Pennsylvania Department of Health
CARBONDALE NURSING & REHABILITATION CENTER
Building Inspection Results

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CARBONDALE NURSING & REHABILITATION CENTER
Inspection Results For:

There are  39 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.
CARBONDALE NURSING & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on May 27, 2025, at Carbondale Nursing and Rehabilitation Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


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


Facility ID# 030702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 27, 2025, it was determined that Carbondale Nursing and Rehabilitation Center was not in compliance with the following requirements of the Life Safety Code for an existing 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 V (111), protected, wood frame building, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in one location, affecting one of one floor.

Findings include:

1. Observation on May 27, 2025, at 12:02 p.m., revealed a penetration of the rated ceiling assembly, located at the exhaust duct work, within the 300 Side Mechanical Room.

Exit interview with the Facility Administrator and the Facilities Manager between 1:10 p.m., and 1:15 p.m., on May 27, 2025, confirmed the building construction deficiency.



 Plan of Correction - To be completed: 06/30/2025

1.The penetration of the rated ceiling assembly, located at the exhaust duct work within the 300 side Mechanical room, has been repaired and sealed with a fire rated caulk per code.
2.Maintenance will be educated on the need to ensure there are no penetrations of the rated ceilings throughout the facility.
3. An audit will be conducted on monthly safety rounds to ensure that no penetrations are noted. Results of the audit will be presented to the monthly QAPI committee for review and recommendations.

NFPA 101 STANDARD Hazardous Areas - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain two hazardous area enclosures, affecting one of one floor.

Findings include:

1. Observation on May 27, 2025, between 11:44 a.m., and 12:24 p.m., revealed the following:

a. 11:44 a.m., The B Wing Soiled Utility Room door was not smoke-tight.
b. 12:24 p.m., the Laundry Room door was held open by unapproved means (rope).

Exit interview with the Facility Administrator and the Facilities Manager between 1:10 p.m., and 1:15 p.m., on May 27, 2025, confirmed the hazardous area enclosure deficiencies.



 Plan of Correction - To be completed: 06/30/2025

1.The B wing soiled utility room door has been fixed and is now smoke-tight per code.
2.Unapproved means that was holding door open was immediately removed from door in laundry room.
3.Education has been provided to the housekeeping/laundry staff on not holding open doors for any reason.
4.Maintenance will be in serviced on maintaining smoke-tight doors per regulations.
5.Random audits will be conducted monthly to ensure all doors remain smoke tight and results of audit will be presented and discussed at the facilities QAPI meetings monthly.
6.Random audits will be conducted weekly to ensure no doors are held open throughout the facility. Results of the audit will be presents and discussed at the facilities QAPI meetings held monthly.

NFPA 101 STANDARD Corridor - Doors:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. 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: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain four corridor openings, affecting one of one floor.

Findings include:

1. Observation on May 27, 2025, between 11:39 a.m., and 12:39 p.m., revealed the following:

a. 11:39 a.m., the 400 Hall Clean Utility Room door was not smoke-tight.
b. 11:43 a.m., the 300 Hall Clean Utility Room door was not smoke-tight.
c. 12:36 p.m., the Resident Room 202 door required adjustment to fully latch.
d. 12:39 p.m., the A Wing Medication Room door was not smoke-tight.

Exit interview with the Facility Administrator and the Facilities Manager between 1:10 p.m., and 1:15 p.m., on May 27, 2025, confirmed the corridor opening deficiencies.



 Plan of Correction - To be completed: 06/30/2025

1.The 400 hall clean utility room door has been fixed and is now smoke-tight according to code.
2.The 300 hall clean utility room door has been fixed and is now smoke-tight according to code.
3.The resident door in 202 has been adjusted and the door is able to fully latch to meet code.
4.The A wing medication room door has been fixed and is now smoke-tight according to code.
5.Maintenance will be in serviced on maintaining smoke-tight doors per regulations and fully latching doors.
6.Random audits will be conducted monthly to ensure all doors remain smoke tight and results of audit will be presented and discussed at the facilities QAPI meetings monthly.

Initial comments:Name: THERAPY ADDITION - Component: 02 - Tag: 0000


Facility ID# 030702
Component 02
Therapy Building

Based on a Medicare/Medicaid Recertification Survey completed on May 27, 2025, at Carbondale Nursing and Rehabilitation Center, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing 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 V (111), protected, wood frame building, that is fully sprinklered.




 Plan of Correction:



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