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

There are 44 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.


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 a Relicensure Survey completed on October 29, 2025, it was determined that Foulkeways at Gwynedd 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 (111), protected non-combustible building, with a basement and unused attic, 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 (GWYNEDD HOUSE) - Component: 01 - Tag: 0100

Based on document review and interview, it was determined the facility failed to provide accurate, portable floor plans as required, affecting the entire facility.

Findings include:

1. Document review on October 29, 2025, at 9:00 a.m., it was determined the facility failed to provide portable Life Safety Code Floor Plans that included the following information:

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

Exit interview with the facility Administrator and facility Maintenance Director, on October 29, 2025, at 2:00 p.m., confirmed the facility lacked accurate, portable floor plans.

Plan of Correction - To be completed: 12/31/2025

The facility will have accurate portable floor plans as recommended per regulations. The Facilities Director or designee will meet with the architectural vendor to acquire the required portable Life Safety Code Floor plans which will include smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits to be noted and shaft walls. These plans will be obtained by 12/31/2025. In addition, the Facilities Director or designee will ensure these plans are always on site and accessible. The plan of correction will be included in the Quality Assurance Performance Improvement meeting.

NFPA 101 STANDARD Multiple Occupancies - Construction Type:

Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3

Observations:
Name: MAIN BUILDING 01 (GWYNEDD HOUSE) - Component: 01 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of fire barriers, affecting one of three levels.

Findings include:

Observation on October 29, 2025, at 12:15 p.m., revealed an open penetration around data lines and MC Cable above the ceiling tile, Basement double fire doors that separate Gwynedd and Personal Care.

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

Plan of Correction - To be completed: 11/20/2025

The Facilities Department repaired the one penetration on 11/20/2025 and this area complies with the regulations. The Facilities Director or designee will continue to monitor and work with vendors in collaboration to ensure penetrations are sealed correctly using UL stop gap penetration 3M Fire Barrier Sealant CP-25WB+. The Director of Facilities or Designee will be sure to inspect contractors penetrations through walls for proper sealant product after each scheduled project and after every performed work on an ongoing basis. The plan of correction will be reviewed at the Quality Assurance Performance Improvement meeting.

NFPA 101 STANDARD Exit Signage:

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING 01 (GWYNEDD HOUSE) - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed to maintain exit signage, affecting one of three levels.

Findings include:

Observation on October 29, 2025, at 12:55 p.m., revealed a missing exit sign, on the first floor, Gwynedd Dining Room exit door.

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

Plan of Correction - To be completed: 12/31/2025

The Facilities Director or designee will install directional signage with continuous illumination as per regulation on the first floor of Gwynedd dining room exit door. The Facilities Director or designee will ensure exit sign is installed properly by 12/31/2025. The Facilities Director or designee will audit all exit doors to ensure there are properly installed exit signage. The result of the audit will be reviewed at Quality Assurance Performance Improvement meeting.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 (GWYNEDD HOUSE) - Component: 01 - Tag: 0345

Based on observation review and interview, it was determined the facility failed to maintain the fire alarm system in proper operating condition, affecting the entire facility.

Findings Include:

Observation on October 29, 2025, at 12:45 p.m., revealed the facility fire alarm panel was in trouble mode at the time of survey.

Exit interview with the facility Administrator and facility Maintenance Director, on October 29, 2025, at 2:00 p.m., confirmed the fire alarm panel was in trouble mode.

Plan of Correction - To be completed: 11/17/2025

On the day of survey, the facilities had the system on test due to work being completed on the sprinkler system. The system is normally on standby as per the fire watch policy. The Facilities Director or designee will ensure the policy is in force while the fire alarm system is in testing, when work is not being completed on the sprinkler system. The Facilities Director or designee will continue to monitor the fire system when on test and while work is being completed in the facility. Once the work is completed, the Facilities Director or designee will ensure the system is placed back in normal operations as per regulation. The plan of correction will be included in the Quality Assurance Performance Improvement meeting.

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 (GWYNEDD HOUSE) - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain fire extinguishers, affecting one of three levels.

Findings include:

Observation on October 29, 2025, at 12:40 p.m., revealed a portable fire extinguisher cabinet was missing wall location signage, on the first floor, Entrance to Abington North.

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

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

The signage was placed on the portable fire extinguisher cabinet on 10/31/2025. The Facilities Director or designee will audit all fire extinguisher cabinets monthly to ensure they have the proper wall identification. The Director of Facilities or designee will review audits to ensure compliance. The results of the audits will be review at the Quality Assurance Performance Improvement meeting.

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
2012 EXISTING
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.
There is no impediment to the closing of the doors. Clearance between bottom of door and floor covering is not exceeding 1 inch. Roller latches are prohibited by CMS regulations on corridor doors and rooms containing flammable or combustible materials. Powered doors complying with 7.2.1.9 are permissible. 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 (GWYNEDD HOUSE) - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure that corridor doors were maintained to resist the passage of smoke and positively latch when tested, affecting one of three levels.

Findings include:

Observation on October 29, 2025, from 12:20 p.m. to 1:22 p.m., revealed corridor doors failed to close and latch at the following locations:

a. 12:20 p.m., in the basement, Water Heater Room.
b. 1:22 p.m., on the second floor, Soiled Linen Room near Room 36A.

Exit interview with the facility Administrator and facility Maintenance Director, on October 29, 2025, at 2:00 p.m., confirmed the doors failed to close and latch.

Plan of Correction - To be completed: 11/28/2025

Repairs were completed by an outside contractor on 11/7/2025 for the water heater room; a Schlage mortise lock was installed. In addition, on the second floor, soiled linen room near room 36A, the repair was complete with the recommended locking mechanism. The Facilities Director or designee will complete random monthly audits for proper latching of doors. The Facilities Director will review the audits for accuracy. The plan of correction and results of the audits will be reviewed at the Quality Assurance Performance Improvement meeting.

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:

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.

Plan of Correction - To be completed: 12/31/2025

The Facilities Director is working closely with the Life Safety Service company to complete the required repairs to the deficient smoke dampers. The Facilities Director or designee will maintain service and inspection reports of the HVAC system. Once the repairs are complete, the Facilities Director or designee will audit damper system reports from the vendor to ensure all deficiencies cited on 10/29/2025 have been corrected and the system is fully functioning. The results will be reviewed in the Quality Assurance Performance Improvement meeting.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 (GWYNEDD HOUSE) - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain components of the emergency generator affecting seven of seven smoke compartments.

Findings include:

Review of documentation on October 29, 2025, at 9:00 a.m., revealed the facility lacked documentation to support the monthly conductance testing on the emergency generator battery.

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

Plan of Correction - To be completed: 12/31/2025

The Facilities Director or designee will conduct monthly conductance testing. The Facilities Director or designee will test the components monthly when exercising the generator on an ongoing basis. The results of the testing will be reviewed by the Facilities Director for accuracy and the documentation will be maintained in the Facilities department. The monthly testing results will be included in the Quality Assurance Performance Improvement meetings.

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