Pennsylvania Department of Health
PERRY HEALTH & REHAB CENTER
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 39 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.


PERRY HEALTH & REHAB CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Facility ID# 231202
Component 01
Main Building

Based on a Relicensure Survey completed on October 28, 2025, it was determined that Wexford 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 (222), fire resistive building, without a basement, that is fully sprinklered.

Plan of Correction:

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 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain doors to hazardous areas that positively self-latch into the frame, affecting one of twelve smoke compartments.

Findings include:

1. Observation made on October 28, 2025, at 10:25 a.m., revealed the door to the Elevator Room, located in the Maintenance Shop, would not latch into the frame when tested.

Interview with the Facility Administrator and Maintenance Director on October 28, 2025, at 1:00 p.m., confirmed the door would not close and self-latch into the frame.

Plan of Correction - To be completed: 12/01/2025

1. Door to Elevator Room was fixed and is now latching correctly.
2. Maintenance Director or designee will conduct an initial audit of doors to hazardous areas to ensure proper functioning.
3. Maintenance Director or designee will audit three different doors to hazardous areas weekly for the next six weeks to ensure proper functioning.
4. Results of the audits will be brought to the monthly QAPI Meetings for any recommendations/feedback.

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 BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting one of twelve smoke compartments.

Findings include:

1. Observation on October 28, 2025, at 10:50 a.m., revealed excessive storage stored within 18 inches of a sprinkler head, in the Main Storage/Sprinkler Room.

Interview with the Facility Administrator and Maintenance Director on October 28, 2025, at 1:00 p.m., confirmed the automatic sprinkler system deficiency.

Plan of Correction - To be completed: 12/01/2025

1. Main storage/sprinkler room was cleaned and 18 inches from sprinkler head rule is being adhered to.
2. Maintenance Director or designee will conduct an initial audit of facility storage rooms with sprinklers to ensure the 18 inches rule is being adhered to.
3. Maintenance Director or designee will audit one different facility storage room with sprinklers weekly for the next six weeks to ensure continued compliance.
4. Results of the audits will be brought to the monthly QAPI Meetings for any recommendations/feedback.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on documentation review and interview, it was determined the facility failed to maintain portable fire extinguishers in one instance, affecting the entire facility.

Findings include:

1. Documentation review on October 28, 2025, at 8:30 a.m., revealed the facility could not provide a current certificate for the technician that completed the annual portable fire extinguisher inspection.

Interview with the Facility Administrator and Maintenance Director on October 28, 2025, at 1:00 p.m., confirmed the portable fire extinguisher deficiency.

Plan of Correction - To be completed: 12/01/2025

1. Facility contacted Fire Extinguisher Vendor and Certificate was obtained for facility records.
2. NHA will educate Maintenance Director on the S0355 Life Safety Regulation.
3. Maintenance Director or designee will audit annually for a valid Fire Extinguisher Vendor Certificate to ensure continual compliance.
4. Results of the audits will be brought to the monthly QAPI Meetings for any recommendations/feedback.

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 01 - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain corridor doors in one instance, affecting one of 10 smoke compartments.

Findings include:

1. Observation on October 28, 2025, at 10:30 a.m., revealed the door to resident Room 314 would not close and latch when tested.

Interview with the Facility Administrator and Maintenance Director on October 28, 2025, at 1:00 p.m., confirmed the door failed to latch when tested.

Plan of Correction - To be completed: 12/01/2025

1. Door to Resident Room 314 was fixed and latch now properly closes.
2. Maintenance Director or designee will conduct an initial audit of resident room doors to ensure proper functioning.
3. Maintenance Director or Designee will audit three resident room doors weekly for six weeks to ensure continual proper functioning.
4. Results of the audits will be brought to the monthly QAPI Meetings for any recommendations/feedback.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0374
Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in two instances, affecting four of ten smoke compartments.

Findings include:

1. Observation on October 28, 2025, revealed the following smoke barrier door deficiencies;

a) 9:35 a.m., the smoke doors from the Old Lobby near the physician suite failed to close and latch when tested;
b) 10:30 a.m., there was a gap greater than 1/8" between the metting edges of the smoke doors near Resident Room 212.

Interview with the Facility Administrator and the Maintenance Director on October 28, 2025, at 1:00 p.m., confirmed the listed smoke barrier door deficiencies.

Plan of Correction - To be completed: 12/01/2025

1. Both identified doors were corrected to ensure proper closure and latching.
2. An initial audit of all other main smoke barrier double doors will be conducted to ensure proper closure and latching.
3. Maintenance Director or designee will audit three different main smoke barrier double doors weekly for the next six weeks to ensure proper functioning.
4. Results of the audits will be brought to monthly QAPI Meetings for any recommendations/feedback.

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 BUILDING 01 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain the emergency generator in one instance, affecting the entire facility.

Findings include:

1. Review of documentation and interview on October 28, 2025, at 8:35 a.m., revealed the facility failed to perform the required monthly conductance testing.

Interview with the Facility Administrator and Director of Maintenance on October 28, 2025, at 1:00 p.m., confirmed the monthly conductance testing was not being performed.

Plan of Correction - To be completed: 12/01/2025

1. Facility now has proper device to test generator battery.
2. NHA will educate Maintenance Director on monthly required generator battery conductance testing that is part of S0918.
3. Maintenance Director or designee will audit monthly of completed generator battery conductance testing moving forward.
4. Results of the audits will be brought to monthly QAPI Meetings for any recommendations/feedback.

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 01 - Component: 01 - Tag: 0920
Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of twelve smoke compartments.

Findings include:

1. Observation on October 28, 2025, at 11:05 a.m., revealed a microwave and coffee pot plugged into a power strip in the RNAC Office.

Interview with the Facility Administrator and Maintenance Director on October 28, 2025, at 1:00 p.m., confirmed the listed electrical wiring system and equipment deficiency.

Plan of Correction - To be completed: 12/01/2025

1. Microwave and coffee pot were immediately removed from power strip.
2. NHA will educate RNAC office on the S0920 citation.
3. Maintenance director or designee will conduct an audit of all offices to ensure appliances are not plugged into power strips.
4. Maintenance Director or designee will audit one office weekly for six weeks to ensure that no appliances are plugged into power strips.
5. Results of the audits will be brought to monthly QAPI Meetings for any recommendations/feedback.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright � 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement