Pennsylvania Department of Health
LINWOOD NURSING AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 40 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.


LINWOOD NURSING 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 May 7, 2025, it was determined that Linwood Nursing and Rehabilitation Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(c)(3), 416.54(c)(3), 418.113(c)(3), 441.184(c)(3), 482.15(c)(3), 483.475(c)(3), 483.73(c)(3), 484.102(c)(3), 485.542(c)(3), 485.625(c)(3), 485.68(c)(3), 485.727(c)(3), 485.920(c)(3), 486.360(c)(3), 491.12(c)(3), 494.62(c)(3) STANDARD Primary/Alternate Means for Communication:

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.

§403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3).

[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:

(3) Primary and alternate means for communicating with the following:
(i) [Facility] staff.
(ii) Federal, State, tribal, regional, and local emergency management agencies.

*[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies.

Observations:
Name: - Component: -- - Tag: 0032

Based on documentation and interview, it was determined the facility failed to provide an alternate means of communication, affecting two of two floors.

Findings include:

1. Observation on May 7, 2025, at 12:05 p.m., revealed the facility lacked an alternate means of communication.

Exit interview on May 7, 2025, between 12:10 p.m., and 12:15 p.m., with the Facility Administrator and the Facilities Manager, confirmed the lack of an alternate means of communication.

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

The facility has ordered an alternate communication device for first (1st) and second (2nd) floor to ensure adequate communication in the event of an emergency.

No residents were affected.

The NHA/designee will in-service the facility staff regarding the placement and use of the communication device.

The Maintenance director/designee will audit the communication devices 1x/month for 2 months to ensure placement and function are adequate.

The results of the audit will be presented to the Quality Assurance Committee for review and recommendations.

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

Facility ID# 394502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 7, 2025, it was determined that Linwood Nursing 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 483.70(a).

This is a one story, Type V (000), unprotected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

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.

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 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain one stair tower enclosure, affecting two of two floors.

Findings include:

1. Observation on May 7, 2025, at 11:40 a.m., revealed storage items were located within the first floor portion of the number 2 stair tower enclosure.

Exit interview on May 7, 2025, between 12:20 p.m., and 12:30 p.m., with the Facilities Manager and the Facility Administrator, confirmed the stair tower enclosure deficiency.

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

The items being stored in the stairwell (1st floor #2) were removed immediately.

No other stairwells were affected.

The NHA/designee will in-service the staff regarding the storage of items in the stairwells

The maintenance director/designee will audit the stairwells 3x/week for 4 weeks, then 1x/week for 4 weeks then 1x/month for 2 months to ensure there are no items in the stairwells.

The results of the audit will be presented to the Quality Assurance Committee for review and recommendations.

NFPA 101 STANDARD Corridor - Doors:

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 one corridor opening, affecting one of one floor.

Findings include:

1. Observation on May 7, 2025, at 11:07 a.m., revealed the distance between the Dining Room doors exceeded one-eighth-inch.

Exit interview on May 7, 2025, between 12:20 p.m., and 12:30 p.m., with the Facilities Manager and the Facility Administrator, confirmed the corridor opening deficiency.

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

The dining room door gap has been repaired and is smoke tight per NFPA standards.

No other doors were affected.

The Maintenance Director/designee will monitor the dining room doors 1x/month for 2 months to ensure the gap between the doors does not exceed 1/8 inch.

The results of the audit will be presented to the Quality Assurance Committee for review and recommendations.

Initial comments:Name: TWO STORY ADDITION - Component: 03 - Tag: 0000

Facility ID# 394502
Component 03
New Replacement Component

Based on a Medicare/Medicaid Recertification Survey completed on May 7, 2025, it was determined that Linwood Nursing and Rehabilitation Center, was not in compliance with the following requirements of the Life Safety Code for a new health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.70(a).

This is a two story, Type II (111), protected, noncombustible building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Corridor - Doors:

Doors protecting corridor openings shall be constructed to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have self-latching and 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 18.3.6.3.6 are permitted.

18.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatic closing devices, etc.

Observations:
Name: TWO STORY ADDITION - Component: 03 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain one corridor opening, affecting one of two floors.

Findings include:

1. Observation on May 7, 2025, at 11:57 a.m., revealed a penetration of the second floor, Medication Room door.

Exit interview on May 7, 2025, between 12:20 p.m., and 12:30 p.m., with the Facilities Manager and the Facility Administrator, confirmed the corridor opening deficiency.

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

The penetration in the 2nd floor medication room door has been sealed.

No other medication room doors were affected.

The Maintenance Director/designee will audit the medication room door 1x/month for 2 months to ensure there are no penetrations.

The results of the audit will be presented to the Quality Assurance Committee for review and recommendations.

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