Pennsylvania Department of Health
CARBONDALE NURSING & REHABILITATION CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CARBONDALE NURSING & REHABILITATION CENTER
Inspection Results For:

There are 101 surveys for this facility. Please select a date to view the survey results.

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CARBONDALE NURSING & REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance, and State Revisit survey completed on May 1, 2025, it was determined that Carbondale Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(f)(10(i)(ii) REQUIREMENT Protection/Management of Personal Funds:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

§483.10(f)(10) The resident has a right to manage his or her financial affairs. This includes the right to know, in advance, what charges a facility may impose against a resident's personal funds.
(i) The facility must not require residents to deposit their personal funds with the facility. If a resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility, as specified in this section.
(ii) Deposit of Funds.
(A) In general: Except as set out in paragraph (f)( l0)(ii)(B) of this section, the facility must deposit any residents' personal funds in excess of $100 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain a resident's personal funds that do not exceed $100 in a non-interest bearing account, interest-bearing account, or petty cash fund.
(B) Residents whose care is funded by Medicaid: The facility must deposit the residents' personal funds in excess of $50 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain personal funds that do not exceed $50 in a noninterest bearing account, interest-bearing account, or petty cash fund.

Observations:

Based on a review of clinical records, resident financial documentation, and staff interview, it was determined the facility failed to safeguard, manage, and accurately account for the personal funds of one resident (Resident 40) out of 23 residents reviewed

Findings include:

A clinical record review revealed Resident 40 was admitted to the facility on August 17, 2019, with diagnoses that included malignant neoplasm of the lung (an abnormal growth of cells characterized by uncontrolled and rapid growth, invasion of surrounding tissues, and the potential to spread to other areas of the body).

A clinical record review revealed Resident 40's payor source is Medicaid (a joint federal and state program that helps cover medical costs for some people with limited income and resources. Individuals on Medicaid receive a Personal Needs Allowance- a monthly stipend to cover personal expenses. As of January 1, 2025, the PNA for Pennsylvania is $60 for residents residing in long-term care facilities).

A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 5, 2025, revealed that Resident 40 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

During an interview conducted on April 29, 2025, at 12:30 PM, Resident 40 stated he was upset about a charge of $6,092 that appeared on his March 2025 financial statement. He explained that the facility managed his personal funds and presented a copy of the resident fund ledger showing a care cost deduction of $6,092 on March 14, 2025.

Review of Resident 40's resident fund ledger from December 1, 2024, through April 28, 2025, revealed the following charges for care costs totaling $10,025:
December 2024: $324
January 2025: $0
February 2025: $0
March 2025: $7,712
April 2025: $1,989

Resident 40's income from Social Security and pension benefits totaled $10,210 during the same period:
December 2024: $2,014
January 2025: $2,049
February 2025: $2,049
March 2025: $2,049
April 2025: $2,049

According to Pennsylvania Medicaid requirements, the facility was responsible for deducting only the monthly care cost balance after applying the PNA (personal needs allowance-$45.00 before January 2025 and $60.00 after January 2025). Based on the resident's monthly income, the proper care cost charges from January 1, 2025, through April 28, 2025, should have been:

December 2024: $2,014 - $45 = $1,969
January 2025: $2,049 - $60 = $1,989
February 2025: $2,049 - $60 = $1,989
March 2025: $2,049 - $60 = $1,989
April 2025: $2,049 - $60 = $1,989

Resident 40 should have been charged $1,989 each month from January 2025 through April 2025 and charged $1,969 in December 2024, totaling $9,925.

A review of credits Resident 40 received from Social Security and his pension ($10,210) and calculating for the personal needs allowance for Pennsylvania ($285) it was determined the facility over charged the resident by $100.00.

During an interview on May 1, 2025, at approximately 9:00 AM, the Nursing Home Administrator (NHA) confirmed Resident 40 was overcharged due to billing errors. The NHA confirmed it is the facility's responsibility to safeguard, manage, and accurately account for residents' personal funds deposited with the facility. The NHA indicated Resident 40 would be reimbursed for the overcharge.

28 Pa. Code 201.14(b) Responsibility of licensee.

28 Pa. Code 201.18(b)(2) Management.

28 Pa. Code 201.29(a) Resident rights.

Plan of Correction - To be completed: 05/28/2025

The error noted on Resident 40's account has been identified, and resident was refunded the amount owed immediately. The facility has reviewed all Medicaid patients' personal needs allowance (PNA) and adjusted to the appropriate $60.00 per January 1st, 2025, requirements. All accounts noted to be in error have been rectified immediately. All patients and/or responsible parties have received updated statements of accounts per request. Education was provided to the new business office manager on the facilities RFMS policy.
A weekly internal audit on all Medicaid patients with payer changes noted throughout the week will be reviewed, adjusted, and corrected. All accounts noted to have an incorrect balance will be immediately adjusted and refunded the amount owed. Ongoing weekly audits will continue for the next two months to ensure accuracy in billing and reimbursement for all MA patients. The administrator will review the monthly billing with business office manager to ensure compliance with same.
Weekly audits will be implemented and discussed in the facilities monthly/quarterly QAPI meetings and reviewed by the business office manager as well as the Administrator for the first four weeks and then monthly for two months.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on a review of clinical records and select facility policy, observations, and staff interviews, it was determined the facility failed to consistently implement measures planned to promote healing, prevent worsening, and the development of pressure sores for one resident out of 23 residents sampled (Resident 57).

Findings include:

According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: comprehensive skin assessment, standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk.

The American College of Physicians (ACP) is a national organization of internists who specialize in the diagnosis, treatment, and care of adults. The largest medical specialty organization and second-largest physician group in the United States, Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning, and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement, and wound cleansing; using adjunctive therapies; and considering possible surgical repair.

Review of the facility policy entitled "Pressure Injury Prevention and Management", last reviewed January 10, 2025, indicated the facility will provide interventions for prevention and to promote healing in accordance with evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to, redistributing pressure (such as repositioning, protecting, and/or offloading heels, etc.) and providing appropriate, pressure-redistributing support surfaces.

Further review of the policy revealed the facility will provide interventions for prevention to promote healing in accordance with current standards of practice and will be provided for all residents who have a pressure injury present. The goals and preferences of the resident and/or authorized representative will be included in the plan of care, interventions will be documented in the care plan and communicated to all relevant staff, and compliance with interventions will be documented in the weekly summary charting.

A review of the clinical record revealed that Resident 57 was admitted to the facility on August 20, 2024, with diagnoses that included diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet).

A quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) of Resident 57 dated April 10, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 03 (brief interview for mental status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment) and revealed the resident was dependent on staff for activities of daily living of putting on/taking off footwear and was at risk for pressure sore development.

A review of the resident's care plan, initiated July 18, 2024, and last revised April 28, 2025, revealed a problem focus of "risk for skin breakdown and actual impairment to the right heel related to fragile skin and decreased mobility." Planned interventions included use of heel-lift boots at all times (removable only during care), a pro-mat plus air mattress to bed, and a pressure redistribution cushion for the chair.

Physician orders dated November 12, 2024, directed the use of heel-lift boots at all times, allowing removal only for care.

A skin integrity wound assessment dated April 24, 2025, revealed the presence of a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) on the resident's right heel, measuring 0.3 cm (length) x 0.6 cm (width) x 0.2 cm (depth), with 50% slough (yellow/white necrotic tissue) and 50% granulation tissue (new connective tissue) and moderate serous drainage (clear or pale-yellow fluid similar to blood plasma).

An observation of Resident 57 on April 29, 2025, at approximately 10:35 AM revealed the resident was in the activity hall wearing purple slippers and was identified by Employee 1 (Licensed Practical Nurse). An observation of her room revealed heel-lift boots lying on top of the Pro-mat mattress, not on the resident.

A review of the resident's task report (a record of staff-documented care tasks) from April 29, 2025, indicated the heel-lift boots were documented as being on the resident, with no documentation of refusals noted.

A second observation on April 30, 2025, at 10:50 AM revealed the resident sitting in her wheelchair in her room again without heel-lift boots and wearing purple slippers. At the time of the surveyor's observation, a nurse aide applied the heel-lift boots to the resident. An interview with Employee 1 (LPN) at that time confirmed the resident often removes the boots, stating: "She kicks them off, and when she does, we just put the purple slippers on her."

Further clinical review on April 30, 2025, revealed no documentation in the care plan regarding refusal of heel-lift boots, nor documentation of staff interventions to address such refusals. Additionally, the task report for April 30, 2025, indicated the heel-lift boots were on the resident at 9:05 AM, despite observations proving otherwise.

During an interview with the Director of Nursing (DON) on April 30, at 1:10 PM, it was confirmed the facility did not consistently implement the planned interventions to promote healing or prevent the progression of the right heel pressure ulcer for Resident 57.

28 Pa. Code 201.18(b)(1) Management

28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 05/28/2025

The care plan for resident 57 has been updated accordingly to document the occasional refusal or removal of heel lift boots. Patient prefers her purple slippers as purple is her favorite color, the facility has purchased purple heel lift boots for resident to utilize for pressure relief while in and out of bed, with patient agreeable at this time. Care plan updated to reflect same. Additional heel protector cushions will be offered to resident 57 while in bed when refusal of heel lift boots is noted. An audit of all residents preventive measures and redistribution devices has been conducted to ensure proper interventions/devices are in place and residents care plan reflects same.
Nursing staff will be provided with education on the facilities policy on pressure injury prevention and management. Weekly audits will be conducted by the DON/nurse managers/supervisors to ensure interventions are in place, monitored, and care planned appropriately. All audits will continue until compliance is noted with same.
Findings of audits will be reported and discussed in the facilities Monthly/Quarterly QAPI meetings to ensure continued compliance with the facilities pressure injury prevention and management policy.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Plan of Correction - To be completed: 05/28/2025

Employee 3 was provided with clinical practice/education on improper/timely documentation of restorative ambulation programs. Resident 40 was ambulated 50ft per RNP order with CNAs after interview with state official was conducted. The facility will ensure that all residents with restorative ambulation programs are implemented and documented appropriately moving forward. All residents on ambulation restorative program have been audited to ensure plan of care is accurate.
Education will be provided to all nursing staff on the facilities policy on restorative nursing program and restorative nursing documentation. Weekly audits will be conducted and reviewed by the DON/nurse managers/nurse supervisors to ensure the ambulation RNP was completed per individual resident's care plan as well as refusal of same if applicable. Results of audits will be discussed and reviewed at the facilities monthly/ quarterly QAPI meetings. Audits will continue until compliance with same is noted.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on observation, review of select facility policy, and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and in two of two resident pantries.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

Review of a facility policy titled "Use and Storage of Food Brought in by Family or Visitors", last reviewed on February 10, 2025, indicated food must be handled in a way to ensure the safety of the resident. The facility may refrigerate, label, and date prepared items in nourishment refrigerator and that food must be consumed by the resident within 3-days.

Observation during the initial tour of the kitchen with the facility's registered dietitian on April 29, 2025, at 9:40 AM, revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness:

There was a heavy build-up of a black substance along the wall located under the soiled side (area where dirty dishes are slid into the dishwasher) counter space of the dishwasher.

There was a build-up of debris under the ceiling light shield located in the janitor's closet.

Interview with the registered dietitian at this time confirmed the kitchen was to be maintained in a clean and sanitary manner.

An observation on April 29, 2025, at 11:13 AM, in the Nursing B Hall Pantry, revealed a resident food refrigerator/freezer with 5 plastic undated and unmarked containers with resident food. The refrigerator also contained the following items that were also not dated: a stick of butter wrapped in plastic, a piece of white bread in a plastic bag, a vanilla ice cream sundae with caramel, and an ice cream tub.

During an interview on April 29, 2025, at 11:15 AM, Employee 2, Registered Nurse (RN), confirmed the food items identified during the observation were not dated. Employee 2, RN, explained that facility staff should date all food items when opened or received by residents or residents' families.

Observation of the A Hall Nursing Unit resident pantry on April 30, 2025, at 1:30 PM revealed there was a build-up of a black substance on the end of the condensation hose (removes excess water from the ice machine) of the ice machine.

Observation of the B Hall Nursing Unit resident pantry on May 1, 2025, at 9:20 AM revealed a build-up of a wet black substance on the end of the condensation hose of the ice machine.

Interview with the maintenance director on May 1, 2025, at 9:25 AM confirmed that the ice machines, including the condensation hoses of the ice machines, were not cleaned and sanitized frequently enough to prevent the build-up of the black substance.

28 Pa. Code 201.18 (e) (2.1) Management

Plan of Correction - To be completed: 05/28/2025

Heavy build up of black substance noted on wall under soiled side of dishwasher in kitchen was immediately removed, cleaned, and sanitized upon discovery. Debris noted under the ceiling light located in janitor's closet was also immediately removed and cleaned upon discovery. All items in pantries that were found to be opened without proper labeling were immediately discarded. Black substance on the end of condensation hose of the ice machines in both pantries were immediately cleaned and sanitized by maintenance upon discovery. An initial audit was completed in the kitchen and pantry to ensure all other areas were in compliance, with no further concerns noted.
Nursing staff will be educated on the facilities policy on use and storage of food brought in by the family or visitors and weekly audits will be conducted of each pantry to ensure all items are properly labeled and dated by the DON/nurse managers/ nurse supervisors. Kitchen staff will be educated on the facilities policy for food safety requirements which include sanitizing areas used for dishwashing. Weekly audits will be conducted by the administrator to ensure the area under dishwasher and ceiling lights in the kitchen are free from any build up or debris. Cleaning and sanitizing of the ice machines in both pantries will be added to the routine maintenance monthly checklist in TELS system to ensure proper sanitization per ice machine manufacturer. Education will be provided to maintenance on same.
All audits will be reviewed and discussed at the facilities monthly/Quarterly QAPI meetings to ensure compliance with the above. Audits will continue until compliance with same is noted.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Plan of Correction - To be completed: 05/28/2025

The facility cannot retroactively correct past ratios for night shift. Deployment sheets continue to be reviewed in advance of upcoming shifts to ensure sufficient staff are scheduled for PPD/ratios. Best efforts continue to be made to recruit and retain employees for all shifts. The facility is completing wage reviews and initiated agency nursing staff to assist with meeting nursing ratios. Facility continues with employments ads on all hiring platforms.
Education provided to nurse scheduler and Director of Nursing on staffing ratios. Nurse manager and nurse scheduler will notify administration/designee when staffing ratios fall below minimum staff ratio. The administrator/DON will conduct random weekly audits to ensure staffing ratios are met.
The results of the audits will be reviewed and discussed at the facilities monthly/quarterly QAPI meetings. Audits will continue until compliance with same is noted.

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