Pennsylvania Department of Health
STERLING HEALTH CARE AND REHAB CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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STERLING HEALTH CARE AND REHAB CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000

Facility ID #17450201
Component 01

Based on a Relicensure Survey completed on November 20, 2025, it was determined that Sterling Health Care and Rehab Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy.

This is a three-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:

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 - Component: 01 - Tag: 0161

Based on observation, document review, and interview, the facility failed to maintain the building construction type, affecting four of four building levels.

Findings include:

Observation and document review on November 20, 2025, at 9:30 a.m., revealed the building was classified as three-storied, with a basement, Type III (200), unprotected, ordinary building, that is fully sprinklered. The story height of the facility exceeded the allowance for an unprotected, ordinary building.

Exit interview with the Administrator and Maintenance Director on November 20, 2025, at 11:15 a.m., confirmed the building construction type.

Plan of Correction:

No approved Plan of Correction is on file.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0225

Based on observation, document review, and interview, the facility failed to maintain minimum headroom clearance, affecting three of four levels.

Findings include:

1. Observation and document review on November 20, 2025, at 9:30 a.m., revealed the headroom clearance was less than the minimum six feet, eight inches requirement between the ground and first floors, in the annex communicating stairway. The headroom clearance measured five feet, nine inches. The annex communicating stairway was not a required exit, but was identified as an exit leading from the basement to the first floor corridor only.

Exit interview with the Administrator and Maintenance Director on November 20, 2025, at 11:15 a.m., confirmed the minimum headroom clearance inside the stairway.

Plan of Correction:

No approved Plan of Correction is on file.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
2012 EXISTING
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4-hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous locations with a smoke tight separation, in sprinklered locations, affecting one of four levels.

Findings Include:

Observations made on November 20, 2025, between 9:30 a.m, and 11:15 a.m., revealed:
a) Ground floor, Central Supply Storage Room, lacked self-closing hardware on the door.b) Ground floor, Laundry Room door cannot positivetly latch sure to missing strike plate.

Exit interview with the Administrator and Maintenance Director on November 20, 2025, at 11:15 a.m., confirmed the hazardous area required a smoke tight enclosure.

Plan of Correction:

No approved Plan of Correction is on file.

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 BUILDING - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure there were no impediments to the closing and latching of the corridor doors, affecting three of seven smoke compartments.

Findings include:

Observations on November 20, 2025, between 9:15 a.m., and 11:15 a.m., revealed at the following locations, there were impediments blocking or preventing the corridor from closing and positively latching:

a) Resident room 319, failed to positively latch.b) Resident room 102, privacy curtain was preventing the door from closing into the frame.c) Resident room 303, privacy curtain was preventing the door from closing into the frame.d) Resident room G9, privacy curtain was preventing the door from closing into the frame.

Exit interview with the Administrator and Maintenance Director on November 20, 2025, at 11:15 a.m., confirmed the impediments to properly closing the corridor doors.

Plan of Correction:

No approved Plan of Correction is on file.

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: MAIN BUILDING - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical devices, affecting one of four levels.

Findings include:

Observation on November 20, 2025, at 10:45 a.m., revealed a refrigerator plugged into a power strip inside the DON office.

Exit interview with the Administrator and Maintenance Director on November 20, 2025, at 11:15 a.m., confirmed the unauthorized use of an electrical device.

Plan of Correction:

No approved Plan of Correction is on file.

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 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain storage of oxygen cylinders, affecting one of four levels.

Findings include:

Observation on November 20, 2025, at 11:05 a.m., inside the Ground Floor, long hall oxygen storage room, revealed oxygen cylinders were not separated and lacked identification whether full or empty.

Exit interview with the Administrator and Maintenance Director on November 20, 2025, at 11:15 a.m., confirmed the oxygen cylinder storage deficiencies.

Plan of Correction:

No approved Plan of Correction is on file.

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