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 41 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 April 24, 2024, 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 April 24, 2024, 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 April 24, 2024, at 10:00 a.m., revealed the facility lacked one of two reports for semi-annual kitchen exhaust hood/duct cleanings at the time of the survey.

Interview with the maintenance supervisor on April 24, 2024, at 10:00 a.m., confirmed the missing semi-annual documentation.

Plan of Correction - To be completed: 06/12/2024

Director of Maintenance immediately contacted hood cleaning company, C&S Hood and Exhaust Cleaning, to resend documentation of service from date missing during survey review. Documentation was obtained and forwarded.

Director of Maintenance will request future documentation for semi-annual hood cleaning services provided be sent directly to him. All documentation will be placed in the Life Safety survey book.

NFPA 101 STANDARD Corridor - Doors:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, the facility failed to maintain corridor doors for two of over fifty corridor doors.

Findings include:

Observation on April 24, 2024, between 11:59 a.m. and 12:31 p.m., revealed the following resident room doors failed to positively latch in the frame:
A. (11:59 a.m.) B-Hall, room 11;
B. (12:31 p.m.) B-Hall, room 4.

Interview with the maintenance supervisor on April 24, 2024, at 12:31 p.m., confirmed the corridor doors lacked positive latching.

Plan of Correction - To be completed: 06/12/2024

B-Hall, room 11 door and B-Hall, room 4 door that failed to positively latch in the frame were immediately fixed.

Corridor doors are checked daily using a checklist to confirm this has been done. Doors will be corrected immediately if failing to latch. Director of Maintenance will review this checklist to ensure completion.

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 April 24, 2024, at The Ball Pavilion, it was determined there were no deficiencies identified under 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 a Medicare/Medicaid Recertification Survey completed on April 24, 2024, at The Ball Pavilion, it was determined there were no deficiencies identified under 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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