Pennsylvania Department of Health
WAYNESBURG 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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WAYNESBURG 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 February 9, 2026, at Waynesburg 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 01 - Component: 01 - Tag: 0000

Facility ID# 074602
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 9, 2026, it was determined that Waynesburg 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 building, without a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

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.

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 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain exit discharge access to be clear and unobstructed in one instance, affecting one of six marked exits.

Findings include:

1. Observation on February 9, 2026, at 11:00 a.m., revealed the egress path from the Therapy Exit was snow covered, obstructing egress.

Interview with the Facility Administrator and Maintenance Director on February 9, 2026, at 12:30 p.m., confirmed the facility failed to maintain the egress pathways to be clear and unobstructed.

Plan of Correction - To be completed: 03/10/2026

The NHA immediately educated the Director of Maintenance on the need to maintain the egress paths around the facility clear of snow.
The Maintenance Director immediately inspected all the exit discharge access to ensure that they were all clear and unobstructed.
The Maintenance Director immediately cleaned the subject egress path from the therapy exit of snow.
The Maintenance Director or designee will audit the egress path from therapy for clearance daily x 5 days, then 3 times a week x 1 week and then weekly x 4 weeks.
Results will be discussed in QAPI

NFPA 101 STANDARD Doors with Self-Closing Devices:

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain self-closing doors in one instance, affecting one of seven smoke compartments.

Findings include:

1. Observation on February 9, 2026, at 10:55 a.m., revealed the self-closing door to the medcation room had an unsealed hole in it.

Interview with the Facility Administrator and Maintenance Director on February 9, 2026, at 12:30 p.m., confirmed the self-closing door deficiency.

Plan of Correction - To be completed: 03/10/2026

The NHA immediately educated the Director of Maintenance on the need to ensure that self-closing doors in the facility are free of holes.
The Maintenance Director immediately inspected all self-closing doors in the facility to ensure that they were free of holes.
The Maintenance Director immediately sealed the holes in the self-closing door to the medication room.
The Maintenance Director or designee will audit the self-closing door to the med room to ensure that holes are sealed daily x 5 days, then 3 times a week x 1 week and then weekly x 4 weeks.
Results will be discussed in QAPI

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting one of seven smoke compartments.

Findings include:

1. Observation on February 9, 2026, at 11:25 a.m., revealed there was a gap greater than 1/8th inch, surrounding a sprinkler head in the RN Supervisor's office.

Interview with the Facility Administrator and Maintenance Director on February 9, 2026, at 12:30 p.m., confirmed the automatic sprinkler system deficiency.

Plan of Correction - To be completed: 03/10/2026

The Maintenance Director/designee immediately completed an inspection of all automatic sprinklers in all smoke compartments to ensure that there were no gaps greater than 1/8th inch surrounding sprinkler heads.
The Maintenance Director immediately sealed the gap greater than 1/8 inch surrounding the sprinkler head in the nursing supervisor's office.
The Maintenance Director or designee will audit the sprinkler head in the nursing supervisor's office to ensure that there is no gap greater than 1/8inch surrounding it daily x 5 days, then 3 times a week x 1 week and then weekly x 4 weeks
Results will be discussed in QAPI

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on observation and interview, it was determined the facility failed to comply with HVAC requirements in one instance, affecting one of seven smoke compartments.

Findings include:

1. Observation on February 9, 2026, at 9:46 a.m., revealed a portable air conditioning unit in the Director of Nursing office was ducted directly into the space above the ceiling.

Interview with the Facility Administrator and Maintenance Director on February 9, 2026, at 12:30 p.m., confirmed the HVAC deficiency.

Plan of Correction - To be completed: 03/10/2026

The NHA immediately educated the Director of Maintenance on the regulation regarding ducting portable air conditioners directly into the space above the ceiling.
The Maintenance Director immediately removed the portable air conditioner from the Director of Nursing's office.
The Maintenance Director or designee will audit for absence of portable air conditioner in Director of nursing office daily x 5 days, then 3 times a week x 1 week and then weekly x 4 weeks.
Results will be discussed in QAPI.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0916

Based on observation and interview, it was determined the facility failed to maintain essential electrical systems in one instance, affecting the entire facility.

Findings include:

1. Observation on February 9, 2026, at 10:47 a.m., revealed the emergency generator remote annunciator failed the lamp test.

Interview with the Facility Administrator and Maintenance Director on February 9, 2026, at 12:30 p.m., confirmed the remote annunciator deficiency.

Plan of Correction - To be completed: 03/10/2026

The vendor was immediately notified about the emergency generator remote annunciator failing the lamp test on 02/09/2026.
The emergency generator remote annunciator was replaced and operation verified on 02/18/2026.
The Maintenance Director will audit placement and operation of the Annunciator weekly x 4
Results will be discussed in QAPI

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