Pennsylvania Department of Health
SUSQUEHANNA HEALTH AND WELLNESS CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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SUSQUEHANNA HEALTH AND WELLNESS 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 June 25, 2026, at Susquehanna Health and Wellness Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000
Facility ID #084802Component 01Main BuildingBased on a Medicare/Medicaid Recertification Survey completed on June 25, 2026, it was determined that Susquehanna Health and Wellness Center 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 structure, without a basement, which is fully sprinklered.

Plan of Correction:

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 - Component: 01 - Tag: 0353 Based on observation and interview, it was determined the facility failed to maintain hardware components of the automatic sprinkler system, affecting the entire component. Findings include: 1. Observation on June 25, 2026, at 11:10 AM, revealed the sprinkler head within the Physical Therapy Room, closest to the Director of Therapy's Office, was missing an escutcheon. Interview with the Director of Plant Operations on June 25, 2026, at 11:10 AM, confirmed the missing escutcheon.

Plan of Correction - To be completed: 08/18/2026

Facility to replace escutcheon on the sprinkler head within the Physical Therapy Room, closest to the Director of Therapy's Office.

Escutcheon ordered and will be replaced when it arrives

Facility maintenance director or designee will audit 5 random sprinkler heads to ensure escutcheons are in place daily x 1 week, weekly x 1month and monthly x 4 months and report findings to QAPI committee.

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: MAIN BUILDING - Component: 01 - Tag: 0362 Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of corridor walls, affecting the entire component. Findings include: 1. Observation on June 25, 2026, at 11:49 AM, revealed an unprotected penetration of the corridor wall, located in the "A" Wing Lounge area, by the door to the hallway. Interview with the Director of Plant Operations on June 25, 2026, at 11:49 AM, confirmed the unprotected penetration of the corridor wall.

Plan of Correction - To be completed: 08/18/2026

Facility repaired unprotected penetration of the corridor wall, located in the "A" Wing Lounge area, by the door to the hallway.

Facility maintenance director or designee will audit 5 random rooms to ensure there are no unprotected penetration of the corridor wall daily x 1 week, weekly x 1 month and monthly x 12 months and report findings to QAPI committee who will review findings adjust plan of correction if needed.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:

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.

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 BUILDING - Component: 01 - Tag: 0371 Based on observation and interview, it was determined the facility failed to provide at least two smoke compartments on every sleeping floor, with 30 or more patient beds, affecting the entire component. Findings include: 1. Observation on June 25, 2026, at 12:30 PM, revealed the facility lacked smoke barrier walls. Interview with the Director of Plant Operations on June 25, 2026, at 12:30 PM, confirmed the facility lacked smoke barriers.

Plan of Correction - To be completed: 07/10/2026

Facility requests that DSI conducts an FSES

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