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 a Revisit to a Relicensure Survey completed on October 29, 2025, it was determined that Foulkeways At Gwynedd was not in substantial 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.

*****************************************

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

Item 1 Not Completed. The facility failed to provide portable Life Safety Code Floor Plans.

Exit interview with the Administrator and Maintenance Director on January 7, 2026, at 11:00 a.m., confirmed that portable floor plans were not available.

Plan of Correction - To be completed: 02/13/2026

The Facilities Director and Nursing Home Administrator met 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. The facility will have plans by 2/13/2026. 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 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.

***************************************

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.

Plan of Correction - To be completed: 03/01/2026

Life Safety Service company has completed the inspection and found two deficiencies. At this time the community is awaiting confirmed schedule for repair. Estimate repair are expected to be complete by 3/1/26 .The Facilities Director or designee will maintain inspection reports of the HVAC system. The Facilities Director completed an audit of 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 meetings

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