Pennsylvania Department of Health
FOULKEWAYS AT GWYNEDD
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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FOULKEWAYS AT GWYNEDD - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: MAIN BUILDING 01 (GWYNEDD HOUSE) - Component: 01 - Tag: 0000

Facility ID# 060902
Component 01
Gwynedd House

Based on this Revisit to a Relicensure Survey completed on October 29, 2025, it was determined that Foulkeways At Gwynedd was in substantial compliance with the requirements of the Life Safety Code for an existing Nursing health care occupancy.

This is a two-story, Type II (111), protected non-combustible building, with a basement and unused attic, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: MAIN BUILDING 01 (GWYNEDD HOUSE) - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility failed to maintain inspection and service of heating, ventilating and air conditioning (HVAC) equipment at required intervals, affecting the entire facility.

Findings include:

1. Document review on October 29, 2025, at 9:00 a.m., revealed the smoke damper testing resulted in two fails and three non-tested based on obstructed/ non-accessible locations.

Exit interview with the facility Administrator and facility Maintenance Director, on October 29, 2025, at 2:00 p.m., confirmed the failed and missing testing.

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Based on an onsite Revisit conducted on January 7, 2026, the following was determined:

Item 1 Not Completed. The smoke damper testing resulted in two fails and three non-tested dampers based on obstructed/ non-accessible locations.

Exit interview with the Administrator and Maintenance Director on January 7, 2026, at 11:00 a.m., confirmed fire damper testing was incomplete.

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Based on this Second Revisit conducted on March 11, 2026, the following was determined:

Item 1 Not Completed. The smoke damper testing resulted in two fails and three non-tested dampers based on obstructed/ non-accessible locations. Evidence of corrective action could not be found at the time of revisit.

Exit interview with the Administrator and Maintenance Director on March 11, 2026, at 11:00 a.m., confirmed the missing documentation.

Plan of Correction - To be completed: 04/27/2026

At this time the community is confirmed for scheduled repairs on 4/7/2026; repairs are expected to be completed on this date. Once complete, the Facilities Director or designee will maintain inspection reports of the HVAC system. The Facilities Director will audit the damper system reports from the vendor to ensure all deficiencies have been corrected and the system is fully functioning. The results will be included in the Quality Assurance Performance Improvement meeting.

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