Pennsylvania Department of Health
WILLIAM PENN NURSING AND REHAB
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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WILLIAM PENN NURSING AND REHAB - 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 19, 2025, at William Penn Nursing and Rehab, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000

Facility ID #750602
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 19, 2025, it was determined that William Penn Nursing and Rehab was not in compliance with the following requirements of the Life Safety Code for an existing 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 V (000), unprotected wood frame structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Corridors - Construction of Walls:

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.

Corridors - Construction of Walls
2012 EXISTING
Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code.
Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames.
If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area.
19.3.6.2, 19.3.6.2.7

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0362

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of corridor walls, affecting one of seven smoke compartments within the component.

Findings include:

1. Observation on May 19, 2025, at 11:19 AM, revealed an unprotected penetration of the corridor wall, behind a wall kiosk, located next to the Honey Creek Lounge.

Interview with the Maintenance Director on May 19, 2025, at 11:19 AM, confirmed the unprotected penetration of the corridor wall.

Plan of Correction - To be completed: 06/10/2025

The unprotected wall penetration located behind the kiosk near the Honey Creek Lounge was sealed on 5/20/2025 by the Maintenance Director.

All corridors have the risk of being affected. Maintenance will complete a full house audit to determine if similar areas (behind kiosks, wall-mounted fixtures, etc.), are affected and correct as needed.

Facility staff will be educated on K0362 regarding corridors – construction of walls, to include how to identify potential obstructions and proper notification to maintenance staff for repairs.

Maintenance Director or designee will complete twice weekly random audits of corridors and random resident's rooms to ensure there are no damages or hazards to corridor walls. Audits will be completed twice weekly x 4 weeks and then monthly. Results will be reviewed at QAPI meeting.

NFPA 101 STANDARD Corridor - Doors:

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 BUILDING - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain the positive latching of corridor doors, affecting one of seven smoke compartments within the component.

Findings include:

1. Observation on May 19, 2025, at 12:00 PM, revealed the door, to the Station 1 Linen Closet, failed to positively latch within the door frame.

Interview with the Maintenance Director on May 19, 2025, at 12:00 PM, confirmed the corridor door failed to latch within the frame.

Plan of Correction - To be completed: 06/10/2025

Station 1 Linen Closet door was repaired on 5/20/2025. Latch adjusted to ensure it engages the strike plate and the door remains securely closed without impediment.

All corridors have the risk of being affected. Maintenance will complete a full house audit to determine if any other corridors are obstructed from closing and obstructions will be removed

Facility staff will be educated on K0363 regarding corridor doors and doors to rooms to include ensuring there is no impediment to the closing of the doors.

Maintenance Director or designee will complete twice weekly random audits of corridors and random resident's rooms to ensure there are no obstructions causing inability to close the door. Audits will be completed twice weekly x 4 weeks and then monthly. Results will be reviewed at QAPI meeting.

NFPA 101 STANDARD Gas Equipment - Precautions for Handling Oxyg:

Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds
Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99)
11.6.2 (NFPA 99)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0929

Based on observation and interview, it was determined the facility failed to secure portable oxygen cylinders, affecting one of seven smoke compartments within the component.

Findings include:

1. Observation on May 19, 2025, at 11:47 AM, revealed two unsecured "E" size portable oxygen cylinders, located within the Charting Room.

Interview with the Maintenance Director on May 19, 2025, at 11:47 AM, confirmed the portable oxygen cylinders were not secured.

Plan of Correction - To be completed: 06/10/2025

Two unsecured oxygen cylinders located in the Charting Room were immediately placed into an approved oxygen cylinder holder on 5/19/2025

Maintenance Director or designee will conduct a full house audit of all oxygen storage and usage locations to identify any other unsecured cylinders. All portable cylinders found not to be secured will be corrected immediately.

Facility Staff will be educated on K0929 regarding precautions for handling oxygen to include ensuring proper oxygen cylinder storage techniques.

Maintenance Director or designee will conduct weekly audits of all areas where oxygen cylinders are stored or used twice weekly x4 weeks, then monthly. Audit results will be reviewed at QAPI meeting.

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