Pennsylvania Department of Health
AMOROSO HEALTHCARE AND REHABILITATION WOODRIDGE
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 48 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.


AMOROSO HEALTHCARE AND REHABILITATION WOODRIDGE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Facility ID #022002
Component 01
Main Building

Based on a Relicensure Survey completed on October 28, 2025, it was determined that Amoroso Healthcare and Rehabilitation Woodridge was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a one-story, Type III (200), unprotected ordinary structure, which is fully sprinklered.

Plan of Correction:

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 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of exit stairtower enclosures, affecting one of three smoke compartments within the component.

Findings include:

1. Observation on October 28, 2025, at 11:10 AM, revealed an unprotected penetration of the Basement Stairtower, located above the suspended ceiling, around a group of red wires, above the fire alarm manual pull station.

Interview with the Maintenance Director on October 28, 2025, at 11:10 AM, confirmed the unprotected penetration of the exit stairtower enclosure.

Plan of Correction - To be completed: 12/09/2025

1. Maintenance Director was educated by the NHA on the need to have penetrations protected on 11/7/25 to maintain the rating of the stair towers.
2. The Maintenance Director did protect the penetration with an approved through penetration fire stop system on 10/30/25 to maintain the rating of the stair towers.
3. The maintenance director will follow any construction that is completed in the facility to ensure that any penetrations are protected to maintain the rating of the stair towers Results to be reviewed withe the QAPI committee.
4. Compliance by 12/9/25.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0345

Based on observation and interview, it was determined the facility failed to maintain the installation of smoke detectors, affecting one of three smoke compartments within the component.

Findings include:

1. Observation on October 28, 2025, at 10:53 AM, revealed the smoke detector within the basement Rear Dryer Room was disconnected from its mounting bracket and suspended from internal wiring.

Interview with the Maintenance Director on October 28, 2025, at 10:53 AM, confirmed the smoke detector was suspended from internal wiring.

Plan of Correction - To be completed: 12/09/2025

1. Maintenance director was educated by the NHA on the need for the smoke detectors to be secured to its mounting on 11/7/25.
2. The Maintenance director did secure the smoke detector to its mounting on 10/29/25.
3. Maintenance director to QA 5 smoke detectors in the facility weekly x 4 weeks then monthly to ensure that they are mounted securely. Results to be reviewed with the QAPI committee.
4. Compliance by 12/9/25.

Initial comments:Name: NEW BUILDING - Component: 02 - Tag: 0000

Facility ID #022002
Component 02
New Building

Based on a Relicensure Survey completed on October 28, 2025, it was determined that Amoroso Healthcare and Rehabilitation Woodridge was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a one-story, Type II (000), unprotected noncombustible structure, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Spinkler System - Installation:

Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Observations:
Name: NEW BUILDING - Component: 02 - Tag: 0351

Based on observation and interview, it was determined the facility failed to install sprinkler heads of consistent thermal sensitivity, affecting one of three smoke compartments within the component.

Findings include:

1. Observation on October 28, 2025, at 12:05 PM, revealed one quick response and one standard response sprinkler head, installed on a level plane with each other, located within Resident Room 106.

Interview with the Maintenance Director on October 28, 2025, at 12:05 PM, confirmed the inconsistent thermal sensitivity of sprinkler heads protecting the same area.

Plan of Correction - To be completed: 12/09/2025

1. Maintenance Director educated on sprinkler heads with consistent thermal sensitivity need to be in a smoke compartment on 11/7/25.
2. Johnson Control replaced the standard sprinkler head with quick response sprinkler head on 10/31/25.
3. Maintenance Director will QA 5 smoke compartments weekly then monthly to ensure that they have the consistent thermal sensitivity. Results to be reviewed with the QAPI committee.
4. Compliance by 12/9/25.

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
2012 EXISTING
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.
There is no impediment to the closing of the doors. Clearance between bottom of door and floor covering is not exceeding 1 inch. Roller latches are prohibited by CMS regulations on corridor doors and rooms containing flammable or combustible materials. Powered doors complying with 7.2.1.9 are permissible. 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: NEW BUILDING - Component: 02 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain the positive latching of corridor doors, affecting one of three smoke compartments within the component.

Findings include:

1. Observation on October 28, 2025, at 11:50 AM, revealed the door to the Unit 2 Storage Room, by the Nurses' Station, failed to positively latch within the door frame.

Interview with the Maintenance Director on October 28, 2025, at 11:50 AM, confirmed the corridor door did not latch within the frame.

Plan of Correction - To be completed: 12/09/2025

1. Maintenance Director was educated by the NHA regarding the need for the corridor doors to have positive latching.
2. Maintenance Director repaired the door on unit 2 storage room to allow for positive latching on 10/29/25.
3. Maintenance Director to QA 5 corridor doors weekly for 4 weeks then monthly to ensure that they positive latch. Results to be reviewed with the QAPI committee.
4. Compliance by 12/9/25.

NFPA 101 STANDARD Utilities - Gas and Electric:

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Observations:
Name: NEW BUILDING - Component: 02 - Tag: 0511

Based on observation and interview, it was determined the facility failed to maintain access to electrical panels as restricted to authorized users only, affecting the entire component.

Findings include:

1. Observation on October 28, 2025, at 11:55 AM, revealed two electrical panels, located within the corridor wall next to the Director of Nursing's Office, were unlocked and accessible to visitors and residents.

Interview with the Maintenance Director on October 28, 2025, at 11:55 AM, confirmed the electrical panels were accessible to unauthorized users.

Plan of Correction - To be completed: 12/09/2025

1. Maintenance Director was educated by the NHA on 11/7/25 regarding the need for the electrical panel doors to be locked to prevent access from residents and visitors.
2. Maintenance Director did lock the electrical panels between the DON's office and NHA's office on 10/29/25.
3. Maintenance Director will QA the electrical panels weekly for 4 weeks then monthly to ensure that the electrical panel doors are locked. Results to be reviewed with the QAPI committee.
4. Compliance by 12/9/25.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu:

Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82

Observations:
Name: NEW BUILDING - Component: 02 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of soiled-linen chute enclosures, affecting one of three smoke compartments within the component.

Findings include:

1. Observation on October 28, 2025, at 12:00 PM, revealed the access panel, to the ground floor Linen Chute, was propped open with a wooden chock.

Interview with the Maintenance Director on October 28, 2025, at 12:00 PM, confirmed the access panel door did not automatically close and latch within the frame, and therefore compromised the fire resistance rating of the enclosure.

Plan of Correction - To be completed: 12/09/2025

1. NHA educated the maintenance director and the floor on 11/7/25 on the need for the laundry chute door not to be propped opened.
2. The maintenance director repaired the laundry chute door so it was not propped opened on 10/29/25.
3. The maintenance director will QA the laundry chute door weekly for 4 weeks then monthly to ensure that the door is not propped opened. Results to be reviewed by the QAPI committee.
4. Compliance by 12/9/25.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright � 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement