Pennsylvania Department of Health
 WESLEY ENHANCED LIVING AT STAPELEY
Building Inspection Results

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WESLEY ENHANCED LIVING AT STAPELEY
Inspection Results For:

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WESLEY ENHANCED LIVING AT STAPELEY - 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 11, 2026, at Wesley Enhanced Living at Stapeley, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.
 Plan of Correction:


Initial comments:Name: MAIN BLDG & NEW LOBBY, LAUNDRY, STORAGE ADDITION - Component: 01 - Tag: 0000
Facility ID# 455502Component 01Main Bldg &; New Lobby, Laundry, Storage AdditionBased on a Medicare/Medicaid Recertification Survey completed on May 11, 2026, it was determined that Wesley Enhanced Living at Stapeley 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 six-story, Type II (222), fire resistive building, that is fully sprinklered.
 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General: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.
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: MAIN BLDG & NEW LOBBY, LAUNDRY, STORAGE ADDITION - Component: 01 - Tag: 0211 Based on observations and interview, it was determined the facility failed to ensure there were no obstructions to egress, affecting one of six floors. Findings include: 1. Observation on May 11, 2026, at 11:40 a.m., revealed an enclosed porch could be mistaken for an exit and lacked signage indicating "Not an Exit", on the second floor Dining Room sliding glass door. Exit Interview with the Administrator and Maintenance Director on May 11, 2026, at 12:30 p.m., confirmed the missing signage.
 Plan of Correction - To be completed: 07/01/2026

A. A "Not an Exit" sign was installed on the second-floor dining room sliding door on May 27, 2026, to ensure proper identification of non-exit doors.
B. Monthly environmental and Life Safety inspections have been incorporated into the maintenance department's preventive maintenance program to ensure exit signage and means of egress remain compliant.
C. The Director of Facilities Operations or designee will review monthly inspection findings for ongoing compliance.

NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
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: MAIN BLDG & NEW LOBBY, LAUNDRY, STORAGE ADDITION - Component: 01 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintain a hazardous area enclosure, affecting one of six floors. Findings include: 1. Observation on May 11, 2026, at 11:55 a.m., revealed double doors to the Laundry Room had the following deficiencies: a. left door was propped open with a wedge. b. right door was missing its self-closer. c. right door was propped open due to the sweep dragging on the floor. Exit Interview with the Administrator and Maintenance Director on May 11, 2026, at 12:30 p.m., confirmed the door deficiencies.
 Plan of Correction - To be completed: 07/01/2026

A. A door closer was installed on May 18, 2026, and the door was adjusted to the proper height to ensure proper operation and latching. Wedge was removed. Self closer installed.
c. Door adjusted to avoid dragging or sweeping on the floor.

B. An inspection of fire-rated and corridor doors was completed to identify any additional doors with closure or latching deficiencies. Any identified issues were corrected.
C. The Director of Facilities Operations or designee will review monthly door inspection reports and work orders to ensure ongoing compliance.

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 & NEW LOBBY, LAUNDRY, STORAGE ADDITION - Component: 01 - Tag: 0353 Based on document review, observation and interview, it was determined the facility failed to maintain and inspect the sprinkler system, affecting the entire facility. Findings include: 1. Document review on May 11, 2026, at 9:00 a.m., revealed the facility could not provide documentation of the following inspections: a. Sprinkler report dated, July 7, 2025, had deficiencies that stated, "Sprinkler piping and check valves need 5-year internal inspection due 2025" and "Need to troubleshoot 2 tampers SW 2nd Floor Front Tower." Evidence of corrective action was not available at time of survey. b. Missing second quarter sprinkler report. c. Missing 5-year internal pipe and valve inspection report. Exit Interview with the Administrator and Maintenance Director on May 11, 2026, at 12:30 p.m., confirmed the missing documentations. 2. Observation on May 11, 2026, at 12:00 p.m., revealed 2 sprinklers missing their escutcheons, Laundry Room above washing machines and in the dirty laundry area. Exit Interview with the Administrator and Maintenance Director on May 11, 2026, at 12:30 p.m., confirmed the missing escutcheons.
 Plan of Correction - To be completed: 07/01/2026

A. Escutcheons were installed in the main laundry room on June 2, 2026. Required sprinkler system documentation was obtained and maintained, including the date of the last sprinkler test, testing vendor, water supply verification, second-quarter sprinkler inspection, and five-year internal pipe and valve inspection documentation.
B. Facility-wide inspection of sprinkler system components and associated documentation was conducted to identify any additional deficiencies. No additional issues requiring correction were identified.
C. The Director of Facilities Operations or designee will review sprinkler documentation and monthly inspection reports for ongoing compliance.

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 & NEW LOBBY, LAUNDRY, STORAGE ADDITION - 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, affecting one of six floors. Findings include: 1. Observation on May 11, 2026, at 11:45 a.m., revealed the door failed to close and latch when tested, Room 210. Exit Interview with the Administrator and Maintenance Director on May 11, 2026, at 12:30 p.m., confirmed the door failed to close and latch.
 Plan of Correction - To be completed: 07/01/2026

A. 210 door close and latch corrected on 05/12/2026.
B. Monthly inspections of applicable Life Safety Code features will be conducted by maintenance personnel and incorporated into the preventive maintenance program.
C. The Director of Facilities Operations or designee will review monthly inspection reports to ensure continued compliance.

NFPA 101 STANDARD HVAC: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.
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 & NEW LOBBY, LAUNDRY, STORAGE ADDITION - Component: 01 - Tag: 0521 Based on document review and interview, it was determined the facility failed to maintain and inspect HVAC systems, affecting the entire facility. Findings include: 1. Document review on May 11, 2026, at 9:00 a.m., revealed the facility could not provide documentation of a fire/smoke damper inspection performed within the past 4 years. Exit Interview with the Administrator and Maintenance Director on May 11, 2026, at 12:30 p.m., confirmed the missing documentation.
 Plan of Correction - To be completed: 07/01/2026

A. The fire/smoke damper inspection has been scheduled for July 2026.
B. The facility has established a four-year inspection schedule with the contracted vendor. A recurring annual Outlook calendar reminder has been implemented to ensure testing is scheduled within the required timeframe.
C. The Director of Facilities Operations or designee will maintain and review inspection records to ensure future testing is completed as required.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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 - 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: MAIN BLDG & NEW LOBBY, LAUNDRY, STORAGE ADDITION - Component: 01 - Tag: 0918 Based on document review and interview, it was determined the facility failed to maintain and test the generator, affecting one of nine emergency generator documents. Findings include: 1. Document review on May 11, 2026, at 9:00 a.m., revealed the facility could not produce documentation of the Annual Fuel Quality Test. Exit Interview with the Administrator and Maintenance Director on May 11, 2026, at 12:30 p.m., confirmed the missing documentation.
 Plan of Correction - To be completed: 07/01/2026

A. The fuel quality test has been scheduled for July 2026.
B. The facility has established an annual fuel quality testing schedule with the contracted vendor. A recurring annual Outlook calendar reminder has been implemented to ensure testing is completed within the required timeframe.
C. The Director of Facilities Operations, or designee will review generator testing records.


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