Pennsylvania Department of Health
BURGH CARE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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BURGH CARE 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 May 7, 2025, it was determined that Burgh Care Center was not in compliance with the following 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:

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.

§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, documentation review, and interview, it was determined the facility failed to maintain a policy for emergency and standby power systems one instance, affecting the entire facility.

Findings include:

1. Observation and review of documentation on May 7, 2025, at 12:35 p.m., revealed the facility lacked an emergency generator and failed to maintain a policy that the facility would evacuate within 90 minutes in the event of a power failure.

Interview with the Facility Administrator and Maintenance Director on May 7, 2025, at 1:00 p.m., confirmed the facility emergency plan did not address the lack of an emergency generator and the requirement to evacuate within 90 minutes.

Plan of Correction - To be completed: 05/15/2025

E0041
1.The policy was updated 5-12-24 and will be provided on the date of revisit.
2.The Command Incident Team has been educated on the policy.

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

Facility ID# 016002
Component 01
Main Building

Based on an Abbreviated survey, as part of a complaint investigation, completed on May 7, 2025, it was determined that Burgh Care Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a five story, Type II (222), fire resistive building, without a basement, that 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 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain stairways and smokeproof enclosures in one instance, affecting one of three stairways.

Findings include:

1. Observation on May 7, 2025, at 11:50 a.m., revealed there was no self-closing device on the first floor rear stairway door of the South Stairway.

Interview with the Facility Administrator and Maintenance Director on May 7, 2025, at 1:00 p.m., confirmed the rear South Stairway door lacked a self-closing device.

Plan of Correction - To be completed: 05/15/2025

K0225:
1.Door closer was put on the stair well door.
2. The Maintenance direct was in-serviced on the purpose of maintaining a smoke compartment.
3. The maintenance director will continue his monthly inspection as per code.
4. All concerns will be reported to the Quality Assurance Performance Improvement committee to ensure all corrections are made.

NFPA 101 STANDARD Emergency Lighting:

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.

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on observation and interview, it was determined the facility failed to maintain emergency lighting in one instance, for one of over 20 emergency lights tested.

Findings include:

1. Observation on May 7, 2025, at 12:45 p.m., revealed a battery-powered emergency light near Room 323, on the third floor, failed to illuminate when tested.

Interview with the Facility Administrator and Maintenance Director on May 7, 2025, at 1:00 p.m., confirmed emergency light failed to illuminate and a new battery was previously ordered.

Plan of Correction - To be completed: 05/15/2025

K0291
1.The documentation was updated 4/11/25 and all lights had the 90-minute annual test completed.
2.The maintenance director was in-serviced on 90 annual minute inspection.
3.The maintenance director will continue his monthly inspection as per code.
4.All concerns will be reported to Quality Assurance Performance Improvement committee to ensure all corrections are made.

NFPA 101 STANDARD Evacuation and Relocation Plan:

Evacuation and Relocation Plan
There is a written plan for the protection of all patients and for their evacuation in the event of an emergency.
Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2.
18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0711

Based on observation, documentation review, and interview, it was determined the facility failed to maintain an evacuation plan one instance, affecting the entire facility.

Findings include:

1. Observation and review of documentation on May 7, 2025, at 12:37 p.m., revealed the facility lacked an emergency generator and failed to maintain a policy that the facility would evacuate all residents within 90 minutes in the event of a power failure. On May 4, 2025, there was a power failure from approximately 3:00 p.m., to 5:10 p.m., and in that time only four out of 75 residents were evacuated.

Interview with the Facility Administrator and Maintenance Director on May 7, 2025, at 1:00 p.m., confirmed the facility evacuation plan did not address the lack of an emergency generator and the requirement to evacuate within 90 minutes during a power failure, and when the building lost all electricity on May 4, 2025, four out of 75 residents were evacuated.

Plan of Correction - To be completed: 05/15/2025

K0711
1.If both power legs are lost, the building will be evacuated before the 90-minute time frame.
2.The Command Incident Team has been educated on the policy.

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