Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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], 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
Page 1 of 3
Event ID:
395717
Printed: 05/15/2026
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
395717
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)
F 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review and staff interview, the facility failed to ensure adequate monitoring of behaviors and
potential adverse consequences prior to administering psychoactive medications for one of 10 residents
reviewed (Resident 2). Findings include: Review of Resident 2's clinical record revealed the resident was
admitted to the facility on [DATE], with diagnoses which included anxiety disorder (a group of symptoms,
such as stress, anxiety, feeling sad or hopeless, and physical symptoms that can occur after you go through
a stressful life event), encephalopathy ( a medical condition characterized by a general dysfunction of the
brain that affects cognitive function, consciousness, and behavior), and chronic pain. Review of a quarterly
Minimum Data Set Assessment (MDS-a federally mandated standardized assessment process completed
at specific intervals to plan resident care) dated April 14, 2025, indicated the resident had a BIMS (brief
interview mental screener that aids in detecting cognitive impairment) score of 15(a score of 13-15
indicates a cognitively intact resident). A review of the clinical record revealed multiple physician orders for
Lorazepam 0.5mg (psychotropic medication used to treat anxiety) The following orders were
documented:April 22, 2025- 0.5 mg every 12 hours for anxiety.May 19, 2025-0.5 mg every 12 hours as
needed (PRN) for anxiety.August 12, 2025-0.5 mg every 12 hours as needed (PRN)for anxiety.August 14,
2025-0.5 mg every 8 hours as needed (PRN)for anxiety. A review of Resident 2's June 2025 Medication
Administration Record (MAR) revealed the resident was administered one dose of as needed (PRN)
Lorazepam 0.5mg on June 4, 2025, at 1:35PM. The facility failed to document the specific behaviors the
resident was exhibiting for the Lorazepam to be administered, and the Documentation Survey Report for
June 2025 noted that the resident was exhibiting no behaviors related to anxiety on that date. A review of
Resident 2's August 2025 MAR revealed the resident received Lorazepam on 13 occasions (August 12-27,
2025) without documented evidence of anxiety-related behaviors or symptoms to justify administration.
Examples include:August 12, 2025, at 10:50 PMAugust 14, 2025, at 9:26 AM and 9:03 PMAugust 15, 2025,
at 9:13 PMAugust 16, 2025, at 9:18 PMAugust 17, 2025, at 6:40 AM and 8:34 PMAugust 18, 2025, at 4:49
AM and 9:02 PMAugust 25, 2025, at 10:06 PMAugust 26, 2025, at 12:21 PM and 11:24 PMAugust 27,
2025, at 9:53 PM An interview with Resident 2 conducted on September 23, 2025, at 12:35 PM revealed
the resident reported frequent pain but denied experiencing anxiety symptoms on the above dates. The
resident stated she did not request Lorazepam and that staff administered it in addition to her pain
medication to help me sleep. Review of Resident 2's MAR confirmed on the following dates the resident
was administered the lorazepam in addition to the prescribed controlled substance (drug which has been
declared by federal or state law to be illegal for sale or use but may be dispensed under a physician's
prescription. The basis for control and regulation is the danger of addiction, abuse, physical and mental
harm including death), pain medication Hydrocodone/Acetaminophen 5/325mg (an opioid pain medication)
without documented indication. Examples include:June 2, 2025 -Hydrocodone/Acetaminophen at 2:00 PM,
25 minutes after Lorazepam was given.August 14, 2025 -Both medications administered at 9:03 PM.August
17, 2025 -Hydrocodone/Acetaminophen at 8:40 PM, 6 minutes after Lorazepam was given.August 25, 2025
-Hydrocodone/Acetaminophen at 10:05 PM, 1 minute before Lorazepam was given.August 26, 2025
-Hydrocodone/Acetaminophen at 11:26 PM, 2 minutes after Lorazepam was given. The above information
documented in the clinical record confirmed Resident 2 was administered a controlled substance pain
medication with the as needed (PRN) lorazepam without proper indication for use, as stated in the resident
interview.Interview with the Director of Nursing on September 23, 2025, at 1:20 PM confirmed the facility
was unable to provide documentation supporting the need for Lorazepam when administered. The DON
acknowledged that monitoring of behaviors and clinical
Residents Affected - Few
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395717
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
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
395717
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)
F 0757
Level of Harm - Minimal harm
or potential for actual harm
indications was not consistently documented. The facility failed to record adequate monitoring for behaviors
and the use of psychoactive medication in combination with opioid medication, with no documented
evidence supporting the need for administration of the lorazepam. 28 Pa. Code 211.12(c)(d)(1)(3)(5)
Nursing services
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395717
If continuation sheet
Page 3 of 3
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
FAQ · About this visit
Common questions about this visit
What happened during the September 23, 2025 survey of LINWOOD NURSING AND REHABILITATION CENTER?
This was a inspection survey of LINWOOD NURSING AND REHABILITATION CENTER on September 23, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LINWOOD NURSING AND REHABILITATION CENTER on September 23, 2025?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.