Pennsylvania Department of Health
WESLEY ENHANCED LIVING MAIN LINE REHAB AND SKD NURSING
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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WESLEY ENHANCED LIVING MAIN LINE REHAB AND SKD NURSING - 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 January 24, 2024, at Wesley Enhanced Living Main Line Rehab and Skilled Nursing, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: CARE CENTER BLDG 01 (MAIN & 1996 ADD COMBINED) - Component: 01 - Tag: 0000

Facility ID# 390102
Component 01
Care Center Building

Based on a Medicare/Medicaid Recertification Survey completed on January 24, 2024, it was determined Wesley Enhanced Living Main Line Rehab and Skilled Nursing 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 one-story, Type II (000), noncombustible construction building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - 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.

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 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.

Observations:
Name: CARE CENTER BLDG 01 (MAIN & 1996 ADD COMBINED) - Component: 01 - Tag: 0100

Based on observation and interview, it was determined the facility failed to maintain portable, accurate floor plans, affecting the entire facility.

Findings include:

Document review on January 24, 2024, at 10:00 a.m., revealed 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
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 Maintenance Director on January 24, 2024, at 11:45 a.m., confirmed portable floor plans were not available at time of survey.

Plan of Correction - To be completed: 02/13/2024

Original prints of the building blueprints with all necessary information have been downsized and copies are now available. Copies will be kept in a Life Safety binder.

NFPA 101 STANDARD Means of Egress - General:

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: CARE CENTER BLDG 01 (MAIN & 1996 ADD COMBINED) - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain the means of egress free of impediments, affecting one of four smoke compartments.

Findings include:

Observation on January 24, 2024, at 11:20 a.m., revealed dining room emergency exit egress path was obstructed by ice/snow along the path to the public way.

Exit Interview with the Maintenance Director on January 24, 2024, at 11:45 a.m., confirmed the obstructed egress path.

Plan of Correction - To be completed: 02/13/2024

Staff have been educated and in serviced on snow removal policy. During any winter event, staff will be monitoring and checking exit areas for accumulation, snow drifts, or ice accumulation and will remove immediately.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: CARE CENTER BLDG 01 (MAIN & 1996 ADD COMBINED) - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous areas in sprinklered locations, affecting one of four smoke compartments.

Findings Include:

Observation on January 24, 2024, at 10:40 a.m., revealed Low-side Hall Soiled room door failed to self-close latch when tested.

Exit Interview with the Maintenance Director on January 24, 2024, at 11:45 a.m., confirmed the door deficiency.

Plan of Correction - To be completed: 02/13/2024

The facility's team has repaired the soiled utility door, and it now positively latches. A weekly audit will be conducted on the soiled utility door to ensure positive latch.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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.

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, readily identifiable, and separate from normal power circuits. 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: CARE CENTER BLDG 01 (MAIN & 1996 ADD COMBINED) - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain the emergency generators, affecting the entire facility.

Findings include:

1. Document review on January 24, 2024, at 9:30 a.m., revealed 5 of 12 monthly generator load tests were documented less than the required 30 minutes.

Exit Interview with the Maintenance Director on January 24, 2024, at 11:45 a.m., confirmed the partial load tests.

2. Document review on January 24, 2024, at 9:35 a.m., revealed the March 23, 2023, generator fuel quality report indicated Total Sulfur levels above the maximum allowable quantity. Evidence of corrective action/resampling was unavailable at time of survey.

Exit Interview with the Maintenance Director on January 24, 2024, at 11:45 a.m., confirmed the generator fuel deficiency.

Plan of Correction - To be completed: 02/13/2024

Staff have been reeducated on fuel testing and load bank testing requirements. A new fuel test was conducted on 2/1/2024 and results were released on 2/6/2024 showing the facility meets all the requirements. A monthly audit will be conducted to ensure load bank testing meets the time requirements for compliance.

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