Pennsylvania Department of Health
WESLEY ENHANCED LIVING PENNYPACK PARK
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 PENNYPACK PARK - 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 February 1, 2024, at Wesley Enhances Living Pennypack Park it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: BUILDING (B BUILDING) - Component: 01 - Tag: 0000

Facility ID# 311202
Component 01

Based on a Medicare/Medicaid Recertification Survey completed on February 1, 2024, it was determined that Wesley Enhanced Living Pennypack Park 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 three-story, Type II (222), fire resistive construction, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

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: BUILDING (B BUILDING) - Component: 01 - Tag: 0100

Based on observation and interview, it was determined the facility failed to maintain carbon monoxide equipment in proper operating condition, affecting the entire health care facility.

Findings Include:

Observation made on February 1, 2024, revealed the carbon monoxide alarm for the emergency generator exhaust, located at the end of the hall outside room 213, could not be clearly heard above ambient noise by facility personnel at the nurse station when occupied, 2nd floor.

Exit Interview with the Director of Facilities Operations and the Maintenance Manager on February 1, 2024, confirmed the current location of the CO alarm.

Plan of Correction - To be completed: 04/01/2024

The carbon monoxide detector located at the end of the hall outside R213 will be replaced with a new Sara System carbon monoxide detector which will alert all handheld nursing phones if the monitor were to go into alarm. The carbon monoxide detector will be monitored through the daily Sara System report to ensure its ongoing functioning status.

NFPA 101 STANDARD Egress 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.

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

Observations:
Name: BUILDING (B BUILDING) - Component: 01 - Tag: 0222

Based on observation and interview, it was determined the facility failed to maintain Special Locking Arrangements in proper operating condition, affecting 1 of three levels.

Findings Include:

Observation made on February 1, 2024, revealed the delayed egress device installed on the courtyard doors would not release when tested, 1st floor.

Exit Interview with the Director of Facilities Operations and the Maintenance Manager on February 1, 2024, confirmed the door locking mechanism was not operable at the time of inspection.

Plan of Correction - To be completed: 04/01/2024

The delayed egress device on the 1st floor courtyard door will be corrected to function properly to release after the required 15 second delay. All other delayed egress doors will be checked daily by security while doing safety rounds and logged.

NFPA 101 STANDARD Corridors - Construction of Walls:

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: BUILDING (B BUILDING) - Component: 01 - Tag: 0362

Based on observation and interview, it was determined the facility failed to maintain corridor wall partitions with smoke tight resistance, affecting 1 of three levels.

Findings Include:

Observation made on February 1, 2024, revealed there were two flexible conduit penetrations in the corridor wall in the HC1 hall by the common area, 1st floor.

Exit Interview with the Director of Facilities Operations and the Maintenance Manager on February 1, 2024, confirmed the openings in the corridor wall.

Plan of Correction - To be completed: 04/01/2024

This facility does and shall continue to ensure common fire wall separations are maintained free of unsealed penetrations. The penetration in the corridor wall in HC1 hall by the common areas 1st floor shall be sealed with through stop penetration product as per recommended fire sealant standards. System # W-J-3050 will be used with FS-One Max Intumescent sealant as per recommended fire sealant standards. The facility will continue to conduct inspections on a semiannual basis to identify and penetrations of common walls and seal the with the required sealant.

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 Alarm Annunciator
A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator.
6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)

Observations:
Name: BUILDING (B BUILDING) - Component: 01 - Tag: 0916

Based on observation and interview, it was determined the facility failed to maintain required monitoring for components of the Essential Electrical System, affecting the entire facility.

Findings Include:

Observation made on February 1, 2024, revealed the emergency generator remote annunciator panel inside the nurse station room was not readily observed. The area was unattended by staff during the time of inspection, 2nd floor.

Exit Interview with the Director of Facilities Operations and the Maintenance Manager on February 1, 2024, confirmed the annunciator panel was not continuously monitored.

Plan of Correction - To be completed: 04/01/2024

The generator remote annunciator panel inside the nurse room will have a new Sara System monitoring device installed that will alert all handheld nursing phones if the monitor were to go into alarm. This new device will be monitored through the daily Sara System report to ensure its ongoing functioning status.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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: BUILDING (B BUILDING) - Component: 01 - Tag: 0918

Based on observation and interview, it was determined the facility failed to maintain required inspection and testing of components of the Essential Electrical System, affecting the entire facility.

Findings Include:

Documentation reviewed on February 1, 2024, revealed verification of monthly conductance testing for sealed batteries for the emergency generator was not available at the time of inspection.

Exit Interview with the Director of Facilities Operations and the Maintenance Manager on February 1, 2024, confirmed testing of emergency generator components was incomplete.

Plan of Correction - To be completed: 04/01/2024

The generator form used to log monthly conductance testing for sealed batteries will be modified to clearly show that conductance testing is completed with the proper verbiage used.

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