Pennsylvania Department of Health
 CARLISLE SKILLED NURSING AND REHABILITATION CENTER
Building Inspection Results

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CARLISLE SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  38 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.
CARLISLE SKILLED NURSING AND 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 July 29, 2024, at Carlisle Skilled 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 - Component: 01 - Tag: 0000


Facility ID #392802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on July 29, 2024, it was determined that Carlisle Skilled 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(000), unprotected wood frame structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Exit Signage: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.
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0293

Based on observation and interview, it was determined the facility failed to maintain exit signs to be displayed with continuous illumination, affecting two of six smoke compartments within the component.

Findings include:

1. Observation on July 29, 2024, at 11:20 AM, revealed that exit signs above the West Corridor double smoke door, by the Resident Lounge, had only one of two bulbs lit.

Interview with the Director of Maintenance on July 29, 2024, at 11:20 AM, confirmed one of the two bulbs in the exit signs was not lit.


 Plan of Correction - To be completed: 08/14/2024

Maintenance Director replaced the bulb in exit sign.

Maintenance Director or Designee will complete weekly audits for one month then monthly thereafter.
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 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors to be within the allowed gap margins, and to self-close, in three of six smoke compartments within the component.

Findings include:

1. Observation on July 29, 2024, at 11:22 AM, revealed the West Wing Lounge was being used for storage and the door lacked a closure.

Interview with the Director of Maintenance at July 29, 2024, at 11:22 AM, confirmed the room was us for storage and the door lacked a closure.


2. Observation on July 29, 2024, between 12:10 PM and 12:30 PM, revealed rated doors did not meet the required 1/8 inch or less gap, at the following locations:

a. 12:10 PM, the C Hall Storage;
b. 12:30 PM, the Arcardia Storage Room.

Interview with the Director of Maintenance at July 29, 2024, at 12:30 PM, confirmed the rated door gaps were greater than 1/8 inch.




 Plan of Correction - To be completed: 09/17/2024

Maintenance Director removed PPE being stored on the West Wing Lounge and moved to supply room.

Maintenance Director repaired gap margin on Main Hall Janitor's closet to meet the allowable gap margin.

Maintenance Director or Designee will complete an audit on hazardous area doors to be within allowable gap margins. Audits will be completed monthly thereafter. Findings will be reported the QAPI for recommendations and the need for further audits.
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 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain unobstructed closing of corridor doors, in one of six smoke compartments within the component.

Findings include:

1. Observation on July 29, 2024, at 12:00 PM, revealed the corridor door to Resident Rooms 133 and 135 were hitting the frame and not closing and latching.

Interview with the Director of Maintenance on July 29, 2024, at 12:00 PM, confirmed the doors did not latch.


 Plan of Correction - To be completed: 09/17/2024

Maintenance Director repaired gap margin on corridor door to Resident Rooms 133 and 135 to ensure it does not hit the frame and will close and latch.

Maintenance Director or Designee will complete an audit on hazardous area doors to be within appropiate close/latch.

Audits will be completed monthly thereafter. Findings will be reported the QAPI for recommendations and the need for further audits.
NFPA 101 STANDARD Soiled Linen and Trash Containers: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.
Soiled Linen and Trash Containers
Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended.
Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent.
18.7.5.7, 19.7.5.7
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0754

Based on observation and interview, it was determined the facility failed to maintain soiled-linen/trash containers were stored in a protected area, in one of six smoke compartments within the component.

Findings include:

1. Observation on July 29, 2024, at 12:50 PM, revealed 4 soiled-linen/trash containers were being stored in the D Hall Shower Room.

Interview with the Director of Maintenance on July 29, 2024, at 12:50 PM, confirmed the soiled-linen/trash containers were not being stored in a rated assembly.


 Plan of Correction - To be completed: 09/17/2024

The soiled-linen container in shower room was removed.


Audit will be completed monthly by Maintenance Director Designee and reported at QAPI for 3 months, then quarterly for a year.

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