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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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CLAREMONT 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 November 17, 2025, at Claremont Nursing &; Rehabilitation Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: A,B,G,H - Component: 01 - Tag: 0000
Facility ID #037602Component 01A, B (Administration), G and H Wings, Tower BuildingBased on a Medicare/Medicaid Recertification Survey completed on November 17, 2025, it was determined that Claremont Nursing &; 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 five-story, Type II (000), unprotected noncombustible structure, with a penthouse, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

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: A,B,G,H - Component: 01 - Tag: 0161 Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire component. Findings include: 1. Observation on November 17, 2025, at 9:00 AM, revealed the component to be a five-story, Type II (000), unprotected noncombustible structure, with a penthouse, which is fully sprinklered. This type of construction is not permitted to be greater than two stories in height. Interview with the Director of Plant Operations on November 17, 2025, at 9:00 AM, confirmed the building construction type was not allowed in Health Care.

Plan of Correction - To be completed: 12/26/2025

The facility requests DSI conduct the FSES for our Construction Type II (000) deficiency.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

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.

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: A,B,G,H - Component: 01 - Tag: 0225 Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of exit stairtower enclosures, affecting one of 13 smoke compartments within the component. Findings include: 1. Observation on November 17, 2025, at 12:44 PM, revealed the door, to the Tower Ground Center Stair, did not positively latch within the frame, due to painter's tape over the strike plate. Interview with the Director of Plant Operations on November 17, 2025, at 12:44 PM, confirmed the stairtower door did not positively latch within the door frame.

Plan of Correction - To be completed: 12/26/2025

The painter's tape covering the latch to the door frame of the Tower Ground Center stair was removed on 11/17/25. Each month Maintenance will conduct an inspection of a portion of the building door latches to ensure they are in proper latching condition. Within a 12 month period the monthly inspections will include the entire building. The Director of Building Services will report the findings of the monthly door inspections to the Quality Assurance Performance Improvement committee.

NFPA 101 STANDARD Travel Distance to Exits:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Travel Distance to Exits
Travel distance (excluding suites) to exits are measured in accordance with 7.6.
* From any point in the room or suite to exit less than or equal to 150 feet (less than or equal to 200 feet if the building is fully sprinklered)
* Point in a room to room door less than or equal to 50 feet
18.2.6, 19.2.6

Observations:
Name: A,B,G,H - Component: 01 - Tag: 0261 Based on observation and interview, it was determined the facility failed to provide smoke compartments, with a travel distance not exceeding 200 feet to an exit, affecting two of thirteen smoke compartments within the component. Findings include: 1. Observation on November 17, 2025, at 2:00 PM, revealed travel distance exceeded 200 feet from the furthest point to reach an exit, within smoke compartments one and two. Interview with the Director of Plant Operations on November 17, 2025, at 2:00 PM, confirmed the travel distance exceeded 200 feet.

Plan of Correction - To be completed: 12/26/2025

The Travel Distance exceeds 200 feet from the furthest point to reach an exit in smoke compartments one and two. The facility would like DSI to conduct the FSES survey.

NFPA 101 STANDARD Hazardous Areas - Enclosure:

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: A,B,G,H - Component: 01 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of hazardous area enclosures, affecting one of 13 smoke compartments within the component. Findings include: 1. Observation on November 17, 2025, at 11:46 AM, revealed the alcove door, to the 3rd floor Zone 11 Soiled Utility Room, failed to positively latch within the door frame, due to cotton within and tape over the strike plate. Interview with the Director of Plant Operations on November 17, 2025, at 11:46 AM, confirmed the door to the hazardous area enclosure did not positively latch within the frame.

Plan of Correction - To be completed: 12/26/2025

The cotton and tape covering the latch to the door frame of the 3rd floor Zone 11 Soiled Utility Room was removed on 11/17/25. All doors in the facility will be inspected to ensure they latch appropriately and that the strike plates are not tampered with. Staff will be educated on the need to maintain smoke resistance by ensuring doors latch appropraitely. Each month Maintenance will conduct an inspection of a portion of the building door latches to ensure they are in proper latching condition. Within a 12 month period the monthly inspections will include the entire building. The Director of Building Services will report the findings of the monthly door inspections to the Quality Assurance Performance Improvement committee.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: A,B,G,H - Component: 01 - Tag: 0353 Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system to be free from extraneous weight, affecting one of 13 smoke compartments within the component. Findings include: 1. Observation on November 17, 2025, at 12:50 PM, revealed a metallic-clad electrical cable, zip-tied to sprinkler piping, at the Receiving Dock, outside the Morgue. Interview with the Director on Plant Operations on November 17, 2025, at 12:50 PM, confirmed the electrical cable was supported by the sprinkler system.

Plan of Correction - To be completed: 12/26/2025

The metallic-clad electrical cable that was zip-tied to the sprinkler piping at the Receiving Dock outside the morgue was adjusted so that it was not zip-tied to the sprinkler pipe on 12/8/25. Maintenance staff will be in-serviced that nothing can be supported from the sprinkler pipes; to look for items that are supported by sprinkler pipes while conducting work above the suspending ceilings; and to remove the items when found. The Director of Building Services will report any sprinkler pipe deficiencies that were found and corrected to the Quality Assurance Performance Improvement committee.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: A,B,G,H - Component: 01 - Tag: 0355 Based on observation and interview, it was determined the facility failed to secure portable fire extinguishers, affecting one of 13 smoke compartments within the component. Findings include: 1. Observation on November 17, 2025, at 1:33 PM, revealed the K-type portable fire extinguisher, located within the Kitchen, was unsecured on a windowsill, approximately 6 feet from the required secondary signage. Interview with the Director of Plant Operations on November 17, 2025, at 1:33 PM, confirmed the portable fire extinguisher was not secured.

Plan of Correction - To be completed: 12/26/2025

The portable K-type fire extinguisher in the kitchen was properly mounted on 12/8/25. An audit of all fire extinguishers was completed on 12/17/25 to ensure they are properly mounted on the wall or in cabinets designed for fire extinguishers. Each month Maintenance staff will conduct an inspection of the fire extinguishers to ensure they are properly mounted on the wall or in cabinets designed for fire extinguishers. The Director of Building Services will report the findings of the monthly fire extinguisher inspections to the Quality Assurance Performance Improvement committee.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:

Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.

Observations:
Name: A,B,G,H - Component: 01 - Tag: 0371 Based on observation and interview, it was determined the facility failed to provide smoke compartments with a travel distance not exceeding 200 feet to a door, in the required smoke barrier, affecting one of thirteen smoke compartments within the component. Findings include: 1. Observation on November 17, 2025, at 2:30 PM, revealed travel distance exceeded 200 feet from the furthest point to reach a door, in the required smoke barrier, within smoke compartment one. Interview with the Director of Plant Operations on November 17, 2025, at 2:30 PM, confirmed the travel distance exceeded 200 feet.

Plan of Correction - To be completed: 12/26/2025

The facility would like DSI to conduct an FSES survey for the travel distance exceeding 200 feet from the furthest point to reach a door in the required smoke barrier, within smoke compartment one.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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.

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: A,B,G,H - Component: 01 - Tag: 0372 Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of smoke barrier walls, affecting four of 13 smoke compartments within the component. Findings include: 1. Observation on November 17, 2025, at 11:32 AM, revealed an unprotected penetration of the 3rd floor smoke barrier wall, located above the suspended ceiling, by the double doors by Resident Room 314, around green, white and blue wires. Interview with the Director of Plant Operations on November 17, 2025, at 11:32 AM, confirmed the unprotected smoke barrier penetration. 2. Observation on November 17, 2025, at 12:00 PM, revealed an unprotected penetration of the 2nd floor smoke barrier wall, located above the suspended ceiling, by Resident Room 215, around green, white and blue wires. Interview with the Director of Plant Operations on November 17, 2025, at 12:00 PM, confirmed the unprotected smoke barrier penetration.

Plan of Correction - To be completed: 12/26/2025

The unsealed penetration hole within the 3rd Floor smoke barrier wall by the double doors near resident room 314 was sealed on 12/8/25 with an approved through penetration fire stop system. The unsealed penetration hole within the 2nd Floor smoke barrier wall near resident room 215 was sealed on 12/8/25 with an approved through penetration fire stop system. Monthly inspections by the Director of Building Services of random smoke / fire barrier walls will be completed to ensure all penetrations are sealed with an approved through penetration fire stop system, thereby maintaining the smoke / fire assembly rating that was approved for that wall assembly per the Life Safety original plans. The Director of Building Services will report the findings of the monthly Smoke / Fire Wall inspections to the Quality Assurance Performance Improvement committee.

NFPA 101 STANDARD Utilities - Gas and Electric:

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Observations:
Name: A,B,G,H - Component: 01 - Tag: 0511 Based on observation and interview, it was determined the facility failed to maintain electrical junction boxes to be secured and covered, affecting one of 13 smoke compartments within the component. Findings include: 1. Observation on November 17, 2025, at 11:20 AM, revealed an open electrical junction box, located beneath the East End air handler, within the Penthouse. Interview with the Director of Plant Operations on November 17, 2025, at 11:20 AM, confirmed the junction box lacked a cover plate.

Plan of Correction - To be completed: 12/26/2025

The open electrical junction box located beneath the East End air handler within the penthouse was repaired on 12/8/25. Maintenance Staff will be in-serviced about looking for electrical deficiencies including missing covers, exposed wires, and open conduits while conducting work. It will include correcting these deficiencies if found as soon as possible. Director of Building Services will report any electrical corrections that were done to the Quality Assurance Performance Improvement committee on a quarterly basis.

NFPA 101 STANDARD Fire Drills:

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: A,B,G,H - Component: 01 - Tag: 0712 Based on document review and interview, it was determined the facility failed to provide documentation verifying staff were subjected to quarterly fire drills, affecting the entire component. Findings include: 1. Review of documentation on November 17, 2025, at 9:45 AM, revealed the facility failed to provide documentation verifying fire drills had been performed since 6/29/2025. Interview with the Director of Plant Operations on November 17, 2025, at 9:45 AM, confirmed the lack of documentation verifying quarterly fire drills had been performed.

Plan of Correction - To be completed: 12/26/2025

The fire drill documentation will now require NHA signature as evidence that the fire drill was conducted and that the fire drill documentation is complete. The facility calendar will have prescheduled dates for the required fire drills to ensure compliance. The Maintenance Director will report the results of the monthly fire drill to the QAPI Committee and the fire drill records will be added to the QAPI Committee meeting minutes.

Initial comments:Name: C & D - Component: 03 - Tag: 0000
Facility ID #037602Component 03C and D WingsBased on a Medicare/Medicaid Recertification Survey completed on November 17, 2025, it was determined that Claremont Nursing &; 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 two-story, Type II (111), protected noncombustible structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Observations:
Name: C & D - Component: 03 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of hazardous area enclosures, affecting one of four smoke compartments within the component. Findings include: 1. Observation on November 17, 2025, at 10:22 AM, revealed the door, to the Soiled Utility Room by Resident Room 86, did not automatically close and latch within the door frame. Interview with the Director of Plant Operations on November 17, 2025, at 10:22 AM, confirmed the hazardous area enclosure door did not automatically close and latch within the frame.

Plan of Correction - To be completed: 12/26/2025

The door to the Soiled Utility Room by resident room 86 was repaired on 12/8/25 so that the door properly latches to the door frame. A facility wide audit of all hazardous area doors in the facility that self-close and latch will be conducted to ensure the doors close and latch automatically. Staff will be educated on the need to maintain smoke resistance by ensuring doors latch appropriately; that all doors on self-closing devices must latch under the power of the closing device without aid by a human; and to report to Maintenance when doors are found to not latch appropriately. Each month Maintenance will conduct an inspection of a portion of the building door latches to ensure they are in proper latching condition. Within a 12 month period the monthly inspections will include the entire building. The Director of Building Services will report the findings of the monthly door inspections to the Quality Assurance Performance Improvement committee.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Observations:
Name: C & D - Component: 03 - Tag: 0353 Based on observation and interview, it was determined the facility failed to maintain hardware components of the automatic sprinkler protection system, affecting one of four smoke compartments within the component. Findings include: 1. Observation on November 17, 2025, at 11:00 AM, revealed a sprinkler head, protecting the Therapy/Rehab Gym, was missing an escutcheon. Interview with the Director of Plant Operations on November 17, 2025, at 11:00 AM, confirmed the sprinkler head lacked an escutcheon.

Plan of Correction - To be completed: 12/26/2025

The escutcheon missing from the sprinkler head protecting the therapy gym was replaced on 12/10/25. Each month Maintenance will conduct an inspection of a portion of the building sprinkler heads to ensure the escutcheons are present. Within a 12 month period the monthly inspections will include the entire building. The Director of Building Services will report the findings of the monthly sprinkler head inspections to the Quality Assurance Performance Improvement committee.

NFPA 101 STANDARD Corridor - Doors:

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: C & D - Component: 03 - Tag: 0363 Based on observation and interview, it was determined the facility failed to maintain the unobstructed closing of corridor doors, affecting one of four smoke compartments within the component. Findings include: 1. Observation on November 17, 2025, at 11:10 AM, revealed the corridor door, to Room R4, was obstructed from closing, by an oxygen concentrator. Interview with the Director of Plant Operations on November 17, 2025, at 11:10 AM, confirmed the corridor door was obstructed from closing.

Plan of Correction - To be completed: 12/26/2025

The oxygen concentrator obstructing the corridor door to room R4 was removed on 11/17/25. Random weekly inspections will be conducted by Maintenance staff to ensure items are not obstructing the corridor doors. Nursing supervisors and staff will be educated on the requirement to keep corridor doors unobstructed at all times, and that doors that are not functioning as intended must be reported to Maintenance staff for repair and not propped open. The Director of Building Services will report the findings of the monthly corridor door inspections to the Quality Assurance Performance Improvement committee.

NFPA 101 STANDARD Fire Drills:

Observations:
Name: C & D - Component: 03 - Tag: 0712 Based on document review and interview, it was determined the facility failed to provide documentation verifying staff were subjected to quarterly fire drills, affecting the entire component. Findings include: 1. Review of documentation on November 17, 2025, at 9:45 AM, revealed the facility failed to provide documentation verifying fire drills had been performed since 6/29/2025. Interview with the Director of Plant Operations on November 17, 2025, at 9:45 AM, confirmed the lack of documentation verifying quarterly fire drills had been performed.

NFPA 101 STANDARD Gas Equipment - Precautions for Handling Oxyg:

Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds
Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99)
11.6.2 (NFPA 99)

Observations:
Name: C & D - Component: 03 - Tag: 0929 Based on observation and interview, it was determined the facility failed to secure portable oxygen cylinders, affecting one of four smoke compartments within the component. Findings include: 1. Observation on November 17, 2025, at 11:04 AM, revealed an unsecured oxygen "E" tank, within the corridor, by Room R17. Interview with the Director of Plant Operations on November 17, 2025, at 11:04 AM, confirmed the unsecured oxygen cylinder.

Plan of Correction - To be completed: 12/26/2025

The unsecured oxygen E-tank within the corridor by room R17 was immediately secured on 11/17/25. Each month Maintenance staff will conduct an inspection of a portion of the building to ensure E-tanks are secured. Within a 12 month period the monthly inspections will include the entire building. Nursing staff will be educated on the requirement to have E-tanks secured at all times. The Director of Building Services will report the findings of the monthly E-tank inspections to the Quality Assurance Performance Improvement committee.

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