Pennsylvania Department of Health
 ONYX WELLNESS CENTER
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ONYX WELLNESS CENTER
Inspection Results For:

There are  42 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.
ONYX WELLNESS 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 27, 2025, it was determined that Onyx Wellness Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.






 Plan of Correction:


403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.
Observations:
Name: - Component: -- - Tag: 0004

Based on documentation review and interview, it was determined the facility failed to ensure Emergency Preparedness Plan policies and procedures were reviewed and updated at least annually, affecting the entire facility.

Findings include:
Document review on May 27, at 8:00 a.m., revealed the Facility's Emergency Preparedness Plan had not been reviewed and updated at least annually.
Exit interview with the Administrator and Maintenance Director on May 27, at 2:30 p.m., confirmed procedural updated documentation could not be provided.




 Plan of Correction - To be completed: 07/01/2025

1. Administrator and Maintenance Director completed a comprehensive review of Emergency preparedness plan.
2. Administrator and Maintenance Director was educated on the requirements to review of conducting a review of the Emergency Preparedness Plan
3. Maintenance Director added agenda item to Monthly Life Safety Meetings to discuss sections of Emergency Preparedness plans.
4. Administrator / Designee will audit Monthly life safety meetings x 3.

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


Facility ID # 124302
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 27, 2025, it was determined that Onyx Wellness Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

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





 Plan of Correction:


NFPA 101 STANDARD Discharge from Exits: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.
Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0271

Based on observation and interview, it was determined the facility failed to maintain the egress discharge, affecting one of five means of egress.

Findings Include:
Observation made on May 27, 2025, at 1:28 p.m., revealed the stair tower egress door discharging to the basement level vestibule, near patio activity room, resulted in exit discharge obstruction to the public way.
Exit interview with the Administrator and Maintenance Director on May 27, 2025, at 2:30 p.m., confirmed the deficient egress discharge.








 Plan of Correction - To be completed: 07/01/2025

1. Maintenance Director Locked Door and added proper directional Signage to direct traffic to proper discharging door.
2. Facility wide audit was completed ensuring that all emergency egresses are free of obstructions.
3. Maintenance Director was educated on requirements to ensure emergency egresses are free of obstruction.
4. Maintenance Director/ Designee will audit emergency egresses Weekly x 4 then monthly x 2 to ensure emergency egresses have directional signage posted and are free from obstructions.

NFPA 101 STANDARD Illumination of Means of Egress: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.
Illumination of Means of Egress
Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention.
18.2.8, 19.2.8
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0281

Based on observation and interview, it was determined the facility failed to maintain the Illumination of means of egress, affecting one of two levels.

Findings include:

1. Observation made on May 27, 2025, at 12:04 p.m. revealed exit signage located in the kitchen failed to illuminate.

2. Observation made on May 27, 2025, at 12:45 p.m. revealed exterior electric lights not working due to missing light bulbs, in the Lower-Level, the exit near Sprinkler Valve Room.

Exit interview with the Administrator and Maintenance Director on May 27, 2025, at 2:30 p.m., confirmed the deficient egress lighting.







 Plan of Correction - To be completed: 07/01/2025

1. Maintenance Director repaired (a) exit signage located in the kitchen, (b) exterior lighting at lower level exit near sprinkler valve room.
2. Maintenance Director / Designee completed house wide audits to ensure all exits are properly illuminated
3. Maintenance Director was educated on requirements to ensure exit area's are properly illuminated.
4. Maintenance Director / designee will audit exits weekly x 4 then monthly x 2 to ensure exits are properly illuminated.

NFPA 101 STANDARD Exit Signage: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.
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 - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed maintain proper directional egress signage in accordance with NFPA 101, affecting one of four smoke zones in the facility.

Findings Include:
Observation on May 27, 2025, at 1:24 p.m., revealed missing directional signage in the activity room near outside patio on the first floor impeding proper timely egress.
Exit interview with the Administrator and Maintenance Director on May 27, 2025, at 2:30 p.m., confirmed missing directional egress signage.




 Plan of Correction - To be completed: 07/01/2025

1. Maintenance Director installed missing Egress Directional signage.
2. Maintenance Director / Designee Conducted house wide audits ensuring Egress Directional signage is posted in accordance with NPA 101
3. Maintenance Director Educated on requirements to have egress Directional Signage in accordance with NPA 101
4. Maintenance Director / Designee will audit weekly x4 then monthly x 2 to ensure that egress directional signage is posted in accordance with NFPA 101

NFPA 101 STANDARD Fire Alarm System - Initiation: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.
Fire Alarm System - Initiation
Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200' travel distance is not exceeded.
18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0342

Based on observation and interview, it was determined the facility failed to maintain fire alarm initiating devices, affecting one of two levels.

Findings include:

Observation on May 27, 2025, at 1:00 p.m., revealed a smoke detector was not securely mounted to the ceiling, in the Lower-Level, the corridor near Maintenance Director's Office.

Exit interview with the Administrator and Maintenance Director on May 27, 2025, at 2:30 p.m., confirmed the deficient smoke detector.




 Plan of Correction - To be completed: 07/01/2025

1. Maintenance Director Repaired smoke detector at lower level corridor near Maintenance Directors Office, ensuring it is securely mounted to ceiling
2. Maintenance Director / Designee completed audits of smoke detectors ensuring they are properly mounted and in satisfactory condition.
3. Maintenance Director educated on requirements to ensure smoke detectors are securely mounted and in good condition.
4. Maintenance Director / Designee will continue to audit smoke detectors weekly x 4 then monthly x 2.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - 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 May 27, 2025, at 11:50 a.m., revealed the facility fire alarm panel was in trouble mode at the time of survey.

Exit interview with the Administrator and Maintenance Director on May 27, 2025, at 2:30 p.m., confirmed the fire alarm panel trouble status.




 Plan of Correction - To be completed: 07/01/2025

1. Facility Fire Alarm servicing vendor repaired fire alarm panel and cleared trouble code
2. Maintenance Director was educated on requirements to ensure Fire alarm system is in good operating condition.
3. Maintenance Director will add agenda item to Monthly Life safety Meetings to discuss Fire alarm systems and control Panel.
4. Maintenance Director / designee will audit fire control Panel Weekly x 4 then Monthly x 2 to ensure there are no trouble code's present and that systems are in functioning condition.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to ensure the automatic sprinkler system and its components-maintained smoke tight assembly throughout the facility.

Findings include:
Observations made on May 27, 2025, between 12.00 p.m. and 1:30 p.m., revealed missing sprinkler escutcheons in the following locations:
a. 12:24 p.m., on the second floor, near cross corridor doors outside janitor closet.
b. 12:36 p.m., on the second floor, outside boiler room.
c. 12:56 p.m., on the second floor, inside maintenance office.
d. 1:07 p.m., on the first floor, inside activity room.
e. 1:08 p.m., on the first floor, outside shower room.
f. 1:25 p.m., on the first floor, inside activity room near outside patio.

Exit interview with the Administrator and Maintenance Director on May 27, 2025, at 2:30 p.m., confirmed the missing escutcheons.



 Plan of Correction - To be completed: 07/01/2025

1. Maintenance Director installed / repaired sprinkler escutcheons at (a.) Second floor near cross corridor doors outside janitors closet (b.) second floor outside boiler room (c.) inside maintenance office (e.) first floor outside shower room (f.) in the first floor activity room near outside patio
2. Maintenance Director / designee completed audits of sprinkler heads to ensure they are in good working condition and that escutcheons are installed.
3. Maintenance Director educated on requirements to maintain fire automatic sprinkler systems
4. Maintenance Director will audit Fire Sprinkler heads weekly x 4 then monthly x 2 to ensure they are being maintained and in good working order.

NFPA 101 STANDARD Portable Fire Extinguishers: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.
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 on observation and interview, it was determined the facility failed to ensure portable fire extinguishers were accessible, and mounted in accordance with NFPA 10, affecting four of four smoke zones in the facility.

Findings Include:

1. Observation on May 27, 2025, at 12:05 p.m., revealed an ABC portable fire extinguisher wall mounted in the kitchen was obstructed by a fixed table.

2. Observation on May 27, 2025, between 12:00 p.m. and 1:25 p.m., revealed several ABC portable fire extinguishers mounted in excessive height in accordance with NFPA 10 chapter 6.

Exit interview with the Administrator and Maintenance Director on May 27, at 2:30 p.m., confirmed obstructed fire extinguisher and several mounting deficiencies.






 Plan of Correction - To be completed: 07/01/2025

1. Maintenance Director Installed fire extinguishers in an un-obstructed location, re-installed ABC portable fire extinguishers mounting apparatus to properly mount fire extinguishers in accordance with NFPA 101 10. 6
2. Maintenance Director / designee completed audits of Fire extinguishers to ensure they are mounted in accordance with NFPA101 10.6
3. Maintenance Director educated on ensuring fire extinguishers are properly mounted in accordance with NFPA 101 10.6
4. Maintenance Director / designee will audit Fire extinguishers Weekly x 4 then monthly x2 to ensure they are mounted in accordance with NFPA 101 10.6

NFPA 101 STANDARD Corridor - Doors: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.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. 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 - Component: 01 - Tag: 0363

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

Findings include:

Observation on May 27, 2025, at 12:20 p.m., revealed a door missing its hardware, in the Upper Level, Janitor's Closet, near Kitchen.

Exit interview with the Administrator and Maintenance Director on May 27, 2025, at 2:30 p.m., confirmed the missing hardware.




 Plan of Correction - To be completed: 07/01/2025

1. Maintenance director Installed Door handle hardware in the upper level janitors closet near kitchen.
2. Maintenance Director / designee completed audits of door closing / Latching hardware to ensure doors can latch and resist the passage of smoke.
3. Maintenance Director educated on requirements to ensure Doors can resist the passage of smoke and can positively latch.
4. Maintenance Director / designee will conduct audits weekly x 4 than monthly x 2 to ensure doors are positivity latching and can resist the passage of smoke.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation, document review, and interview, the facility failed to maintain the fire resistance rating of smoke barrier separations, affecting the entire facility.

Findings include:

Observation and document review on May 27, 2025, at 8:30 a.m., revealed that the smoke barrier walls on the first floor and second floor of the east wing, were incomplete near the central bathrooms.

Exit interview with the Administrator and Maintenance Director on May 27, 2025, at 2:30 p.m., confirmed the smoke barrier separations were incomplete.



 Plan of Correction - To be completed: 07/01/2025

Facility would like to request the continuation of the FSES, at the current time.

NFPA 101 STANDARD Electrical Systems - Other: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.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, affecting three of four smoke compartments.

Findings include:

Observations on May 27, 2025, revealed the following electrical deficiencies:

a. 12:00 p.m., electrical outlet under microwave, Staff Loungein the Upper-Level.
b. 12:05 p.m., electrical outlet next to hot plate warmer, Kitchen in the Upper-Level.
c. 12:45 p.m., MC cable not terminated into a junction box, in the Lower-Level, Boiler Room, ceiling inside entrance door.
d. 1:30 p.m., electrical outlet, Patio Activities Room in the Lower-Level.

Exit interview with the Administrator and Maintenance Director on May 27, 2025, at 2:30 p.m., confirmed the electrical deficiencies.

Refer to NFPA 70, National Electric Code, and NFPA 99, 6.3.2.1.




 Plan of Correction - To be completed: 07/01/2025

1. Maintenance Director / Designee repaired (a.) electrical outlet under microwave, Staff Lounge in the Upper-Level. (b.) electrical outlet next to hot plate warmer, in upper-Level Kitchen. (c.) Installed Junction box for MC cable termination into a junction box, in the Lower-Level, Boiler Room. (d.) repaired ceiling inside entrance door in the boiler room (e.) Repaired electrical outlet, at the Patio Activities Room in the Lower-Level
2. Maintenance Director / Designee conducted audits of electrical systems to ensure they are Maintained and have protections of electrical wiring.
3. Maintenance Director educated on requirements to ensure electrical systems are Maintained and have protections of electrical wiring.
4. Maintenance Director / Designee will audit electrical systems weekly x 4 then monthly x 2 to ensure they are being maintained and have protections of electrical wiring.


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