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 28, 2025, 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 28, 2025, 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 Maintenance, Inspection & Testing - Doors:

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.

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Observations:
Name: REPLACEMENT FACILITY - Component: 03 - Tag: 0761

Based on document review and interview, the facility failed to maintain, inspect, and test fire doors, in accordance with regulations, affecting the entire facility.

Findings include:

Document review on May 28, 2025, at 9:45 a.m., revealed the facility's annual door inspection (conducted May 15, 2025) identified one rated door that was in non-compliancy. The neighborhood #1 fire door next to the SPA had damaged hinges. The facility lacked documentation that the doors were repaired, or the deficiencies corrected, at the time of the survey.

Interview with the maintenance supervisor on May 28, 2025, at 9:45 a.m., confirmed the corrective documentation for the fire door was unavailable.

Plan of Correction - To be completed: 06/25/2025

Maintenance Director Identified fire door deficiency on 3/3/2025 during an audit. Immediately contacted vendor for replacement. Vendor provided quote on replacement 3/8/2025, and quote was approved on 3/13/2025, check for 50% deposit was given to vendor on 3/18/2025. Fire door inspection by contractor completed on 5/15/2025 noted door to be out of compliance during annual inspection. Replacement door has been ordered from the manufacturer by the vendor with an anticipated delivery and installation in August due to manufacturing lead time. Facility will audit fire doors once a week for 10 weeks to ensure fire doors are in compliance.

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