Pennsylvania Department of Health
GWYNEDD HEALTHCARE AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 42 surveys for this facility. Please select a date to view the survey results.

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GWYNEDD HEALTHCARE AND REHABILITATION CENTER - 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 November 17, 2025, at Gwynedd Healthcare and Rehabilitation Center, it was determined that there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

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

Facility ID# 075002
Component 01
Main Building
on a Medicare/Medicaid Recertification Survey completed on November 17, 2025, it was determined that Gwynedd Healthcare And Rehabilitation Center 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).
is a one-story, Type II (000), unprotected non-combustible building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

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.

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 BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0211 Based on observation, document review, and interview, it was determined the facility failed to maintain acceptable exit access, affecting one of two levels. Findings include: 1. Observation and document review on November 17, 2025, at 9:00 a.m., revealed headroom inside the basement-level stairwell enclosure, from the stair tread to the overhead obstruction, was less than the required minimum six feet eight-inch clearance. The stairwell provides one of two recognized means of egress from the basement. Exit Interview with the Administrator and the Maintenance Director, on November 17, 2025, at 12:00 p.m., confirmed the basement level exit access deficiency.

Plan of Correction - To be completed: 01/06/2026

The facility would like to use the FSES currently on File

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 BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintain doors to hazardous areas, affecting three of four soiled utility rooms. Findings include: 1. Observation on November 17, 2025, from 10:50 a.m.to 11:20 a.m., revealed hazardous area doors that failed to close and latch at the following locations: a. 10:50 a.m., A-Wing Soiled Utility Room. b. 11:05 a.m., C-Wing Soiled Utility Room. c. 11:20 a.m., B-Wing Soiled Utility Room. Exit Interview with the Administrator and the Maintenance Director, on November 17, 2025, at 12:00 p.m., confirmed the deficient doors.

Plan of Correction - To be completed: 01/06/2026

a) A wing soiled utility room door had a new door closer installed and now door latches correctly. Maintenance director/ Designee will do random audits on doors with self-closers weekly for 3 months and report findings to QAPI monthly.
b) C wing utility door has been successfully adjusted and now has a positive latch. Maintenance director/ Designee will do random audits on doors with self-closers weekly for 3 months and report findings to QAPI monthly.
c) B wing soiled utility door has been successfully adjusted and now has a positive latch. . Maintenance director/ Designee will do random audits on doors with self-closers weekly for 3 months and report findings to QAPI monthly.

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 BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0353 Based on document review, observation and interview, it was determined the facility failed to ensure sprinkler system components were maintained, affecting the entire facility. Findings include: 1. Document review on November 17, 2025, at 9:00 a.m., revealed a deficiency that sated, "Domestic backflow failed testing" on the 7/14/25 Annual Report. Evidence of corrective action was not available the at time of survey: Exit Interview with the Administrator and the Maintenance Director, on November 17, 2025, at 12:00 p.m., confirmed the lack of documentation. 2. Observations made on November 17, 2025, between 10:40 a.m. and 10:45 a.m., revealed obstructions to the automatic sprinklers in the following areas: a. 10:40 a.m., two sprinklers that had paint on the escutcheon and head, Conference Room. b. 10:45 a.m., one sprinkler that had paint on the escutcheon and head, Therapy Gym. Exit Interview with the Administrator and the Maintenance Director, on November 17, 2025, at 12:00 p.m., confirmed the deficient sprinklers.

Plan of Correction - To be completed: 01/06/2026

1) The facility will ensure that the domestic backflow that failed testing will be completed and ensure paperwork is obtained stating it was completed. The facility Maintenance Director will ensure that the contracted company provides us with paperwork in a timely manner.
2) Sprinkler Escutcheon

a) The Maintenance Director has removed paint from both escutcheon plates in the conference room. The maintenance Director will generate and do an audit weekly for three months checking all sprinklers and their escutcheon plates and report findings to QAPI monthly.
b) The sprinkler head in the therapy gym with paint identified on it will be replaced by our outside sprinkler company vendor. The maintenance Director will generate and do an audit weekly for three months checking all sprinklers and their escutcheon plates will not have paint on them and report findings to QAPI monthly.

NFPA 101 STANDARD Electrical Systems - Other:

Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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.
Chapter 6 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0911 Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, affecting one of two levels. Findings include: 1. Observation on November 17, 2025, at 11:15 a.m., revealed a duplex receptacle was pulled away from the wall, exposing the inner wiring, B-Wing Ice Machine Room. Exit Interview with the Administrator and the Maintenance Director, on November 17, 2025, at 12:00 p.m., confirmed the deficient duplex receptacle. Refer to NFPA 70, National Electric Code, and NFPA 99, 6.3.2.1.

Plan of Correction - To be completed: 01/06/2026

1) The outlet in the ice machine room on B-wing has been repaired.
2) The Maintenance Director will create an audit and check all outlets in common area weekly for three months and report findings to QAPI monthly.

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: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0918 Based on document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire facility. Findings include: 1. Document review on November 17, 2025, at 9:00 a.m., revealed the facility could not produce an Annual 90-minute load bank test report. Exit Interview with the Administrator and the Maintenance Director, on November 17, 2025, at 12:00 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 01/06/2026

1) The facility contacted the contracted generator company and scheduled the 90 minute load bank test. We will ensure the test is completed and ensure we have received documentation.
2) Maintenance Director will ensure that the 90 minute load bank test is completed annually.

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: MAIN BUILDING 01 (ORIGINAL BUILDING) - Component: 01 - Tag: 0923 Based on observation and interview, it was determined the facility failed to maintain storage of oxygen cylinders, affecting one of two levels. Findings include: 1. Observation on November 17, 2025, at 10:50 a.m., revealed an unsecured oxygen cylinder, A Wing Oxygen Storage Room. Exit Interview with the Administrator and the Maintenance Director, on November 17, 2025, at 12:00 p.m., confirmed the unsecured oxygen cylinder.

Plan of Correction - To be completed: 01/06/2026

1) The oxygen tank was immediately placed in the correct holder.
2) The Maintenance Director/Designee will perform weekly random audits x3 then monthly x4 to ensure that oxygen tanks are being placed in the correct holders. Results of the audits will be reviewed at facility QAPI meetings
3) The Maintenance Director/Designee will perform re-education with nursing staff to review the importance of storing oxygen tanks in the proper holders.

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