Pennsylvania Department of Health
WEST CHESTER REHABILITATION AND HEALTHCARE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 51 surveys for this facility. Please select a date to view the survey results.

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WEST CHESTER REHABILITATION AND HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: MAIN/CENTRAL - Component: 01 - Tag: 0000

Facility ID #023902
Component 01
Central Building

Based on a Relicensure Survey completed on October 28, 2025 , it was determined that West Chester Rehabilitation and Healthcare Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a three-story, Type II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.

Plan of Correction:

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: MAIN/CENTRAL - Component: 01 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain the required fire resistance rating of communicating openings, on one of two floors within the component.

Findings include:

1. Observation on October 28, 2025, at 11:36 AM, revealed the basement level component separation double doors, near the Dialysis Den, failed to close and latch when released from their respective hold open devices.

Interview at the time of the exit conference with the Administrator, Regional Maintenance Representative and Facility Maintenance Representative on October 28, 2025, at 12:00 PM, confirmed the doors lacked positive latching.

Plan of Correction - To be completed: 12/17/2025

This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report.
1. The facility is requesting a time limited waiver for dialysis doors to be adjusted/replaced per contractor recommendation to properly close and latch when released.
2. Maintenance staff were educated on fire door codes and requirements.
3. Maintenance Director or Designee will conduct an audit of 5 random fire doors weekly for 4 weeks followed by monthly for 2 months to ensure they close and latch when released. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as need. Further audit frequency will be determined based on audit findings

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:
Name: MAIN/CENTRAL - Component: 01 - Tag: 0161

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

Findings include:

1. Observation on October 28, 2025, between 8:45 AM and 12:00 PM, revealed the facility is a three-story, Type II (000), unprotected noncombustible structure, which is fully sprinklered. This type of construction is not permitted to be greater than two stories in height.

Interview at the time of the exit conference with the Administrator, Regional Maintenance Representative and Facility Maintenance Representative on October 28, 2025, at 12:00 PM, confirmed the construction type and height is not permitted in Health Care.

Plan of Correction - To be completed: 12/04/2025

1. Facility requests the DOH Div of Safety inspection to conduct the FSES.

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/CENTRAL - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to maintain the sprinkler system, which serves the entire component.

Findings include:

1. Review of documentation and interview on October 28, 2025, between 8:45 AM and 10:00 AM, revealed the facility had changed sprinkler inspection contractors and the required documentation was not available at the time of the survey.

Interview at the time of the exit conference with the Administrator, Regional Maintenance Representative and Facility Maintenance Representative on October 28, 2025, at 12:00 PM, confirmed the facility could not provide a complete sprinkler inspection report dated after January 2025.

Plan of Correction - To be completed: 12/04/2025

1. The required sprinkler documentation was received from the contractor. Documentation is available for review.
2. Maintenance staff were educated on required sprinkler paperwork.
3. The Maintenance Director or Designee will conduct an audit of the life safety book weekly for 4 weeks followed by monthly for 2 months to ensure the proper sprinkler documentation is in place for review. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on audit findings

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
2012 EXISTING
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.
There is no impediment to the closing of the doors. Clearance between bottom of door and floor covering is not exceeding 1 inch. Roller latches are prohibited by CMS regulations on corridor doors and rooms containing flammable or combustible materials. Powered doors complying with 7.2.1.9 are permissible. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted.
Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.
19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN/CENTRAL - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors, on two of three floors within the component.

Findings include:

1. Observation on October 28, 2025, between 10:16 AM and 10:56 AM, revealed the following corridor doors lacked smoke-tight integrity:

a. 10:16 AM, 2nd floor Activity Room failed to latch;
b. 10:19 AM, 2nd floor Room 227, not smoke tight when latched in the frame;
c. 10:22 AM, 2nd floor Room 224, not smoke tight when latched in the frame;
d. 10:22 AM, 1st floor Room 128, not smoke tight when latched in the frame;
e. 10:56 AM, 1st floor Room 125, not smoke tight when latched in the frame.

Interview at the time of the exit conference with the Administrator, Regional Maintenance Representative and Facility Maintenance Representative on October 28, 2025, at 12:00 PM, confirmed the corridor doors were not smoke tight.

Plan of Correction - To be completed: 12/17/2025

1. The facility is requesting a time limited waiver for dialysis doors to be adjusted/replaced per contractor recommendation to properly close and latch when released.
2. Rooms 227, 224, 128, and 125 had fire rated door gaskets ordered and installed to seal the door into the frame making it smoke tight.
3. Maintenance staff were educated on smoke/fire door requirements.
4. The Maintenance Director or Designee will conduct an audit of five random doors weekly for 4 weeks followed by monthly for 2 months to ensure that doors latch when closed. The maintenance Director or Designee will conduct an audit of five resident room doors weekly for 4 weeks followed by five resident room doors monthly for 2 months to ensure they are smoke tight when latched in the frame. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on audit findings

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:

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/CENTRAL - Component: 01 - Tag: 0371

Based on document review, observation and interview, it was determined the facility failed to provide at least two smoke compartments on every sleeping room floor, with greater than 30 residents, affecting two of three floors within the component.

Findings include:

1. Review of documentation and observation on October 28, 2025, between 9:00 AM and 11:00 AM, revealed the 1st and 2nd floors lacked smoke barrier walls.

Interview at the time of the exit conference with the Administrator, Regional Maintenance Representative and Facility Maintenance Representative on October 28, 2025, at 12:00 PM, confirmed the lack of smoke barriers.

Plan of Correction - To be completed: 12/04/2025

1. Center will provide an FSES evaluation to be performed to address the lack of smoke barrier wall requirement.

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:
Name: MAIN/CENTRAL - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain the emergency electrical generator, which supplies electrical power throughout the facility in the event of an utility outage, affecting the entire component.

Findings include:

1. Review of documentation and interview on October 28, 2025, between 8:45 AM and 10:00 AM, revealed the facility could not produce documentation of a fuel quality test, since March of 2024.

Interview at the time of the exit conference with the Administrator, Regional Maintenance Representative and Facility Maintenance Representative on October 28, 2025, at 12:00 PM, confirmed the facility could provide the required documentation.

Plan of Correction - To be completed: 12/04/2025

1. A fuel sample was performed in June 2025 and paperwork is available for review.
2. Maintenance staff were educated on fuel sampling requirements for Diesel Generators.
3. Maintenance Director or Designee will conduct an audit of the Life Safety book weekly for 4 weeks followed by monthly for 2 months to ensure proper fuel testing documentation is in place. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on audit findings

Initial comments:Name: NEW/SOUTH - Component: 02 - Tag: 0000

Facility ID #023902
Component 02
New/South Building

Based on a Relicensure Survey completed on October 28, 2025, it was determined that West Chester Rehabilitation and Healthcare Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a one-story, Type II (222), fire resistive structure, with a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Observations:
Name: NEW/SOUTH - Component: 02 - Tag: 0353

Based on document review and interview, it was determined the facility failed to maintain the sprinkler system, which serves the entire component.

Findings include:

1. Review of documentation and interview on October 28, 2025, between 8:45 AM and 10:00 AM, revealed the facility had changed sprinkler inspection contractors and the required documentation was not available at the time of the survey.

Interview at the time of the exit conference with the Administrator, Regional Maintenance Representative and Facility Maintenance Representative on October 28, 2025, at 12:00 PM, confirmed the facility could not provide a complete sprinkler inspection report dated after January 2025.

NFPA 101 STANDARD Corridor - Doors:

Observations:
Name: NEW/SOUTH - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors, on one of two floors within the component.

Findings include:

1. Observation on October 28, 2025, between 11:14 AM and 11:25 AM, revealed the following corridor doors lacked smoke-tight integrity:

a. 11:14 AM, 1st floor Room 140, not some tight latched in the frame;
b. 11:17 AM, 1st floor Room 138, not smoke tight latched in the frame;
c. 11:23 AM, 1st floor Room 154, lacked positive latching;
d. 11:25 AM, 1st floor Room 151, lacked positive latching.

Interview at the time of the exit conference with the Administrator, Regional Maintenance Representative and Facility Maintenance Representative on October 28, 2025, at 12:00 PM, confirmed the corridor deficiencies.

Plan of Correction - To be completed: 12/04/2025

1. Rooms 140, and 138 had fire rated door gaskets ordered and installed to seal the door into the frame making it smoke tight. Rooms 154 and 151 had the latch in the frame adjusted for positive latching.
2. Maintenance staff were educated on smoke/fire door requirements.
3. The maintenance Director or Designee will conduct an audit of five resident room doors weekly for 4 weeks followed by five resident room doors monthly for 2 months to ensure they are smoke tight when latched in the frame. The Maintenance Director or Designee will conduct an audit of five resident room doors weekly for 4 weeks followed by monthly for 2 months to ensure the doors latch when frame. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on audit findings

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: NEW/SOUTH - Component: 02 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors, on one of two floors within the component.

Findings include:

1. Observation on October 28, 2025, at 12:00 PM, revealed the smoke barrier doors, on the 1st floor near Room 160, failed to completely close smoke tight, when tested.

Interview at the time of the exit conference with the Administrator, Regional Maintenance Representative and Facility Maintenance Representative on October 28, 2025, at 12:00 PM, confirmed the smoke barrier doors lacked smoke-tight integrity.

Plan of Correction - To be completed: 12/17/2025

1. The facility is requesting a time limited waiver for the doors near room 160 to be adjusted/replaced per contractor recommendation to properly close to be smoke tight.
2. Maintenance staff were educated on fire door codes and requirements.
3. The Maintenance Director or Designee will conduct an audit for five smoke barrier doors weekly for 4 weeks followed by monthly for 2 months to ensure doors properly close to be smoke tight. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on audit findings.

NFPA 101 STANDARD Electrical Systems - Other:

Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided S-Tags, but are deficient.
Chapter 6 (NFPA 99)

Observations:
Name: NEW/SOUTH - Component: 02 - Tag: 0911

Based on observation and interview, it was determined the facility failed to protect electrical wiring systems in proximity of water sources, on one of two floors within the component.

Findings include:

1. Observation on October 28, 2025, at 11:50 AM, revealed an electrical outlet within approximately 18 inches of the sink, in the basement level Employee Breakroom, was not on a ground fault protected circuit.

Interview at the time of the exit conference with the Administrator, Regional Maintenance Representative and Facility Maintenance Representative on October 28, 2025, at 12:00 PM, confirmed the outlet was not ground fault protected.

Plan of Correction - To be completed: 12/04/2025

1. The outlet in basement level employee breakroom was replaced and tested on GFCI outlet providing ground fault protection.
2. Maintenance staff were educated on GFCI regulations.
3. An Audit was conducted to all outlets within 18 inches of a water source to ensure proper ground fault protection was in place. Additional audits will be conducted monthly for 2 months to ensure proper ground fault protection is in place within 18 inches of a water source. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on audit findings.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: NEW/SOUTH - Component: 02 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain the emergency electrical generator, which supplies electrical power throughout the facility, in the event of an utility outage, affecting the entire component.

Findings include:

1. Review of documentation and interview on October 28, 2025, between 8:45 AM and 10:00 AM, revealed the facility could not produce documentation of a fuel quality test, since March of 2024.

Interview at the time of the exit conference with the Administrator, Regional Maintenance Representative and Facility Maintenance Representative on October 28, 2025, at 12:00 PM, confirmed the facility could not provide the required documentation.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: NEW/SOUTH - Component: 02 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor for the unauthorized use of electrical extension cords, on one of two floors within the component.

Findings include:

1. Observation on October 28, 2025, at 11:16 AM, revealed an extension cord in use powering a phone charger at the B bed, in Room 139 on the 1st floor.

Interview at the time of the exit conference with the Administrator, Regional Maintenance Representative and Facility Maintenance Representative on October 28, 2025, at 12:00 PM, confirmed the extension cord was in use.

Plan of Correction - To be completed: 12/04/2025

1. The extension cord at bed "B" in room 139 on the first floor was removed.
2. Staff were educating on the regulations concerning the use of extension cords and power strips.
3. An audit of all resident rooms was conducted to identify if extension cords or power strips were being used incorrectly. 10 random resident rooms will be audited weekly for 4 weeks followed by monthly for 2 months to ensure extension cords and power strips are not being used incorrectly. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on audit findings.

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