Linwood Nursing And Rehabilitation Center

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a

review of clinical records, select facility policy, observations, and staff interviews, it was determined the facility failed to ensure the resident environment was free from potential accident hazards for one out of four nursing units observed (300 Hall), including observations made of one out of 14 residents' rooms (Resident 1).Findings included: A review of facility policy titled Medication Administration Practice Recommendations, last reviewed by the facility on August 14, 2025, revealed it is facility policy that a nurse or qualified staff should stay with the resident until medication has been taken. A clinical record review revealed Resident 1 was admitted to the facility on [DATE REDACTED], with diagnoses that included chronic kidney disease (gradual loss of kidney function). A physician's order for Tylenol tablet 325 mg (acetaminophen-a pain-relieving medication) with directions to give two tablets by mouth every four hours as needed for mild pain was initiated on April 2, 2025. A physician's order for cranberry oral tablet 300 mg, with directions to give one tablet by mouth two times a day for frequent urinary tract infections, initiated on April 16, 2025. A physician's order for oxycodone HCI (hydrochloride) oral tablet 5.0 mg (oxycodone is a schedule II opiate narcotic medication;

the United States Drug Enforcement Administration indicates schedule II drugs are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence; these drugs are also considered dangerous) with directions to administer 5.0 mg by mouth one time a day for chronic pain initiated on May 26, 2025. A clinical record review revealed an evaluation titled Medication Self-Administration Safety Evaluation-CHR (11-2012), dated July 27, 2025. The evaluation indicated Resident 1 was not determined to be safe to self-administer medications. The evaluation documented that Resident 1 required nursing assistance with medication administration and could not state the purpose of each medication, the proper dosage, or the time the medication was to be taken. The evaluation also directed that medications were to be maintained by the nursing department and administered per facility staff.An observation conducted on September 23, 2025, at 9:23 AM, in Resident 1's room revealed five small clear plastic cups on the bedside table, containing a total of seven tablets and two capsules. The medications were unsecured and accessible in an open resident room, allowing potential access by other residents. The presence of multiple medications at the bedside created the risk of accidental consumption by other residents and the risk of Resident 1 consuming medications outside of prescribed parameters.

During an interview on September 23, 2025, at 10:30 AM, the Director of Nursing (DON) confirmed the medications observed included six Tylenol 325 mg tablets, one cranberry 300 mg tablet, and two oxycodone HCl 5.0 mg capsules. The DON also confirmed the oxycodone medication had been distributed from the pharmacy in a capsule form rather than the ordered tablet form. The DON acknowledged it was facility policy that licensed staff remain with residents until medications are ingested 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Linwood Nursing and Rehabilitation Center

100 Florida Avenue Scranton, PA 18505

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited LINWOOD NURSING AND REHABILITATION CENTER in SCRANTON, PA for a deficiency under regulatory tag F-F0757 during a complaint investigation conducted on 2025-09-23.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure each resident’s drug regimen must be free from unnecessary drugs.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 2 deficiencies cited during this inspection of LINWOOD NURSING AND REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-14.