Pennsylvania Department of Health
WALNUT CREEK NURSING AND REHAB
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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WALNUT CREEK NURSING AND REHAB - 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 20, 2026, at Walnut Creek Nursing and Rehab, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: REPLACEMENT FACILITY - Component: 03 - Tag: 0000

Facility ID #020602
Component 03
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 20, 2026, it was determined that Walnut Creek Nursing and Rehab was not in compliance with the following requirements of the Life Safety Code for an existing 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 one-story, Type V (111), protected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

This is a less serious (but not lowest level) 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 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.

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: REPLACEMENT FACILITY - Component: 03 - Tag: 0345

Based on observation and interview, the facility failed to meet fire alarm system requirements for one of one system, affecting the entire building.

Findings include:

Observation on May 20, 2026, at 11:20 a.m., revealed the fire alarm panel located at the NH4 nurse station displayed trouble signal "Sprinkler Bell."
Interview with the maintenance supervisor on May 20, 2026, at 11:20 a.m., confirmed the fire alarm panel displayed a trouble mode.

Plan of Correction - To be completed: 07/16/2026

Facility Maintenance Director has been in contact with vendors to have Jockey pump and controller replacement options quoted.
Facility Maintenance Director completes daily fire alarm system panel checks to ensure system functionality.
Facility Maintenance Director will ensure Jocky Pump and Controller are replaced and that no other trouble signals are displayed on the fire alarm system panel.
Maintenance Director will conduct weekly Audits of the fire alarm panel for trouble signals for twelve weeks to ensure compliance. The results of these audits will be reviewed by the facility quality assurance and process improvement committee until substantial compliance is achieved.

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: REPLACEMENT FACILITY - Component: 03 - Tag: 0521

Based on document review and interview, the facility failed to maintain heating, ventilating, and air conditioning (HVAC) equipment, affecting the entire facility.

Findings include:

Document review on May 20, 2026, at 9:35 a.m., revealed the fire/smoke damper inspection listed all dampers as inaccessible. Corrections had not been completed at the time of the survey.

Interview with the maintenance supervisor on May 20, 2026, at 9:35 a.m., confirmed corrective documentation was unavailable at the time of the survey.

Plan of Correction - To be completed: 07/16/2026

Facility Maintenance Director has been in contact with vendors to have fire/smoke damper access panel options quoted.
Facility Maintenance Director completes daily fire alarm system panel checks to ensure system functionality.
Facility Maintenance Director will ensure fire/smoke damper accesses are quoted, and a purchase order has been completed, down payment processed for work to be started with a timeline available for completion.
Maintenance Director will conduct weekly Audits of the fire alarm panel for trouble signals for twelve weeks to ensure compliance. The results of these audits will be reviewed by the facility quality assurance and process improvement committee until substantial compliance is achieved.

NFPA 101 STANDARD Smoking Regulations:

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.

Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: REPLACEMENT FACILITY - Component: 03 - Tag: 0741

Based on observation and interview, the facility failed to meet smoking regulation requirements at one of one service entrance area.

Findings include:

Observation on May 20, 2026, at 11:10 a.m., revealed the service entrance area had cigarette butts littering the ground and not in an approved non-combustible container.

Interview with the maintenance supervisor on May 20, 2026, at 11:10 a.m., confirmed the cigarette butts were littering the ground.

Plan of Correction - To be completed: 07/16/2026

Facility Maintenance Director cleaned cigarette filters littering the ground upon notification.
Facility Maintenance Director or designee will audit the entrances to the facility do not contain cigarette filter litter daily. Facility Maintenance Director will ensure that an approved noncombustible container is available in proximity to the entrance.
Facility Nursing Home Administrator will conduct education with the Facility Maintenance personnel on regulation "Smoking Regulations".
Maintenance Director or designee will audit the entrances to the facility do not contain cigarette filter litter weekly for 8 weeks. The results of these audits will be reviewed by the facility quality assurance and process improvement committee until substantial compliance is achieved.

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