Pennsylvania Department of Health
LUTHER WOODS NURSING AND REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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LUTHER WOODS NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on a Revisit to an Emergency Preparedness Survey completed on November 19, 2025, it was determined that Luther Woods Nursing And Rehabilitation Center was in substantial compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000
Facility ID# 640302

Component 01

Main Building

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on November 19, 2025, it was determined that Luther Woods Nursing And Rehabilitation Center was not in substantial compliance with the following requirements of the Life Safety Code for an existing Nursing 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 HVAC:

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.

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: MAIN BUILDING 01 - Component: 01 - Tag: 0521 Based on document review, observation, and interview, it was determined the facility failed to maintain the Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting the entire facility. Findings include: 1. Document review on November 19, 2025, at 9:00 am., revealed the facility could not provide a damper inspection report for the previous 12 months. Exit interview with the Administrator and the Maintenance Director on November 19, 2025, at 1:00 p.m., confirmed the missing documentation. 2. Observation on November 19, 2025, at 12:15 p.m., revealed ductwork that was dislodged from the smoke wall, above double doors near the ARMAC Office, C-Wing. Exit interview with the Administrator and the Maintenance Director on November 19, 2025, at 1:00 p.m., confirmed the open ductwork. ******************************************************************************************************************************************************* Based on document review and interview during an onsite Revisit conducted on January 14, 2026 the following was determined: Not Completed. Observation on January 14, 2026, at 9:45 a.m., revealed ductwork that was dislodged from the smoke wall, above double doors near the ARMAC Office, C-Wing. Exit interview with the Administrator and the Maintenance Director on January 14, 2026, at 10:00 a.m., confirmed the open ductwork.

Plan of Correction - To be completed: 02/13/2026

2. Maintenance has called outside vendor to help with the repair of the dislodged duct work. The repair will be completed by 2/12/26. Maintenance will begin inspecting all duct work weekly x 8 and then monthly. The inspections will be logged in the Maintenance Inspection Log Book.

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