Pennsylvania Department of Health
LAKEWOOD REHABILITATION & HEALTHCARE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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LAKEWOOD REHABILITATION & HEALTHCARE CENTER - 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 June 30, 2025, at Lakewood Rehabilitation and Healthcare Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

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

Facility ID# 191502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 30, 2025, it was determined that Lakewood Rehabilitation and Healthcare Center 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 II (000), unprotected, noncombustible building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Corridor - 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.

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. 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 two corridor doors in one of six smoke compartments.

Findings include:

1. Observation on June 30, 2025, between 10:56 am and 10:57 am, revealed the following doors were getting stuck in their corresponding frames preventing them from fully latching.

a. At 10:56 am, Resident Room 217.
b. At 10:57 am, Resident Room 223.

Interview at the time of the exit conference on June 30, 2025, at 11:30 am, with the Administrator and Director of Maintenance, confirmed the doors failed to positive latch into frame.

Plan of Correction - To be completed: 07/09/2025

Maintenance has repaired the doors to rooms 217 and 223 to ensure that they latch appropriately.
NHA to re-educate facility Maintenance Director on proper latching of corridor doors. A full house audit completed by maintenance to ensure that corridor doors were not getting stuck in their corresponding frames to prevent them from fully latching.
Maintenance will conduct weekly audits x 4 weeks and monthly audits x 2 months to ensure doors latch appropriately.
Audits to be submitted to QAPI for review and recommendations.

NFPA 101 STANDARD Fire Drills:

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.

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform four of twelve fire drills on a random basis.

Findings include:

1. Observation on June 30, 2025, at 10:20 am, revealed that the facility performed the 1st shift fire drills for the last 12 months, within the same hour. (9:59 am, 10:03 am, 9:18 am, 9:08 am).

Interview at the time of the exit conference on June 30, 2025, at 11:30 am, with the Administrator and Director of Maintenance, confirmed the fire drills were not performed on a random basis.

Plan of Correction - To be completed: 07/09/2025

A fire drill has been conducted, for the first shift, at 11:15AM.
Administrator to re-educate Maintenance Director on fire drills being held at random. Maintenance Director will continue to perform monthly fire drills at random basis.
NHA/designee will conduct audits weekly x 4 weeks and monthly x 2 months to ensure fire drills are being held randomly monthly.
Audits to be submitted to QAPI for review and recommendations.

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