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 December 30, 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 December 30, 2024, it was determined that Wesley Enhanced Living Main Line Rehab And Skilled Nursing was not in compliance with the following requirements of the Life Safety Code for a 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 Subdivision of Building Spaces - Smoke Barrie:

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.

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: CARE CENTER BLDG 01 (MAIN & 1996 ADD COMBINED) - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to ensure doors in smoke barrier walls were maintained to resist the passage of smoke, affecting one of one level.

Findings include:

Observation on December 30, 2024, between 10:45 a.m., and 12:00 p.m. revealed, one of the double smoke doors, next to nurses station, had two hole penetrations through both sides of door, above the door closer.

Interview at the exit conference with the Executive Director on December 30, 2024, at 12:00 p.m., confirmed the door holes.

Plan of Correction - To be completed: 01/13/2025

The penetrations were repaired using approved fireproof caulk.

The Facility Director will inspect and audit all fire doors to ensure there is no penetrations. Audits will be conducted at time of repair and then quarterly thereafter.

NFPA 101 STANDARD Electrical Systems - Receptacles:

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: CARE CENTER BLDG 01 (MAIN & 1996 ADD COMBINED) - Component: 01 - Tag: 0912

Based on observation and interview, the facility failed to maintain electric systems in wet locations, affecting one level.

Findings include:

1. Observation on December 30, 2024, between 10:45 a.m, and 12:00 p.m., revealed, in resident room 142 that the Ground Fault Circuit Interrupter (GFCI) receptacle next to sink was damaged.

Interview at the exit conference with the Executive Director on December 30, 2024, at 12:00 p.m., confirmed the damaged GFCI receptacle.

Based on observation and interview, the facility failed to maintain electric receptacles affecting one level.

2. Observation on December 30, 2024, between 10:45 a.m, and 12:00 p.m., revealed, in resident room 112 there was a electrical receptacle pulling out of electrical box behind TV stand and a missing blank receptacle cover at the bottom right of the P-Tec, close to floor.

Interview at the exit conference with the Executive Director on December 30, 2024, at 12:00 p.m., confirmed the damaged receptacles.

Plan of Correction - To be completed: 01/13/2025

The ground fault circuit interrupter (GFCI) receptacle in room 142 was replaced on 01/13/2025.

The Facility Director or appointee will inspect, test, and audit all GFCI receptacles at time of repair and then quarterly thereafter.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: CARE CENTER BLDG 01 (MAIN & 1996 ADD COMBINED) - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to ensure that electrical wiring and equipment was maintained and the improper and unauthorized use of power strips, extension cords, and outlet multipliers are prohibited on one of one level.

Observations on December 30, 2024, revealed between 10:45 a.m and 12:00 p.m:

a) DON office: Space heater plugged into power strip.
b) Resident Room 112: Yellow extension cord powering a power strip with an orange extension cord powering another power strip, providing power to a TV.

Interview at the exit conference with the Executive Director on December 30, 2024, at 12:00 p.m., confirmed the extension cords providing power to power strips.

Plan of Correction - To be completed: 01/18/2025

The space heater was removed the day of inspection (12-30-2024). The extension cord in room 112 was removed on 1-14-2025.

The Facility Director, or appointee, will inspect, and audit each room weekly to ensure space heaters and extension cords are not plugged into power strips.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: CARE CENTER BLDG 01 (MAIN & 1996 ADD COMBINED) - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain oxygen cylinder storage, on one of one level.

Findings include:

Observation on December 30, 2024, between 10:45 a.m. and 12:00 p.m., revealed the Meadow's oxygen storage room door did not latch and could not be secured.

Interview at the exit conference with the Executive Director on December 30, 2024, at 12:00 p.m., confirmed the door did not latch.

Plan of Correction - To be completed: 01/06/2025

The door closer was adjusted on 01-06-2025 allowing the door to latch securely.

The Facility Director, or appointee, will inspect and all storage room doors to ensure positive latching and closing properly at time of repair and then quarterly thereafter.

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