Pennsylvania Department of Health
WAYNE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 42 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


WAYNE 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 May 29, 2025, at Wayne 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 01 (A,B,C, WINGS) - Component: 01 - Tag: 0000

Facility ID #750102
Component 01
A, B, and C Wings

Based on a Medicare/Medicaid Recertification Survey completed on May 29, 2025, it was determined that Wayne Center was not in compliance with the 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 two-story, Type III (200), unprotected ordinary building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

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.

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:
Name: MAIN BUILDING 01 (A,B,C, WINGS) - Component: 01 - Tag: 0161

Based on document review and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire building component.

Findings include:

Document review on May 29, 2025, at 9:00 a.m., revealed the building has been classified as a two-story, Type III (200), unprotected ordinary building, with a basement, that is fully sprinklered. The story height exceeds the maximum allowance by one story.

Exit Interview with the Administrator and Maintenance Director on May 29, 2025, at 2:00 p.m., confirmed the story height exceeded the maximum allowance for this type of construction.

Plan of Correction - To be completed: 07/09/2025

Facility requests that a new FSES be performed to see if it meets the requirements of a waiver for this deficiency. If the facility does not score enough points, what other safety requirements/ improvements can be made to the area to gain enough points to meet waiver. The Maintenance Director submitted information as requested and provided to the inspector on 7/28/2017.

The facility has requested a time-limited waiver until 12/29/25 for deficiency K0161.

NFPA 101 STANDARD Utilities - Gas and Electric:

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.

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Observations:
Name: MAIN BUILDING 01 (A,B,C, WINGS) - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, Section 110.26(A)(1), for electrical wiring and equipment, affecting one of two levels in the component.

Findings include:

Observation on May 29, 2025, at 11:30 a.m., revealed, despite signage instructing not to, a trash can and med cart in front and within three feet of the electrical panels in Nurses station, on the first floor.

Exit interview with the Administrator and the Maintenance Director on May 29, 2025, at 2:00 p.m., confirmed the improper storage in front of the electrical panels.

Plan of Correction - To be completed: 07/09/2025

The trash can and med cart were removed and will not be stored within three feet of the electrical panel. Maintenance will conduct random weekly audits to ensure items are not blocking electrical panels. Maintenance will institute a preventive maintenance program monthly to ensure items are not blocking the electrical programs. Maintenance will educate staff regarding improper storage In front of electrical panels. Findings will be reported to quarterly qapi/safety committee meetings.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 (A,B,C, WINGS) - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to ensure oxygen cylinders were separated on one of two levels of the facility.

Findings Include:

Observation made on May 29, 2025, at 12:45 p.m., revealed, on the second floor, Oxygen Storage room had full oxygen cylinders mixed in with empty oxygen cylinders.

Exit interview with the Administrator and Maintenance Director on May 29, 2025, at 2:00 p.m., confirmed the mixed cylinders.

Plan of Correction - To be completed: 07/09/2025

O2 Cylinders were separated by empty and full. Maintenance will conduct random weekly audits to ensure 02 cylinders are not mixed. Maintenance will educate staff regarding the required separation of O2 tanks. Signage identifying full and empty oxygen cylinders will be installed in the room. Findings will be reported to quarterly qapi/safety committee meetings.

Initial comments:Name: BUILDING 02 (D WING) - Component: 02 - Tag: 0000

Facility ID #750102
Building 02
D Wing

Based on a Medicare/Medicaid Recertification Survey completed on May 29, 2025, it was determined that Wayne Center was not in compliance with the 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 two-story, Type II (111), protected noncombustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

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: BUILDING 02 (D WING) - Component: 02 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain means of egress free of all obstructions, affecting one of two levels in the facility.

Findings include:
Observation on May 29, 2025, at 1:45 p.m., revealed the egress exterior door in stairwell on the first floor, near CRC office, required excessive force to open.
Exit interview with the Administrator and Maintenance Director on May 29, 2025, at 2:00 p.m., confirmed the egress door required excessive force to open.

Plan of Correction - To be completed: 07/09/2025

A third party contractor will repair the exterior door in the stair well on the first floor near CRC office to allow easy egress. Maintenance will conduct random weekly audits to ensure the first floor door near CRC office allows for easy egress. Maintenance will implement a preventive maintenance program monthly to ensure egress doors are in compliance with NFPA 101 standard. Findings will be reported to quarterly qapi/safety committee meetings.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu:

Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82

Observations:
Name: BUILDING 02 (D WING) - Component: 02 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of chute enclosures, affecting 1 of 3 compartments.

Findings include:

1. Observation made on May 29, 2025, at 11:30 a.m., revealed, in the basement, linen chute required a UL listed fusible link on door drop down chain.

Exit interview with the Administrator and Maintenance Director on May 29, 2025, at 2:00 p.m., confirmed the linen chute drop door, did not have a UL listed fusible link installed.

2. Observation made on May 29, 2025 at 1:30 p.m., revealed a trash can, stored in chute access closet, next to Jefferson Room, was inhibiting the chute door from closing.

Exit interview with the Administrator and Maintenance Director on May 29, 2025, at 2:00 p.m., confirmed the unattended, propped open linen chute door.

Plan of Correction - To be completed: 07/09/2025

Maintenance removed the non rated fusible link on the door drop down chain in the linen chute. A new required UL listed fusible link was installed.

Maintenance removed the trash can stored in the chute access closet. Maintenance will educate staff on not propping open linen chute doors.Maintenance will conduct random weekly audits to ensure the chute door is not propped open. Maintenance will implement a preventive Maintenance program monthly to ensure linen chute doors are not propped open. Findings will be reported to quarterly qapi/safety committee meetings.

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