Pennsylvania Department of Health
BALL PAVILION, THE
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

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.


BALL PAVILION, THE - 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 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 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 General Requirements - Other:

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.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on observation and interview, the facility failed to maintain portable floor plans that outlined designated rated partitions, affecting the entire facility.

Findings include:

Document review on March 25, 2025, at 10:24 a.m., revealed the facility failed to provide a set of accurate, portable floor plans. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site, to be used during the Life Safety Code Survey. A perceived restroom was being used for storage near the chapel in the facility. Accurate floor plans were unavailable to verify.

The Life Safety Code Floor Plan shall include the following:
a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls (1-2 hour walls);
c. Horizontal exits;
d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls.

Interview at the exit conference with the maintenance supervisor on March 25, 2025, at 10:24 a.m., confirmed the facility's Life Safety Code Floor Plan was unavailable at the time of the survey.

Plan of Correction - To be completed: 05/24/2025

Director of Maintenance contacted facility architect and created a portable, accurate floor plan that outlines designated rated partitions, affecting the entire facility. This floorplan will remain on-site.

This corrective action will be continuous throughout the year.

NFPA 101 STANDARD Discharge from Exits:

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.

Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0271

Based on observation and interview, the facility failed to meet exit discharge requirements for two of over five emergency exits.

Findings include:

Observation on March 25, 2025, between 11:00 a.m. and 11:30 a.m., revealed the following exit discharge deficiencies:
A. (11:00 a.m.) A wing emergency exit, near room A1, had a pile of leaves and tree trimmings along the exit discharge passage way;
B. (11:30 a.m) B wing emergency exit, near the conference room, had a build-up of debris and a dead bird along the exit discharge passage way.

Interview with the maintenance technician on March 25, 2025, at 11:30 a.m., confirmed the exit discharge deficiencies.

Plan of Correction - To be completed: 05/24/2025

All exits were immediately cleared of obstructions. The groundskeeper will monitor all exits daily and ensure that they will be maintained free of obstructions to meet exit discharge requirements. Maintenance will assume monitoring in groundskeeper's absence.

This corrective action will be continuous throughout the year.

NFPA 101 STANDARD Cooking Facilities:

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.

Plan of Correction - To be completed: 05/24/2025

Facility HVAC service provider has been contacted and is working with facility's fire control company to correct and maintain cooking equipment in kitchen so the return air fans will not shut down upon system activation.

This corrective action will be continuous throughout the year.

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.

Plan of Correction - To be completed: 05/24/2025

All sprinkler heads in the kitchen dish room and the laundry room were immediately cleaned to remove build-up of material. Preventive maintenance task has been added to clean all sprinkler heads and will be completed on a monthly basis to meet sprinkler system maintenance and testing requirements.

This corrective action will be continuous throughout the year.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

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.

Plan of Correction - To be completed: 05/24/2025

Builders Hardware has been contacted and will be installing the proper corner guard, so integrity is not compromised on the doors and they meet door maintenance testing and inspection requirements.

This corrective action will be continuous throughout the year.

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

Facility ID #540302
Component 02
D-Wing

Based on 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 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:

NFPA 101 STANDARD General Requirements - Other:

Observations:
Name: D- WING - Component: 02 - Tag: 0100

Based on observation and interview, the facility failed to maintain portable floor plans that outlined designated rated partitions, affecting the entire facility.

Findings include:

Document review on March 25, 2025, at 10:24 a.m., revealed the facility failed to provide a set of accurate, portable floor plans. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site, to be used during the Life Safety Code Survey.

The Life Safety Code Floor Plan shall include the following:
a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls (1-2 hour walls);
c. Horizontal exits;
d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls.

Interview at the exit conference with the maintenance supervisor on March 25, 2025, at 10:24 a.m., confirmed the facility's Life Safety Code Floor Plan was unavailable at the time of the survey.

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

Facility ID #540302
Component 03
Therapy Addition

Based on 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 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:

NFPA 101 STANDARD General Requirements - Other:

Observations:
Name: THERAPY ADDITION - Component: 03 - Tag: 0100

Based on observation and interview, the facility failed to maintain portable floor plans that outlined designated rated partitions, affecting the entire facility.

Findings include:

Document review on March 25, 2025, at 10:24 a.m., revealed the facility failed to provide a set of accurate, portable floor plans. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site, to be used during the Life Safety Code Survey.

The Life Safety Code Floor Plan shall include the following:
a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls (1-2 hour walls);
c. Horizontal exits;
d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls.

Interview at the exit conference with the maintenance supervisor on March 25, 2025, at 10:24 a.m., confirmed the facility's Life Safety Code Floor Plan was unavailable at the time of the survey.

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: THERAPY ADDITION - Component: 03 - Tag: 0355

Based on observation and interview, the facility failed to meet portable fire extinguisher requirements for one of over five extinguishers.

Findings include:

Observation on March 25, 2025, at 11:33 a.m., revealed the physical therapy fire extinguisher had a 2022 date.

Interview with the maintenance technician on March 25, 2025 at 11:33 a.m., confirmed the fire extinguisher deficiency.

Plan of Correction - To be completed: 05/24/2025

To meet portable fire extinguisher requirements, the physical therapy fire extinguisher was replaced. All fire extinguishers will be checked monthly by maintenance and any problems corrected immediately. Extinguishers not in compliance will be replaced immediately.

This corrective action will be continuous throughout the year.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright � 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement