the Life Safety Code for a new 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 II (111), protected, non-combustible building, that is fully sprinklered.

Plan of Correction:

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