Pennsylvania Department of Health
PETER BECKER COMMUNITY
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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PETER BECKER COMMUNITY - 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 21, 2026, at Peter Becker Community, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BLDG 01 (ASTER,CHERRYBLOSS,TULIP,SWEETWM,PRIM - Component: 01 - Tag: 0000
Facility ID# 160602

Building 01

Aster Avenue, Cherry Blossom Court, Tulip Terrace, Sweet William Way, Primrose Path, Larkspur Lane and the Boxwood Wing

Based on a Medicare/Medicaid Recertification Survey completed on May 21, 2026, it was determined that Peter Becker Community - Aster Avenue, Cherry Blossom Court, Tulip Terrace, Sweet William Way, Primrose Path, Larkspur Lane and the Thrift Shop Wings, were 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 one-story, Type III (200), unprotected ordinary building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Number of Exits - Corridors:

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.

Number of Exits - Corridors
Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies.
18.2.5.4, 19.2.5.4

Observations:
Name: MAIN BLDG 01 (ASTER,CHERRYBLOSS,TULIP,SWEETWM,PRIM - Component: 01 - Tag: 0252 Based on document review and interview, it was determined the facility failed to provide two approved exits from each floor level, affecting two of seven smoke compartments. Findings include: 1. Document review on May 21, 2026, 8:30 a.m., revealed the basement lacked two required exits remote from each other. One of the exits from the basement was through the main laundry. Exit interview with the Sr. Director of Facilities and the Asst. Director of Facilities on May 21, 2026, at 1:30 p.m., confirmed the lack of two acceptable remote exits from the basement. 2. Document review on May 21, 2026, at 8:30 a.m., revealed the exit from the Personal Care Unit was through an intervening lounge. The exit was in Smoke Zone #3, Primrose Path. Exit Interview with the VP of Facilities and Maintenance Director on May 21, 2026, at 1:30 p.m. confirmed exit was through an intervening lounge.

Plan of Correction - To be completed: 07/20/2026

The Facility intends to bring the building into compliance as part of planned renovations. We submitted the previous FSES to the Design Architects and they are addressing the deficient areas in the renovation drawings. Final drawings will be submitted to DOH Plan Review department for review and approval.

The facility is requesting an FSES survey until the repairs are completed.

We will contract with a 3rd party to conduct the FSES survey in the interim between now and approved drawings and renovations.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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.

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BLDG 01 (ASTER,CHERRYBLOSS,TULIP,SWEETWM,PRIM - Component: 01 - Tag: 0345 Based on document review and interview, it was determined the facility failed to ensure the fire alarm system was maintained, affecting the entire facility. Findings include: 1. Document review on May 21, 2026, at 8:30 a.m., revealed the fire alarm inspection report dated December 4, 2025, listed the following fire alarm deficiencies that had not been repaired: a. Oak Dining Room pull station device does not activate when pulled down. b. Replace 2 sounder bases in Ridgeview Room 171. c. Replace 2 sounder bases in Ridgeview Room 150 Exit Interview with the VP of Facilities and Maintenance Director on May 21, 2026, at 1:30 p.m. confirmed the lack of documentation. 2. Document review on May 21, 2026, at 8:30 a.m., revealed the fire alarm inspection report dated June 11, 2025, listed the following fire alarm deficiencies that had not been repaired: a. Two horn strobes in courtyard outside Westview Room failed to activate. b. Elevator shaft devices and elevator recall must be tested with elevator contractor on site. Exit Interview with the VP of Facilities and Maintenance Director on May 21, 2026, at 1:30 p.m. confirmed the lack of documentation. 3. Document review on May 21, 2026, at 8:30 a.m., revealed documentation of smoke detector sensitivity testing was not available at time of survey. Exit Interview with the VP of Facilities and Maintenance Director on May 21, 2026, at 1:30 p.m. confirmed the lack of documentation.

Plan of Correction - To be completed: 07/20/2026

1. Sprinkler contractor was contacted requesting documentation to confirm the repair(s) have been completed for: (a)Oak dining room pull station, (b)replacement of 2 sounder bases in RV Rm 171, and (c)replacement of 2 sounder bases in RV Rm 150.
2. Subsequent fire system inspection and testing indicate that items, (a), (b), and (c) pass and are in working order.
3. To minimize the risk of the deficiency from re-occurring, the VP of Facility Services and/or designee will create an annual inspection calendar (with input from the contractors) to indicate the schedule for all required sprinkler/fire inspections and tests. The VP of Facilities Services and/or designee will review inspection reports from the previous month at a "Monthly Life Safety Review Meeting". Any repairs, recommendations or additional work indicated on the Sprinkler/Fire Reports will be reviewed and addressed for confirmation of timely completion.
4. Maintenance Manager and/or designee will submit work orders for any inspection deficiencies. The work order will be prioritized as "critical" and will be addressed immediately by the Maintenance Manager and/or designee. Updates on all Life Safety work orders will be reviewed at the monthly meeting.
5. To monitor and ensure continued compliance, the VP of Facilities Services and/or designee will submit a copy of inspection reports and monthly life safety meeting minutes to the Nursing Home Administrator. Outcomes of the inspections and compliance will be reported at the monthly QAPI meeting.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:

Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.

Observations:
Name: MAIN BLDG 01 (ASTER,CHERRYBLOSS,TULIP,SWEETWM,PRIM - Component: 01 - Tag: 0371 Based on document review and interview, it was determined the facility failed to ensure the maximum travel distances within smoke compartments was maintained, affecting three of seven smoke compartments. Findings include: 1. Document review on May 21, 2026, at 8:30 a.m., revealed travel distance in smoke compartments, Zones 2 (Personal Care Dementia), 4 (Tulip Terrace and Sweet William Way), and 5 (Cherry Blossom Court and Aster Avenue) exceeded 200 feet in length. Exit Interview with the VP of Facilities and Maintenance Director on May 21, 2026, at 1:30 p.m. confirmed the excess travel distances.

Plan of Correction - To be completed: 07/20/2026

The Facility intends to bring the building into compliance as part of planned renovations. The VP of Facility Services submitted the previous FSES to the Design Architects and they are addressing the deficient areas in the renovation drawings. Final drawings will be submitted to DOH Plan Review department for review and approval.

The facility is requesting an FSES survey until the repairs are completed.

We will contract with a 3rd party to conduct the FSES survey in the interim between now and approved drawings and renovations.

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 01 (ASTER,CHERRYBLOSS,TULIP,SWEETWM,PRIM - Component: 01 - Tag: 0918 Based on document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting two of nine generator reports. Findings include: 1. Document review on May 21, 2026, at 8:30 a.m., revealed the facility could not produce documentation of the following tests and inspections of the 480 Volt Generator: a. Annual 90-minute load bank test. b. 3-year, 4-hour load bank test. Exit Interview with the VP of Facilities and Maintenance Director on May 21, 2026, at 1:30 p.m. confirmed the lack of documentation.

Plan of Correction - To be completed: 07/20/2026

1. The Emergency Generator contractor mistakenly performed the annual 90-minute and 3-year 4-hour load bank tests on the same (120V/208V) generator. (Two separate times in the same year (2025).) After repeated attempts to schedule the same generator service contractor to perform the 90-minute and 3-year 4-hour load bank test on the 480V generator, the contractor was terminated. A new Emergency Generator contractor was hired and performed the required load bank tests on 5/28/26.
2. To minimize the risk of the deficiency from re-occurring, the VP of Facility Services and/or designee will create an annual inspection/testing calendar (with input from the contractors) to indicate the schedule for all required emergency generator inspections and tests. The VP of Facilities Services and/or designee will review inspection reports from the previous month at a "Monthly Life Safety Review Meeting". Any repairs, recommendations or additional work indicated on the Emergency Generator Reports will be reviewed and addressed for confirmation of timely completion.
3. Maintenance Manager and/or designee will submit work orders for any inspection/testing deficiencies. The work order will be prioritized as "critical" and will be addressed immediately by the Maintenance Manager and/or designee. Updates on all Life Safety work orders will be reviewed at the monthly meeting.
4. To monitor and ensure continued compliance, the VP of Facilities Services and/or designee will submit a copy of inspection reports and monthly life safety meeting minutes to the Nursing Home Administrator. Outcomes of the inspections and compliance will be reported at the monthly QAPI meeting.

Initial comments:Name: BUILDING 02 (ADMINISTRATION SUITE & CHAPEL) - Component: 02 - Tag: 0000
Facility ID# 160602

Building 02

Administration Offices &; Chapel

Based on a Medicare/Medicaid Recertification Survey completed on May 21, 2026, at Peter Becker Community - Administration Offices and Chapel, were 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 one-story, Type II (000), unprotected non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies - Construction Type:

Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3

Observations:
Name: BUILDING 02 (ADMINISTRATION SUITE & CHAPEL) - Component: 02 - Tag: 0133 Based on observation and interview, it was determined the facility failed to maintain the fire resistance of fire barriers, affecting one of two smoke zones. Findings include: 1. Observation on May 21, 2026, between 11:35 a.m., and 11:50 a.m., revealed penetrations at the following locations: a. 11:35 a.m., Above double doors in Administrative Hall near Quilt Room. b. 11:50 a.m., Above double doors near HR Office. Exit Interview with the VP of Facilities and Maintenance Director on May 21, 2026, at 1:30 p.m. confirmed the penetrations.

Plan of Correction - To be completed: 07/20/2026

1. The noted penetration in the fire rated wall above the fire doors in a) Administrative Hall near quilt room, and b) above double doors near HR office will be repaired and sealed using 3M Fire Barrier Sealant CP 25WB+ (UL1479/ASTM E814). UL System No. W-L-3210 will be followed in this repair. System No. W-L-3210 is the approved application for Frame construction/Walls. (F-Rated 1-2 Hrs.)
2. VP of Facilities Services and/or designee will educate maintenance staff on requirements related to maintaining fire-rated walls and structures.
3. The Maintenance Director and/or Designee will conduct spot inspections of above ceiling fire walls ensuring areas of penetration are properly sealed. Frequency of 1x each month for 4-months, then on a quarterly basis. Any findings from the inspections will be corrected immediately.
4. The results of the firewall inspections will be reviewed at the monthly QAPI meeting.

Initial comments:Name: 1 STORY CONNECTOR (NOT COMPLETED AS OF 8/15/22) - Component: 03 - Tag: 0000
Facility ID# 160602

Building 3

1 Story Connector

Based on a Medicare/Medicaid Recertification Survey completed on May 21, 2026, at Peter Becker Community � One Story Connector, was not in compliance with the following requirements of the Life Safety Code for a new 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 one-story, Type II (000), unprotected non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies - Construction Type:

Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a two hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
*The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
*The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3

Observations:
Name: 1 STORY CONNECTOR (NOT COMPLETED AS OF 8/15/22) - Component: 03 - Tag: 0133 Based on observation and interview, it was determined the facility failed to maintain the fire resistance of fire barriers, affecting one of two fire barriers. Findings include: 1. Observation on May 21, 2026, at 11:55 a.m., revealed an open penetration and a penetration surrounding a data line, above double doors near the Temporary Receptionist. Exit Interview with the VP of Facilities and Maintenance Director on May 21, 2026, at 1:30 p.m. confirmed the penetrations.

Plan of Correction - To be completed: 07/20/2026

1. The noted penetration in the fire rated wall above the double doors near the Temporary Receptionist will be repaired and sealed using 3M Fire Barrier Sealant CP 25WB+ (UL1479/ASTM E814). UL System No. W-L-3210 will be followed in this repair. System No. W-L-3210 is the approved application for Frame construction/Walls. (F-Rated 1-2 Hrs.)
2. VP of Facilities Services and/or designee will educate maintenance staff on requirements related to maintaining fire-rated walls and structures.
3. The Maintenance Director and/or Designee will conduct spot inspections of above ceiling fire walls ensuring areas of penetration are properly sealed. Frequency of 1x each month for 4-months, then on a quarterly basis. Any findings from the inspections will be corrected immediately.
4. The results of the firewall inspections will be reviewed at the monthly QAPI meeting.

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