Pennsylvania Department of Health
PETER BECKER COMMUNITY
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PETER BECKER COMMUNITY
Inspection Results For:

There are  56 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.
PETER BECKER COMMUNITY - 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 April 14, 2025, at Peter Becker Community, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.



 Plan of Correction:


Initial comments:Name: MAIN BLDG 01 (ASTER,CHERRYBLOSS,TULIP,SWEETWM,PRIM - Component: 01 - Tag: 0000


Facility ID# 160602
Building 01
Aster Avenue, Cherry Blossom Court, Tulip Terrace, Sweet William Way, Primrose Path, Larkspur Lane and the Boxwood Wing

Based on a Medicare/Medicaid Recertification Survey completed on April 14, 2025, it was determined that Peter Becker Community - Aster Avenue, Cherry Blossom Court, Tulip Terrace, Sweet William Way, Primrose Path, Larkspur Lane and the Thrift Shop Wings, were 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 one-story, Type III (200), unprotected ordinary building, with a partial basement, that is fully sprinklered.







 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies: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.
Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623
Observations:
Name: MAIN BLDG 01 (ASTER,CHERRYBLOSS,TULIP,SWEETWM,PRIM - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to ensure common fire wall separations maintained a fire resistance rating, affecting one of two levels.

Findings include:

Observation on April 14, 2025, at 12:00 p.m., revealed above the fire doors separating Main from the connecting corridor, an approximately 4" x 4" inch hole was present around a data wire.

Exit Interview with the Administrator and Maintenance Director on April 14, 2025, at 12:20 p.m., confirmed the common wall deficiency.





 Plan of Correction - To be completed: 05/15/2025

1) The 4"x4" hole in the fire rated wall above the fire doors separating the Main building from the Connecting Corridor have been repaired and sealed using 3M Fire Barrier Sealant CP 25WB+ (UL1479/ASTM E814). Completed 4/15/25

1a) UL System No. W-L-3210 was followed in this repair. System No. W-L-3210 is the approved application for Frame construction/Walls. (F-Rated 1-2 Hrs.)

2) Maintenance staff will be in-serviced on requirements related to maintaining fire rated walls and structures.

3) The Maintenance Director or Designee will conduct spot inspections of above ceiling fire walls ensuring areas of penetration are properly sealed. Frequency of 1x each month for 4-months, then atleast quarterly thereafter. Any findings from the inspections will be corrected immediately.

4) The results of the fire wall inspections will be reviewed at the Facilities Weekly Team Meeting on a minimum of once every quarter.
NFPA 101 STANDARD Number of Exits - Corridors:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Number of Exits - Corridors
Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies.
18.2.5.4, 19.2.5.4




Observations:
Name: MAIN BLDG 01 (ASTER,CHERRYBLOSS,TULIP,SWEETWM,PRIM - Component: 01 - Tag: 0252

Based on document review and interview, it was determined the facility failed to provide two approved exits from each floor level, affecting two of seven smoke compartments.

Findings include:

1. Document review on April 14, 2025, 9:15 a.m., revealed the basement lacked two required exits remote from each other. One of the exits from the basement was through the main laundry.

Exit Interview with the Administrator and Maintenance Director on April 14, 2025, at 12:20 p.m., confirmed the lack of two acceptable remote exits from the basement.


2. Document review on April 14, 2025, at 9:30 a.m., revealed the exit from the Personal Care Unit was through an intervening lounge. The exit was in Smoke Zone #3, Primrose Path.

Exit Interview with the Administrator and Maintenance Director on April 14, 2025, at 12:20 p.m., confirmed exit was through an intervening lounge.





 Plan of Correction - To be completed: 05/15/2025

1) Lacking two remote exits from the basement: Peter Becker Community requests the FSES on file with the Department be utilized and accepted.

2) Exit in Smoke Zone #3 (Primrose Path) exits through an intervening lounge: Peter Becker Community requests the FSES on file with the Department be utilized and accepted.

Update: The Facility is choosing to eliminate the FSES currently in place and will be performing renovations to deficiencies addressed in the current FSES. Our Design Architects are now in possession of the current FSES and will ensure the deficient areas are addressed in the renovation drawings which will be submitted to the DOH Plan Review Department for final review and approval.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 BLDG 01 (ASTER,CHERRYBLOSS,TULIP,SWEETWM,PRIM - Component: 01 - Tag: 0353

Based on document review, observation, and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire facility.

Findings include:

1. Document review on April 14, 2025, at 9:00 a.m., revealed the January 7, 2025, sprinkler inspection report listed the following deficiency. Evidence of corrective action was not available at time of survey.

a. Water gong is not operating properly.

Exit Interview with the Administrator and Maintenance Director on April 14, 2025, at 12:20 p.m., confirmed the sprinkler system deficiency.


2. Document review on April 14, 2025, at 9:05 a.m., revealed the facility could not produce documentation showing the following sprinkler system inspection had been conducted as required:

a. 4th quarter sprinkler inspection;
b. 3-year full-flow dry system trip test.

Exit interview with the Administrator and Maintenance Director on April 14, 2025, at 12:20 p.m., confirmed the missing documentations.


3. Observation on April 14, 2025, at 11:00 a.m., revealed in the Primrose storage room, packages were directly below and within 18 inches of the sprinkler.

Exit Interview with the Administrator and Maintenance Director on April 14, 2025, at 12:20 p.m., confirmed the obstructed sprinklers.


4. Observation on April 14, 2025, at 11:37 a.m., revealed in Cherry Blossom Hall Clean Utility across from room 79 there was a sprinkler head blocked by a lighting fixture.

Exit interview with the Administrator and Maintenance Director on April 14, 2025, at 12:20 p.m., confirmed the obstructed sprinklers.







 Plan of Correction - To be completed: 06/11/2025

#1) Sprinlker contractor has been contacted and a date certain for repair of the water gong was requested. This repair will be completed no later than June 11, 2025.

#2) Sprinlker contractor has been contacted and a date certain for completion of 3-year full-flow dry system trip test was requested. This test and report will be completed and available no later than May 31, 2025.

#3) a. Maintenance/Nursing/Kitchen & Housekeeping staff will be in-serviced on the required 18" minimum clearance allowance for sprinkler heads.
b. Maintenance will install a system of tape or paint lines positioned 18" from the ceiling inside of all storage closets. This will be completed no later than June 11, 2025

#4) The 2'x4'x4" surface mounted light fixture was removed and a slim design L.E.D. strip light was installed, eliminating the sprinkler head from being blocked. Completed 5/1/25

An annual calendar indicatting the planned schedule for all required sprinkler inspections and tests will be established jointly with Peter Becker and the Sprinkler contractor. This calendar and any sprinkler/fire inspection reports from the previous month, will be reviewed monthly at the Facilities Weekly Team Meeting. Any needed repairs, recommendations or additional work indicated on the Sprinkler/Fire Reports will be reviewed and addressed for confirmation of timely completion.

The facility confirmed with the sprinkler contractor that the 4th Qtr. Sprinkler Inspection was not completed as required. The systematic changes outlined above have been put into place into place to ensure deficiency does not occur again.

Update: the 3-yr. Full-Flow Dry Trip Test was performed on 5/8/2025. All tests Passed. Report is on file and available for Surveyor review.

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 BLDG 01 (ASTER,CHERRYBLOSS,TULIP,SWEETWM,PRIM - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure corridor doors were maintained with positive latching, affecting one of two levels.

Findings include:

Observation on April 14, 2025, at 12:10 p.m., Primrose Life Enrichment rear corridor door failed to latch when tested.

Exit Interview with the Administrator and Maintenance Director on April 14, 2025, at 12:20 p.m., confirmed the corridor door failed to latch.






 Plan of Correction - To be completed: 05/15/2025

The door latch on the Primrose Life Enrichment rear corridor door was adjusted and is currently operating with a positive latch.

1) Maintenance staff will be in-serviced on the existing preventive maintenance program specific to door inspections. This will be completed no later than 5/15/25.

2) The Maintenance Director or Designee will review the preventive maintenance log monthly for a period of 4-months, then Quarterly thereafter to ensure the company door inspection PM is followed and necessary repairs are addressed immediately.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
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 BLDG 01 (ASTER,CHERRYBLOSS,TULIP,SWEETWM,PRIM - Component: 01 - Tag: 0371

Based on document review and interview, it was determined the facility failed to ensure the maximum travel distances within smoke compartments was maintained, affecting three of seven smoke compartments.

Findings include:

Document review on April 14, 2025, at 9:30 a.m., revealed travel distance in smoke compartments, Zones 2 (Personal Care Dementia), 4 (Tulip Terrace and Sweet William Way), and 5 (Cherry Blossom Court and Aster Avenue) exceeded 200 feet in length.

Exit Interview with the Administrator and Maintenance Director on April 14, 2025, at 12:20 p.m., confirmed the excess travel distances.





 Plan of Correction - To be completed: 05/15/2025

Failed to ensure the maximum travel distances within smoke compartments:
Peter Becker Community requests the FSES on file with the Department be utilized and accepted.

Update: The Facility is choosing to eliminate the FSES currently in place and will be performing renovations to deficiencies addressed in the current FSES. Our Design Architects are now in possession of the current FSES and will ensure the deficient areas' are addressed in the renovation drawings which will be submitted to the DOH Plan Review Department for final review and approval.
NFPA 101 STANDARD Utilities - Gas and Electric: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.
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2




Observations:
Name: MAIN BLDG 01 (ASTER,CHERRYBLOSS,TULIP,SWEETWM,PRIM - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting one of two levels in the facility.

Findings include:

Observation on April 14, 2025, at 10:58 a.m., revealed in the Primrose Wing, storage within three feet of the electrical panel in the electrical closet across from the nurse station.

Exit Interview with the Administrator and Maintenance Supervisor on April 14, 2025, at 12:20 p.m., confirmed the blocked electrical panel.

NFPA70 110.26(A)(1)




 Plan of Correction - To be completed: 05/31/2025

Condition was corrected immediately.

1) Maintenance Staff will be in-serviced on electrical equipment clearance requirements of NFPA70 110.26(A)(1). This will be completed on or before 5/15/25.

2) Signs/labels and or floor markings will be implemented at electrical panels/equipment indicating NFPA70 Clearance requirements. This will be completed by 5/31/25.

3) Maintenance staff will conduct daily walking rounds and maintain a weekly log of rounding. The Maintenance Director or designee will review the weekly logs 1x per week for 4-weeks, then 1x monthly thereafter. A written log will be maintained for the weekly/monthly log reviews.
NFPA 101 STANDARD HVAC: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.
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 BLDG 01 (ASTER,CHERRYBLOSS,TULIP,SWEETWM,PRIM - Component: 01 - Tag: 0521

Based on observation and interview, it was determined the facility failed to maintain mechanical system components, affecting one of two levels.

Findings include:

Observation on April 14, 2025, revealed dampers missing connective duct work in the following locations:

a. 11:00 a.m., on the first floor, Lark Spur soiled room;
b. 11:50 a.m., on the first floor, Willow Lounge- above rear doors.

Exit Interview with the Administrator and Maintenance Director on April 14, 2025, at 12:20 p.m., confirmed the incomplete damper assemblies.



 Plan of Correction - To be completed: 05/15/2025

A) Larkspur Soiled Linen Room: The missing 8" flex duct will be replaced and reconnected from the damper to the ceiling return vent no later than 5/15/2025.

B) Willow Lounge (rear doors): The thru-wall damper will be capped using a 8" galvanized metal duct termination cap., maintaining the integrity of the wall rating. Correction will be completed on or before 5/15/2025.



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 BLDG 01 (ASTER,CHERRYBLOSS,TULIP,SWEETWM,PRIM - Component: 01 - Tag: 0911

Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting one of two levels.

Findings include:

Observation on April 14, 2025, at 11:40 a.m., revealed a metal clad cable had exposed wires extending from its end, Lark Spur soiled room on the first floor.

Exit Interview with the Administrator and Maintenance Director on April 14, 2025, at 12:20 p.m., confirmed the exposed wiring.





 Plan of Correction - To be completed: 06/11/2025

1) The exposed MC cable was properly terminated using a metal junction box and cover. Repairs were completed on 4/16/2025.

2) Maintenance staff will be in-serviced on the need to inspect for unsafe conditions when working above ceilings. The in-service will be completed on or before 5/15/25.

3) Maintenance Director or Designee will perform a general inspection for unsafe conditions within the visible area when performing the same spot inspections of above ceiling fire wall penetrations as noted in the plan of correction for tag K0131. Inspections to begin on or before 5/15/25.

4) The results and status of findings from inspections will be reviewed monthly during the Facilities Team Meeting. Monthly reviews to begin on or before 6/11/25.
Initial comments:Name: BUILDING 02 (ADMINISTRATION SUITE & CHAPEL) - Component: 02 - Tag: 0000


Facility ID# 160602
Building 02
Administration Offices & Chapel

Based on a Medicare/Medicaid Recertification Survey completed on April 14, 2025, at Peter Becker Community - Administration Offices and Chapel , it was determined there were no deficiencies identified under the 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 one-story, Type II (000), unprotected non-combustible building, that is fully sprinklered.





 Plan of Correction:



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