Pennsylvania Department of Health
TWINBROOK HEALTHCARE AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 44 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.


TWINBROOK HEALTHCARE AND REHABILITATION 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 April 17, 2025, it was determined that Twinbrook Healthcare and Rehabilitation Center was in compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

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

Facility ID #200602
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 17, 2025, it was determined that Twinbrook Healthcare and Rehabilitation 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 two-story, Type II (000), unprotected, non-combustible building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies - Construction Type:

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.

Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3

Observations:
Name: MAIN BUILDING 01/EAST - Component: 01 - Tag: 0133

Based on observation and interview, the facility failed to maintain two-hour fire barriers between multiple occupancies on one of three building levels.

Findings include:

Observation on April 17, 2025, at 9:40 a.m., revealed the basement fire barrier doors that separate components 01 and 02 lacked positive latching in the frame.

Interview with the maintenance director on April 17, 2025, at 9:40 a.m., confirmed the two-hour fire barrier doors lacked positive latching.

Plan of Correction - To be completed: 05/09/2025

1. Maintenance Director or designee will adjust the door so they close correctly.

2. Maintenance Director or designee will audit Fire Doors to ensure they are in working order weekly x4 weeks then monthly x3 months.

3. Results of the audits will be reported to the QAPI committee for review and further recommendation.

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 01/EAST - Component: 01 - Tag: 0225

Based on observation and interview, the facility failed to maintain exit stair towers on one of three building levels.

Findings include:

Observation on April 17, 2025, at 9:50 a.m., revealed the first floor stair tower door in the foyer leading to basement had a broken latch.

Interview with the maintenance director on April 17, 2025, at 9:50 a.m., confirmed the stair tower door deficiency.

Plan of Correction - To be completed: 05/09/2025

1. Maintenance Director or designee will fix the broken latch.

2. Maintenance Director or designee will audit Fire Doors to ensure it is correct and working weekly x4 weeks then monthly x3 months.

3. Results of the audits will be reported to QAPI committee for review and further recommendation.

Initial comments:Name: BLDG 02/SOUTH BLDG. - Component: 02 - Tag: 0000

Facility ID #200602
Component 02
South Building

Based on a Medicare/Medicaid Recertification Survey completed on April 17, 2025, it was determined that Twinbrook Healthcare and Rehabilitation 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 III (200), unprotected, ordinary building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies - Construction Type:

Observations:
Name: BLDG 02/SOUTH BLDG. - Component: 02 - Tag: 0133

Based on observation and interview, the facility failed to maintain two-hour fire barriers between multiple occupancies on one of three building levels.

Findings include:

Observation on April 17, 2025, at 9:40 a.m., revealed the basement fire barrier doors that separate components 01 and 02 lacked positive latching in the frame.

Interview with the maintenance director on April 17, 2025, at 9:40 a.m., confirmed the two-hour fire barrier doors lacked positive latching.

Plan of Correction - To be completed: 05/09/2025

1. Maintenance Director or designee will adjust the door so they close properly.

2. Maintenance Director or designee will audit Fire Doors to ensure they are in working order weekly x4 weeks then monthly x3 months.

3. Results of the audits will be reported to QAPI committee for review and further recommendation.

NFPA 101 STANDARD Building Construction Type and Height:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

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: BLDG 02/SOUTH BLDG. - Component: 02 - Tag: 0161

Based on observation and interview, the facility failed to maintain building construction type in one of over four rooms.

Findings include:

Observation on April 17, 2025, at 9:35 a.m., revealed the basement water room had missing ceiling tiles, with remaining ceiling tiles showing noticeable signs of water damage.

Interview with the maintenance director on April 17, 2025, at 9:35 a.m., confirmed the area had missing and damaged ceiling tiles.

Plan of Correction - To be completed: 05/09/2025

1. Maintenance Director or designee will replace the tiles that have fallen or are damaged.

2. Maintenance Director or designee will audit tiles to ensure they are correct and in place weekly x4 weeks then monthly x3 months.

3. Results of the audits will be reported to QAPI committee for review and further recommendation.

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: BLDG 02/SOUTH BLDG. - Component: 02 - Tag: 0355

Based on observation and interview, the facility failed to maintain portable fire extinguishers for one of over fifty portable fire extinguishers.

Findings include:

Observation on April 17, 2025, at 9:20 a.m., revealed the first floor activities room had a fire extinguisher that had obstructed access due to a television and storage bins.

Interview with the maintenance director on April 17, 2025, at 9:20 a.m., confirmed the fire extinguisher was obstructed.

Plan of Correction - To be completed: 05/09/2025

1. Maintenance Director or designee will remove any obstructed access.

2. Maintenance Director or designee will audit to ensure it is corrected and in place weekly x4 weeks then monthly x3 months.

3. All staff will be re-educated on fire safety and not obstructing access to fire extinguishers.

4. Results of the audits will be reported to QAPI committee for review and further recommendation.

NFPA 101 STANDARD Electrical Systems - Receptacles:

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: BLDG 02/SOUTH BLDG. - Component: 02 - Tag: 0912

Based on observation and interview, the facility failed to maintain electrical receptacles in one of over twenty rooms.

Findings include:

Observation on April 17, 2025, at 9:29 a.m., revealed the first floor food cart room ice machine receptacle was not protected with a ground fault circuit interrupter (GFCI).

Interview with the maintenance director on April 17, 2025, at 9:29 a.m., confirmed the electrical outlet deficiency.

Plan of Correction - To be completed: 05/09/2025

1. Maintenance Director or designee will replace the outlet for the Ice Machine with a GFCI outlet.

Initial comments:Name: BLDG 03/SOUTHEAST BUILDING - Component: 03 - Tag: 0000

Facility ID #200602
Component 03
South East Building

Based on a Medicare/Medicaid Recertification Survey completed on April 17, 2025, at Twinbrook Healthcare and Rehabilitation Center, it was determined there were no deficiencies identified under the 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, non-combustible building, that is fully sprinklered.

Plan of Correction:

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