Pennsylvania Department of Health
BRISTOL HEALTH & REHAB CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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BRISTOL HEALTH & REHAB CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Facility ID# 131902
Component 01
Main building 01

Based on a Relicensure Survey completed on October 29, 2025, it was determined Silver Lake Healthcare Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy.

This is a two-story, Type II (000), unprotected non-combustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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 S-tags, but are deficient.

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

Based on observation and interview, it was determined the facility failed to conform to applicable State Department of Health regulations, affecting the entire facility.

Findings Include:

1. Document review on October 29, 2025, at 10:00 a.m., revealed the facility failed to provide a set of accurate portable floor plans. The Division of Safety Inspection requires that all facilities under our 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 (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 their Life Safety Code Floor Plan.
e. Required Exits should be clearly noted; and
f. Shafts Walls

In addition to the above, the following information is required on the portable floor plans for facilities utilizing the Fire Safety Evaluation System (FSES):

dimensions (length and width)
Room numbers and numbers of residents in each room
station locations to include number of nurses at each location
arrows for emergency movement routes
room use must be identified (dining, soiled linen, housekeeping, office, etc.)
where FSES deficiency exists on floor plans.

Exit Interview with the Administrator and Maintenance Director, on October 29, 2025, at 12:00 p.m., confirmed an accurate set of portable floor plans was not available.

Plan of Correction - To be completed: 11/30/2025

1.No residents were affected as a result of this deficient practice.
2.The facility currently has a Life Safety Code Floor Plan items required on life safety floor plans readily available on site.
3.The Maintenance Director or designee will conduct monthly audits for three consecutive months to ensure that the Life Safety Code documentation remains current and readily accessible.
4.Results of the audits and any identified trends will be reported to the Quality Assurance and Performance Improvement (QAPI) Committee to determine the need for ongoing or additional audits.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

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 that the facility failed to maintain stairways, affecting one of four stairways.

Findings include:

Observation on October 29, 2025, revealed stairway deficiencies in the following locations:

a. 10:15 a.m., in the basement exit stairway, carts, multiple paint buckets and various other items stored under the landing.
b. 11:15 a.m., on the second floor, in the B-hall exit stairway, patient bed frame stored on the landing.

Exit Interview with the Administrator and Maintenance Director, on October 29, 2025, at 12:00 p.m., confirmed the stairway deficiencies.

Plan of Correction - To be completed: 11/30/2025

1.No residents were affected as a result of this deficient practice.
2.The basement exit stairway second floor B hall has been cleared of all items and obstructions, ensuring the exit path is safe and accessible at all times.
3.The Maintenance Director or designee will conduct weekly audits for four weeks, followed by monthly audits for two months, to verify that all stairwells remain free of storage or items that could obstruct egress.
4.Results and trends from these audits will be reviewed and reported to the Quality Assurance and Performance Improvement (QAPI) Committee to determine if continued monitoring or additional corrective actions are necessary.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based upon document review and interview, it was determined the facility failed to maintain portable fire extinguishers, affecting one of three levels.

Document Review on October 29, 2025, at 9:15 a.m., revealed, the September 2025 Annual Fire Extinguisher Report listed the following deficiency, which remained uncorrected at time of survey: " PW fire extinguisher is due for service and should be replaced. Customer needs a quote " .

Exit Interview with the Administrator and Maintenance Director, on October 29, 2025, at 12:00 p.m., confirmed the fire extinguisher deficiency.

Plan of Correction - To be completed: 11/30/2025

1.No residents were affected by the deficient practice.
2.The fire extinguisher has been scheduled for replacement to ensure compliance with Life Safety Code requirements.
3.The Maintenance Director or designee will conduct weekly audits for four weeks, followed by monthly audits for two months, to verify that all fire extinguishers are within date limits and have been properly inspected.
4.Audit results and trends will be reported to the Quality Assurance and Performance Improvement (QAPI) Committee for review and to determine the need for continued or additional audits.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:

Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0371

Based on observation, document review, and interview, it was determined the facility failed to provide required smoke barrier partitions and maintain the minimum travel distances for each smoke compartment, affecting two of three levels within the facility.

Findings include:

1. Document review and observation on October 29, 2025, between 8:30 a.m. and 11:00 a.m., revealed the facility lacked a required smoke barrier partition, on the second floor.

Exit Interview with the Administrator and Maintenance Director, on October 29, 2025, at 12:00 p.m., confirmed the lack of a smoke barrier separation.

2. Document review and observation on October 29, 2025, between 8:30 a.m. and 11:00 a.m., revealed smoke compartments 2 and 3 had travel distances exceeding the allowable 200 feet, on the first floor.

Exit Interview with the Administrator and Maintenance Director, on October 29, 2025, at 12:00 p.m., confirmed the travel distances were excessive.

Plan of Correction - To be completed: 11/30/2025

1.No residents were affected by the deficient practice.
2.Silver Lake Healthcare Center is requesting a Fire Safety Evaluation System (FSES) to be completed by the Division of Life Safety for the smoke barrier separation on the 2nd floor, and an additional FSES to be completed for smoke compartments #2 and #3 located on the 1st floor, which have travel distances that exceed the allowable 200 feet.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the improper and unauthorized use of extension cords and outlet multipliers on one of three levels.

Findings include:

Observation on October 29, 2025, at 10:40 am, revealed an extension cord was in use powering a microwave, Nurse Practitioner office, on the first floor.

Exit Interview with the Administrator and Maintenance Director, on October 29, 2025, at 12:00 p.m., confirmed the unauthorized use of electrical devices.

Plan of Correction - To be completed: 11/30/2025

1.No residents were affected by the deficient practice.
2.The extension cord in the staff office was immediately removed at the time of the survey.
3.The Maintenance Director or designee will educate Management team regarding the prohibition of using extension cords and surge protectors in resident care areas and offices. The Maintenance Director or designee will conduct weekly audits for four weeks, followed by monthly audits for two months, to ensure compliance.
4.Audit results and trends will be reported to the Quality Assurance and Performance Improvement (QAPI) Committee for review to determine the need for further audits or additional corrective action.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain oxygen cylinder storage affecting two of three levels.

Findings include:

Observation on October 29, 2025, at 10:25 a.m., revealed, on the first floor, Unit #1 oxygen storage room, door failed to close smoke tight due to frame contact.

Exit Interview with the Administrator and Maintenance Director, on October 29, 2025, at 12:00 p.m., confirmed the door condition.

Plan of Correction - To be completed: 11/30/2025

1.No residents were affected by the deficient practice.
2.The 1st Floor Unit 1 Oxygen Storage Room door was repaired to ensure the door closure is smoke-tight at the frame contact.
3.The Maintenance Director or designee will conduct audits weekly for four (4) weeks and then monthly for two (2) months to ensure proper door closure.
4.Audit findings and trends will be reported to QAPI for review and determination of the need for further audits.

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