Pennsylvania Department of Health
SHARON REGIONAL MEDICAL CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 62 surveys for this facility. Please select a date to view the survey results.

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SHARON REGIONAL MEDICAL 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 December 17, 2025, it was determined that Sharon Regional Health System was not in compliance with the requirements of 42 CFR 482.15.

Plan of Correction:

403.748(b), 416.54(b), 418.113(b), 441.184(b), 482.15(b), 483.475(b), 483.73(b), 484.102(b), 485.542(b), 485.625(b), 485.68(b), 485.727(b), 485.920(b), 486.360(b), 491.12(b), 494.62(b) STANDARD Development of EP Policies and Procedures:

§403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b).

(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years.

*[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.

*Additional Requirements for PACE and ESRD Facilities:

*[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years.

*[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area.

Observations:
Name: - Component: -- - Tag: 0013

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one emergency preparedness plan.

Findings include:

Document review and interview on December 17, 2025, at 9:55 a.m., revealed the facility failed to follow its established emergency preparedness plan and "loss of heating system" policy when the heating system failed and limited the facility's ability to maintain adequate temperatures. The facility implemented portable space heaters, and the heaters were still being used at the time of the survey. Additionally, the facility reported that various methods were being utilized to mitigate the reduced heating sources and were investigating portable heating units to rent. However, there was no formal or documented contingency plan available during the time of the survey.

Interview with the facilities manager on December 17, 2025, at 9:55 a.m., confirmed the facility failed to follow the elements of its emergency preparedness plan.

Plan of Correction - To be completed: 01/13/2026

Following receipt of the finding, the Facilities Manager, Safety Officer, Chief Clinical Officer, and CEO met to review and discuss the finding.
1. Portable space heaters were removed from patient care areas 12/17/25. Staff and Leadership notified portable space heaters are only permissible in nonsleeping staff and employee areas

2. Reinforced that portable space heaters are only permissible in nonsleeping staff and employee areas at Safety Huddles and Leadership meetings 12/19/25 & 12/23/25, per NFPA 101.

3. Reviewed the facility's response to diminished heating systems and limited ability to maintain adequate temperatures as well as the EOP-Loss of Heating System Guide at the 12/30/25 Emergency Management meeting. The EOP-Loss of Heating System Guide was revised to include notation that "Portable space heaters may only be used in nonsleeping staff and employee areas."

4. Reviewed the facility's response to diminished heating systems and limited ability to maintain adequate temperatures as well as the EOP-Loss of Heating System Guide at the 12/30/25 Environment of Care Committee (EOC) meeting. The EOC committee discussed the revision to the EOP-Loss of Heating System Guide which includes the notation that "Portable space heaters may only be used in nonsleeping staff and employee areas."

5. Leadership re-education focused on adherence to established emergency preparedness plans, documentation of contingency planning, and revision of the EOP-Loss of Heating System Guide will be conducted 1/13/26.

6. Developed documented contingency plans in the event the heating system proves insufficient at maintaining adequate temperatures. Secured contingency agreement for rental of temporary boiler for immediate deployment and installation.

7. Implemented enhanced monitoring of daily temperature readings in affected areas in addition to the building automation system. Notification procedure established to alert Facility personnel should temperatures fall outside acceptable ranges.

Monitoring:
The Safety Officer & Facilities Manager will conduct regular rounds to ensure portable space heaters are not in use in any patient care areas or where members of the workforce sleep.
The Safety Officer will ensure that established emergency preparedness plans are followed and documented as appropriate during emergent events impacting patient safety, patient care, and/or facility operations.

Responsible Person: Safety Officer

Initial comments:Name: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0000

Facility ID # 196601
Component 01
B/C Building

Based on an Onsite Survey that was part of an unannounced Compliant Investigation completed on December 17-18, 2025, it was determined that Sharon Regional Health System was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a five-story ,Type II (000), unprotected, non-combustible building, that is fully sprinklered.

Plan of Correction:

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:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0100

Based on document review, observation, and interview, the facility failed to maintain general requirements that are not addressed by the provided K-tags, but are deficient, affecting two of two building components.

Findings include:

Observation on December 17, 2025, between 12:30 p.m. and 12:45 p.m., revealed the facility failed to obtain required approval from the Department of Health State Plan Review and a granted occupancy from the Life Safety Division for the following projects:

A. (12:30 p.m.) The roofing service / recondition mitigation plan to address leaks affecting various sections of the building. This project was initially identified and cited on the February 4, 2025, survey (survey ID JHWM21). The facility communicated that a narrative and plans were submitted to Plan Review, but could not provide documentation of approved drawings on the day of the survey. The facility stated that the vendor completed the reconditioning section of this project (approximately 70% of the roof) without approved plans in place. Additionally, there was no occupancy inspection completed from the Life Safety Division.
B. (12:45 p.m.), MRI replacement project was initially identified and cited on the February 4, 2025 survey (survey ID JHWM21). The facility communicated that a narrative and plans were submitted to Plan Review, but could not provide documentation of approved drawings on the day of the survey. The facility stated that work was completed in this area without approved plans in place. Additionally, there was no occupancy inspection completed from the Life Safety Division.

Interview with the facilities manager on December 17, 2025, at 12:45 p.m., confirmed the projects were being completed without State Plan Review approval and a granted occupancy from the Life Safety Division.

Plan of Correction - To be completed: 02/27/2026

Following receipt of the finding, the Facilities Manager, Safety Officer, Chief Clinical Officer and CEO met to review and discuss the findings.
A. The Safety Officer/Facilities Manager will contact the Department of Health State Plan Review and work with the Plan Reviewer to provide necessary information, ensure he/she has the information required to determine the next steps, and schedule an occupancy survey if required.

B. The Safety Officer/Facilities Manager will contact the Department of Health State Plan Review and work with the Plan Reviewer to provide necessary information, ensure he/she has the information required to determine the next steps, and schedule an occupancy survey if required.

Monitoring:
The Facilities Manager will submit proposed project work to the Department of Health State Plan Review for approval prior to commencing facility project work.
The Facilities Manager will report project work and progress at monthly Environment of Care (EOC) Meetings
Senior leadership are active members of EOC and EOC minutes will be forwarded to the Board of Directors.

Responsible Person: Facilities Manager

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: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0133

Based on document review, observation, and interview, the facility failed to maintain fire barrier doors, affecting two of two building components.

Findings include:

Document review and interview on December 18, 2025, at 11:35 a.m., revealed the fire doors that separate building components 01 and 02 failed to release and remain open during the fire alarm activation. This deficiency was originally identified and cited during the February 4, 2025 survey (survey ID JHWM21). The facility provided a fire alarm replacement quote from a vendor, but no work was completed at the time of the survey.

Interview with the facilities manager on December 18, 2025, at 11:35 a.m., confirmed the fire door deficiency.

Plan of Correction - To be completed: 02/25/2026

Following receipt of the finding, the Facilities Manager, Safety Officer, Chief Clinical Officer and CEO met to review and discuss the finding.
The Facilities Manager will work with Senior Leadership, Safety Officer, and Vendor B
to establish project development plans appropriate to the fire alarm replacement project.

The Facilities Manager will contact the Department of Health State Plan Review and work with the Plan Reviewer to provide necessary information, ensure he/she has the information required to determine the next steps, and schedule an occupancy survey if required.

The Facilities Manager will submit a request for a Time-Limited Waiver for deficiency K-0133, Component – 01, Fire Barrier Doors.

Monitoring:
The Facilities Manager will submit proposed project work to the Department of Health State Plan Review for approval prior to commencing facility project work.
The Facilities Manager will report project work and progress at monthly Environment of Care (EOC) Meetings
Senior leadership are active members of EOC and EOC minutes will be forwarded to the Board of Directors.

Responsible Person: Facilities Manager

NFPA 101 STANDARD Portable Space Heaters:

Portable Space Heaters
Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius).
18.7.8, 19.7.8

Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0781

Based on document review, observation, and interview, the facility was found utilizing portable electric heaters in patient-occupied areas, affecting two of two building components.

Findings include:

Observation on December 17, 2025, between 11:27 a.m. and 11:35 a.m., revealed 1500-watt oil-filled radiant electric space heaters in use throughout the second floor, cardiovascular unit (CVU). Through interview, it was communicated that eight heating units were distributed to help warm the cooler patient-occupied areas. Through document review, the hospital utilized a document titled "Increased Surveillance Log" to track and observe the space heaters while in use. Further review indicated that the surveillance tracking began on December 8, 2025, at 4:00 p.m., for this area.

Interview with the facilities manager on December 17, 2025, at 11:35 a.m., confirmed the area had portable space heaters in use at the time of the survey.

Plan of Correction - To be completed: 01/13/2026

Following receipt of the finding, the Facilities Manager, Safety Officer, Chief Clinical Officer and CEO met to review and discuss the finding.
Portable space heaters were removed from patient care areas 12/17/25. Staff and Leadership notified portable space heaters are only permissible in nonsleeping staff and employee areas.
Reinforced that portable space heaters are only permissible in nonsleeping staff and employee areas at Safety Huddles and Leadership meetings 12/19/25 & 12/23/25, per NFPA 101.
Leadership re-education on Space Heater Policy will be conducted 1/13/26.

Monitoring:
The Safety Officer & Facilities Manager will conduct regular rounds to ensure portable space heaters are not in use in any patient care areas or where members of the workforce sleep.

Responsible Person: Safety Officer

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: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0918

Based on document review and interview, the facility failed to maintain essential electric system maintenance and testing for one of one emergency generator.

Findings include:

Document review and interview on December 18, 2025, at 11:55 a.m., revealed a temporary generator was installed to substitute for a failed generator following an event submitted on December 21, 2021. The facility continues to rely on this temporary setup to power its electrical feeds and supporting components during an emergency. The facility failed to provide a clear plan or timeline to rectify the temporary configuration. However, the facility provided a quote from a vendor, dated May 27, 2025. This deficiency was originally identified and cited during the February 4, 2025 survey (survey ID JHWM21).

Interview with the facilities manager on December 18, 2025, at 11:55 a.m., confirmed the emergency generator deficiencies at the time of the survey.

Plan of Correction - To be completed: 02/25/2026

Following receipt of the finding, the Facilities Manager, Safety Officer, Chief Clinical Officer and CEO met to review and discuss the finding.
The Facilities Manager will work with Senior Leadership, Safety Officer, and Vendor C
to establish a clear plan with a timeline to rectify the temporary configuration.

The Facilities Manager will contact the Department of Health State Plan Review and work with the Plan Reviewer to provide necessary information, ensure he/she has the information required to determine the next steps, and schedule an occupancy survey if required.

The Facilities Manager will submit a request for a Time-Limited Waiver for deficiency K-0918, Component - 01, Temporary Generator.

Monitoring:
The Facilities Manager will submit proposed project work to the Department of Health State Plan Review for approval prior to commencing facility project work.
The Facilities Manager will report project work and progress at monthly Environment of Care (EOC) Meetings
Senior leadership are active members of EOC and EOC minutes will be forwarded to the Board of Directors

Responsible Person: Facilities Manager

Initial comments:Name: SHARON REGIONAL HEALTH SYSTEM - Component: 02 - Tag: 0000

Facility ID # 196601
Component 02
A Building

Based on an Onsite Survey that was part of an unannounced Compliant Investigation completed on December 17-18, 2025, it was determined that Sharon Regional Health System was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a six-story, Type II (222), fire resistive building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 02 - Tag: 0100

Based on document review, observation, and interview, the facility failed to maintain general requirements that are not addressed by the provided K-tags, but are deficient, affecting two of two building components.

Findings include:

Observation on December 17, 2025, between 11:39 a.m. and 12:30 p.m., revealed the facility failed to obtain required approval from the Department of Health State Plan Review and a granted occupancy from the Life Safety Division for the following projects:

A. (11:39 a.m.) The replacement of the existing return dual temperature piping system throughout building component 02, floors 3, 4, and 5. The facility submitted a narrative to Plan Review on July 17, 2025, and indicated that work was scheduled to begin on July 14, 2025. Plan Review sent a response letter on August 26, 2025, requesting additional information pertaining to the project. However, the facility had no documentation outlining a response to the request and continued work without approval. There were multiple rooms observed on floors 3 and 4 where work on this project was being completed at the time of the survey.
B. (12:30 p.m.) The roofing service / recondition mitigation plan to address leaks affecting various sections of the building. This project was initially identified and cited on the February 4, 2025 survey (survey ID JHWM21). The facility stated that a narrative and plans were submitted to Plan Review, but could not provide documentation of approved drawings on the day of the survey. The facility stated that the vendor completed the reconditioning section of this project (approximately 70% of the roof) without approved plans in place. Additionally, there was no occupancy inspection completed from the Life Safety Division.

Interview with the facilities manager on December 17, 2025, at 12:30 p.m., confirmed the projects were being completed without State Plan Review approval and a granted occupancy from the Life Safety Division.

2. Document review and Interview on December 18, 2025, at 11:20 a.m. revealed the roofing / mitigation project for the boiler room was not started at the time of the survey. This deficiency was originally identified and cited on February 4, 2025 survey (survey ID JHWM21). The boiler room is a non-inspected building for DSI; however, the boiler systems and its supporting components are critical for the hospital and are subject to building services provisions. The facility provided an agreement with a contractor on the day of the survey, but no work has been completed.

Interview with the facilities manager on December 18, 2025, at 11:20 a.m., confirmed the project was not started at the time of the survey.

Plan of Correction - To be completed: 02/25/2026

Following receipt of the finding, the Facilities Manager, Safety Officer, Chief Clinical Officer and CEO met to review and discuss the findings.
A. The Safety Officer/Facilities Manager will contact the Department of Health State Plan Review and work with the Plan Reviewer to provide necessary information, ensure he/she has the information required to determine the next steps, and schedule an occupancy survey if required.

B. The Safety Officer/Facilities Manager will contact the Department of Health State Plan Review and work with the Plan Reviewer to provide necessary information, ensure he/she has the information required to determine the next steps, and schedule an occupancy survey if required.

The Facilities Manager will submit a request for a Time-Limited Waiver for deficiency K-0100, Component – 02, Plans Review, Roofing Project.

2. The Facilities Manager will work with Senior Leadership, Safety Officer, and Vendor A
to establish project development plans appropriate to the roofing/mitigation project
for the boiler room.

The Facilities Manager will contact the Department of Health State Plan Review and work with the Plan Reviewer to provide necessary information, ensure he/she has the information required to determine the next steps, and schedule an occupancy survey if required.

The Facilities Manager will submit a request for a Time-Limited Waiver for deficiency K-0100, Component – 02, Plans Review, Boiler Room Roofing/Mitigation Project.

Monitoring:
The Facilities Manager will submit proposed project work to the Department of Health State Plan Review for approval prior to commencing facility project work.
The Facilities Manager will report project work and progress at monthly Environment of Care (EOC) Meetings
Senior leadership are active members of EOC and EOC minutes will be forwarded to the Board of Directors

Responsible Person: Facilities Manager

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: SHARON REGIONAL HEALTH SYSTEM - Component: 02 - Tag: 0353

Based on document review, observation, and interview, the facility failed to maintain and test the fire sprinkler suppression system for one of two building components.

Findings include:

Observation on February 3, 2025, between 10:45 a.m. and 11:55 a.m., revealed the following areas had damaged or missing ceiling tiles. Missing ceiling tiles can delay the activation of fire alarm detectors and sprinkler heads:

A. (10:45 a.m. - 11:37 a.m.) First floor had multiple removed or damaged ceiling tiles in various rooms / areas from the converter and steam trap failure;
B. (11:37 a.m. - 11:55 a.m.) Third and fourth floors had multiple ceiling tiles removed in various rooms for the replacement of the return dual temperature piping project that was being completed.

Interview with the facilities manager on December 17, 2025, at 11:55 a.m., confirmed the sprinkler system deficiencies at the time of the survey.

Plan of Correction - To be completed: 01/16/2026

Following receipt of the finding, the Director of Facilities, Safety Officer, Chief Clinical Officer and CEO met to review and discuss the finding.
A & B - All damaged and missing ceiling tiles will be replaced by 1/16/26.

Monitoring:
Open for business tours conducted by department leaders/designee and does include ceiling tile evaluations.
The findings will be reported to EOC.

Senior leadership are active members of EOC and EOC minutes will be forwarded to the Board of Directors.

Responsible Person: Facilities Manager

NFPA 101 STANDARD Portable Space Heaters:

Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 02 - Tag: 0781

Based on document review, observation, and interview, the facility utilized portable electric heaters in patient-occupied areas, affecting two of two building components.

Findings include:

Observation on December 17, 2025, between 11:40 a.m. and 11:50 a.m., revealed 1500-watt oil-filled radiant electric space heaters in use throughout the fourth floor west. Through interview, it was communicated that there were six heating units distributed to help warm the cooler patient-occupied areas. Through document review, the hospital incorporated a document titled "Increased Surveillance Log" to track and observe the space heaters while in use. Further review indicated that the heater surveillance began on December 13, 2025, at 12:30 p.m., for this area.

Interview with the facilities manager on December 17, 2025, at 11:50 a.m., confirmed the area had portable space heaters in use at the time of the survey.

Plan of Correction - To be completed: 01/13/2026

Following receipt of the finding, the Facilities Manager, Safety Officer, Chief Clinical Officer and CEO met to review and discuss the finding.
Portable space heaters were removed from patient care areas 12/17/25. Staff and Leadership notified portable space heaters are only permissible in nonsleeping staff and employee areas
Reinforced that portable space heaters are only permissible in nonsleeping staff and employee areas at Safety Huddles and Leadership meetings 12/19/25 & 12/23/25, per NFPA 101.
Leadership re-education on Space Heater Policy will be conducted 1/13/26.

Monitoring:
The Safety Officer & Facilities Manager will conduct regular rounds to ensure portable space heaters are not in use in any patient care areas or where members of the workforce sleep.

Responsible Person: Safety Officer

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