Pennsylvania Department of Health

WESLEY ENHANCED LIVING AT STAPELEY

Building Inspection Results
Information About Building Safety Inspections

Information about the buildings for this facility

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Severity Designations

Minimal Citation -
Minimal Harm Actual Harm Serious Harm
No Harm
WESLEY ENHANCED LIVING AT STAPELEY
Inspection Results For: 10/30/2017 Print Current Report View Previous Reports
There are 31 surveys for this facility. Please select a date to view the survey results.

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exit date of the survey.

Scope of Citation
WESLEY ENHANCED LIVING AT
Number of Residents Affected
STAPELEY - Inspection Results
By Deficient Practice
Initial comments:Name: MAIN BLDG Plan of Correction:
& 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
October 30, 2017, it was determined that
Wesley Enhanced Living At Stapeley
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 483.70(a).

This is a six-story, Type II (222), fire

resistive structure, which is fully
sprinklered.

NFPA 101 STANDARD General

Requirements - Other:

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: Plan of Correction - To be completed:
Name: MAIN BLDG & NEW LOBBY, 12/15/2017
LAUNDRY, STORAGE ADDITION -
Component: 01 - Tag: 0100 a. We are adding two carbon monoxide
alarms in the main laundry room. One
Based on observation and interview, it inside the room the other outside the room
was determined the facility failed to which will be synchronize.
install carbon monoxide alarms in close b. We are adding two carbon monoxide
proximity to fossil fuel-burning devices alarms in the mechanical room. One
in accordance with the 2016 Act 48 - inside the room the other outside the room
Care Facility Carbon Monoxide Alarms which will be synchronize.
Standards Act, affecting the entire c. We will in-service all staff and update
facility. the emergency/disaster manual to include
the CO procedures.
Findings include: d . All batteries shall be inspected and
changed appropriately, as deemed
1. Observation on October 30, 2017, necessary. Ongoing inspections will be
between 10:11 am and 10:40 am, done in conjunction with preventive
revealed the facility failed to install maintenance program.
carbon monoxide alarms, where it can be Adherence to this corrective action will be
heard by staff on duty within the facility, monitored by Director of Community Ops
at the following locations: or designee. Audits will occur monthly x
three months and then quarterly, with
a. 10:11 am, at the gas dryers in the results reported through community
Laundry room 2nd floor; Quality Improvement Committee.
b. 10:40 am, at the gas fired water heaters
in the Mechanical room 1st floor;
c. In addition, staff must be in-serviced
and the emergency/disaster manual
updated to include carbon monoxide
emergency procedures.
Interview with the Administrator,
Director of Facilities Operations, and
Maintenance Supervisor, at the exit
conference on October 30, 2017, at 11:45
am, confirmed the carbon monoxide
alarms were not installed.

NFPA 101 STANDARD Building

Construction Type and Height:

Building Construction Type and Height

2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise
permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered

Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered

4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered

8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised
automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories,
including basements, floors on which patients are located, location of smoke or fire
barriers and dates of approval. Complete sketch or attach small floor plan of the
building as appropriate.
Observations: Plan of Correction - To be completed:
Name: MAIN BLDG & NEW LOBBY, 12/15/2017
LAUNDRY, STORAGE ADDITION -
Component: 01 - Tag: 0161 A. We will add FIRE PROOFTHERMAL
COATING (FIRE RETARDANT) to the
Based on observation and interview, it steel beam using an approved fire stop
was determined the facility failed to system and while maintaining the rating
maintain the building construction type of the construction type of the building.
in one of two hundred rooms within the
facility.
Findings include:
1. Observation on October 30, 2017, at
10:45 am, revealed the first floor loading
dock had missing fire-proofing
approximately 3 feet in length at the
underside of the structural steel beam.
The Facility construction type is Type II
(222).
Interview with the Administrator,
Director of Facilities Operations, and
Maintenance Supervisor at the exit
interview on October 30, 2017, at 11:45
am, confirmed the missing fire-proofing.
B. Similar areas shall be inspected and
appropriate action will be made, as
deemed necessary. Ongoing inspections
will be done in conjunction with
preventive maintenance program.
C.
Adherence to this corrective action will be
monitored by Director of Community Ops
or designee. Audits of the exposed steel
beams above the ceiling assembly on a
quarterly basis will occur monthly x three
months and then quarterly, with results
reported through community Quality
Improvement Committee.

NFPA 101 STANDARD Stairways and

Smokeproof Enclosures:

Stairways and Smokeproof Enclosures

Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations: Plan of Correction - To be completed:

Name: MAIN BLDG & NEW LOBBY, 11/18/2017
LAUNDRY, STORAGE ADDITION -
Component: 01 - Tag: 0225 A. We will use the "Through Penetration
Firestop System" an approved through
Based on observation and interview, it penetration fire stop system was used for
was determined the facility failed to the repair.
maintain the fire resistance rating of and the facility will maintain the rating of
stairways on one of six levels within the the stair towers.
facility. B. Similar penetration shall be inspected
and appropriate repair will be made, as
Findings include: deemed necessary. Ongoing inspections
will be done in conjunction with
1. Observation on October 30, 2017, at preventive maintenance program.
10:20 am, revealed the first floor dining C. Adherence to this corrective action will
room side of stairway had an unsealed be monitored by Director of Community
penetration of the cement block wall. Ops or designee. Audits will occur
 monthly x three months and then
Interview with the Administrator, quarterly, with results reported through
Director of Facilities Operations, and community Quality
Maintenance Supervisor at the exit
interview on October 30, 2017, at 11:45
am, confirmed the unsealed penetration.

NFPA 101 STANDARD Subdivision of

Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction

2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke
barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not
required in duct penetrations in fully ducted HVAC systems where an approved
sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations: Plan of Correction - To be completed:
Name: MAIN BLDG & NEW LOBBY, 12/15/2017
LAUNDRY, STORAGE ADDITION -
Component: 01 - Tag: 0372 a. We used the "Through Penetration
Firestop System" to repair the penetration
Based on observation and interview, it near room 118 and 109 above the smoke
was determined the facility failed to doors and the repairs were made using an
maintain the fire resistance rating of approved through penetration fire stop
smoke barrier walls on one of six levels system and we will maintain the rating of
within the facility. the smoke barrier walls .

Findings include:
1. Observations on October 30, 2017,
between 10:23 am and 10:38 am,
revealed unsealed penetrations of the
smoke barrier walls, on the first floor, in
the following locations:
a. 10:23 am, near room 118, above the
smoke barrier doors; on both sides;
c.The Director of Community Ops or
designee will audit the smoke barrier
walls for penetrations on a quarterly basis
Similar penetration shall be inspected and
appropriate repair will be made, as
deemed necessary. Ongoing inspections
will be done in conjunction with
preventive maintenance program.
Adherence to this corrective action will be
b. 10:38 am, near room 109, above the
smoke barrier doors; on both sides.
Interview with the Administrator,
Director of Facilities Operations, and
Maintenance Supervisor at the exit
interview on October 30, 2017, at 11:45
am, confirmed the unsealed penetrations.
monitored by Director of Community Ops
or designee. Audits will occur monthly x
three months and then quarterly, with
results reported through community
Quality Improvement Committee.

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
and readily identifiable. 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: Plan of Correction - To be completed:
Name: MAIN BLDG & NEW LOBBY, 12/15/2017
LAUNDRY, STORAGE ADDITION -
Component: 01 - Tag: 0918 a. We created a document for the
generator's weekly visual inspection,
Based on document review and weekly electrolyte inspection, and the
interview, it was determined the facility monthly specific gravity checks.
failed to maintain documentation for the b. . Ongoing inspections will be done in
Essential Electric System Maintenance conjunction with preventive maintenance
and Testing on one of one generator program
within the facility. c. Adherence to this corrective action will
be monitored by Director of Community
Findings include: Ops or designee. Audits of
generator/battery inspections will occur
1. Observations on October 30, 2017, monthly x three months and then
between 8:00 am and 9:30 am, revealed quarterly, with results reported through
no documentation available for the community Quality Improvement
generator's weekly visual inspection, Committee.
weekly electrolyte inspection, and the
monthly specific gravity checks at the
time of survey.

Interview with the Administrator,

Director of Facilities Operations, and
Maintenance Supervisor at the exit
interview on October 30, 2017, at 11:45
am, confirmed there was no
documentation for generator's weekly
visual inspection, weekly electrolyte
inspection, and/or monthly specific
gravity checks.

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