Pennsylvania Department of Health
WESLEY ENHANCED LIVING AT STAPELEY
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 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 August 13, 2024, 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# 455502
Component 01
Main Bldg & New Lobby, Laundry, Storage Addition

Based on a Medicare/Medicaid Recertification Survey completed on August 13, 2024, it was determined 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 structure, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Emergency Lighting:

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.

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BLDG & NEW LOBBY, LAUNDRY, STORAGE ADDITION - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to provide the annual 90-minute battery operated light test, in eight of eight smoke zones within the component.

Findings include:

1. Review of documentation on August 13, 2024, at 12:00 PM, revealed the facility could not provide documentation of the annual 90-minute battery-operated light test.

Interview with the Director of Facilities on August 13, 2024, at 1:00 PM, confirmed the facility could not provide documentation of the annual battery operated light test.

Plan of Correction - To be completed: 08/25/2056

A. Created a 90-minute annual battery operated light test audit sheet. Tested on 8/15/2024. Audit form stored in the Director of Facility Operations office.
B. Adherence to this corrective action will be monitored by the Director of Facility Operations.

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 the rating of the hazardous area, in one of eight smoke zones within the component.

Findings include:

1. Observation on August 13, 2024, at 12:36 PM, revealed a hole in the corridor wall of the 2nd floor Biohazard Room, by Room 231.

Interview with the Director of Facilities on August 13, 2024, at 1:00 PM, confirmed the hazardous area rating was compromised.

Plan of Correction - To be completed: 08/25/2024

A. Completed on August 14, 2024, to meet hazardous rating. Penetration was sealed using an approved stop gap penetration system.
B. Director of Facility Operations completed an inspection of the area.

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