Pennsylvania Department of Health
CAPITOL REHABILITATION AND HEALTHCARE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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CAPITOL REHABILITATION AND HEALTHCARE 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 24, 2025, at Capitol Rehabilitation and Healthcare 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 #102002Component 01Main BuildingBased on a Medicare/Medicaid Recertification Survey completed on November 24, 2025, it was determined that Capitol Rehabilitation and Healthcare 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 II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies:

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.

Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0131 Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of common walls to non-conforming buildings, affecting one of ten smoke compartments within the component. Findings include: 1. Observation on November 24, 2025, at 12:30 PM, revealed the fire exit hardware, installed on the double doors within the building separating common wall, were missing hardware components and not complete. Interview with the Maintenance Director on November 24, 2025, at 12:30 PM, confirmed the compromised fire resistance rating of the building separating wall.

Plan of Correction - To be completed: 01/13/2026

1. The fire exit hardware will be installed on the double doors within the building separating the common wall.
2. The Plant Operations staff will be educated on the need for completeness and installation of fire exit hardware.
3. Five random audits will be completed weekly for four weeks then monthly for three months and then quarterly for a full year on the installation and completeness of fire exit hardware. All audits will be shared with the QAPI committee for further recommendations.

NFPA 101 STANDARD Fire Alarm System - Installation:

Fire Alarm System - Installation
A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity.
18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0341 Based on observation and interview, it was determined the facility failed to install manual fire alarm pull stations within five feet of exterior exit doors, affecting one of ten smoke compartments within the component. Findings include: 1. Observation on November 24, 2025, at 11:05 AM, revealed no manual fire alarm pull station within five feet of the Therapy Gym rear exit door. Interview with the Maintenance Director on November 24, 2025, at 11:05 AM, confirmed the lack of a manual fire alarm pull station within five feet of an exterior exit door.

Plan of Correction - To be completed: 01/13/2026

1. Plan Review contacted and requested that a plan including a drawing and narrative be submitted through the DCI portal for the installation of a pull station within five feet of the Therapy Gym rear exit door. The Center will be requesting a Time Limited Waiver.
2. The Plant Operations staff will be educated on the pull station requirements.
3. Five random audits will be completed weekly for four weeks then monthly for three months on the placement of manual fire pull stations to ensure they meet the requirement of five feet. All audits will be shared with the QAPI committee for further recommendations

NFPA 101 STANDARD Sprinkler System - Installation:

Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0351 Based on observation and interview, it was determined the facility failed to provide a complete automatic sprinkler protection system, affecting one of ten smoke compartments within the component. Findings include: 1. Observation on November 24, 2025, at 10:50 AM, revealed the Therapy Staff Closet, within the Therapy Gym, was not sprinklered. Interview with the Maintenance Director on November 24, 2025, at 10:50 AM, confirmed the lack of sprinkler protection.

Plan of Correction - To be completed: 01/13/2026

1. After inspection of the existing automatic sprinkler system, it was noted the sprinkler pipe and drop were already in place in the Therapy Staff Closet, within the therapy gym and just required a head to be added to the drop from the sprinkler pipe. The sprinkler head has been added.
2. The Plant Operations staff will be educated on ensuring proper sprinkler coverage.
3. Five random audits will be completed weekly for four weeks then monthly for three months on proper sprinkler head coverage. All audits will be shared with the QAPI committee for further recommendations

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

This is a less serious (but not lowest level) 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 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.

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: MAIN BUILDING - Component: 01 - Tag: 0353 Based on document review, observation, and interview, it was determined the facility failed to provide documentation verifying mechanical water flow alarm devices were inspected on a quarterly basis, and to maintain the automatic sprinkler protected system to be free from extraneous weight, affecting the entire component. Findings include: 1. Review of documentation on November 24, 2025, at 9:00 AM, revealed the facility lacked documentation verifying mechanical water flow alarm devices had been inspected since 5/29/2025. Interview with the Maintenance Director on November 24, 2025, at 9:00 AM, confirmed the facility lacked documentation verifying mechanical water flow alarm devices had been inspected since 5/29/2025. 2. Observation on November 24, 2025, at 10:46 AM, revealed brown wires, taped to sprinkler piping, located within the corridor by Resident Room 110. Interview with the Maintenance Director on November 24, 2025, at 10:46 AM, confirmed the wires were supported by the sprinkler system.

Plan of Correction - To be completed: 01/13/2026

1. The quarterly inspection was located and filed in the Life Safety Book for the May 2025 sprinkler report. Regarding the sprinkler piping, an audit for items bearing weight on the sprinkler pipes will be performed whenever above ceiling work is performed.
2. The Plant Operations staff will be educated on the inspection time frame for the mechanical water flow alarm devices and the sprinkler pipes being free from extraneous weight whenever above the ceiling work is performed.
3. Five random audits will be completed weekly for four weeks then monthly for six months to ensure no extraneous weight is on the sprinkler pipes. A monthly check of the Life Safety Book will be completed to ensure all sprinkler reports are filed in the book and the next inspection is scheduled to completed at least quarterly. All audits will be shared with the QAPI committee for further recommendations.

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: MAIN BUILDING - 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 two of ten smoke compartments within the component. Findings include: 1. Observation on November 24, 2025, at 10:23 AM, revealed multiple unprotected penetrations of the smoke barrier wall, located above the suspended ceiling within the South Dining Room, around electrical cables, conduits and a sprinkler pipe. Interview with the Maintenance Director on November 24, 2025, at 10:23 AM, confirmed the unprotected penetrations of the smoke barrier wall.

Plan of Correction - To be completed: 01/13/2026

1. The multiple unprotected penetrations of the smoke barrier wall, located above the suspended ceiling within the South Dining Room, around the electrical cables, conduits and a sprinkler pipe have been closed using an approved through penetration fire stop system. The facility will maintain the rating of hte smoke barrier walls.
2. The Plant Operations staff will be educated on ensuring any penetrations are sealed to maintain the rating of hte smoke barrier walls.
3. Five random audits will be completed weekly for four weeks then monthly for six months then every six months to inspect for any uncaulked penetrations. All audits will be shared with the QAPI committee for further recommendations

NFPA 101 STANDARD Fire Drills:

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.

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: MAIN BUILDING - 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 24, 2025, at 8:51 AM, revealed the facility failed to provide documentation verifying 3rd shift employees were subjected to a fire drill, between 9/16/2024 - 3/25/2025. Interview with the Maintenance Director on November 24, 2025, at 8:51 AM, confirmed the lack of documentation verifying a 3rd shift fire drill occurred within the 4th quarter of 2024.

Plan of Correction - To be completed: 01/13/2026

1. A third shift fire drill will be completed.
2. The Plant Operations staff will be educated on the requirement that all shifts be included in fire drills at least quarterly.
3. Monthly audits will be completed for six months then quarterly for three quarters to ensure that all shifts fire drills are completed at least quarterly. All audits will be shared with the QAPI committee for further recommendations

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0918 Based on document review and interview, it was determined the facility failed to provide documentation verifying generator weekly, monthly, annual, and triennial inspections and testing had occurred within the previous three years, affecting the entire component. Findings include: 1. Review of documentation on November 24, 2025, at 9:04 AM, revealed the facility failed to provide documentation verifying the following inspections and testing took place: a: annual diesel fuel quality testing. (Last known test done on 6/25/2024); b. monthly exercise under load. (Last known exercise done on 4/16/2025); c. annual load bank. (Last known exercise done on 5/29/2024); d. triennial 4-hour exercise under load. (Date of last known exercise unknown); e. weekly visual inspection. (Date of last known inspection unknown). Interview with the Maintenance Director on November 24, 2025, at 9:04 AM, confirmed the lack of documentation verifying weekly, monthly, annual and triennial inspections and testing had occurred within the previous three years.

Plan of Correction - To be completed: 01/13/2026

1. The monthly exercise under load, annual diesel fuel quality test, annual load bank, triennial 4-hour exercise under load and weekly visual inspection will be completed to meet all requirements and establish compliance.
2. The Plant Operations staff will be educated on the requirements of testing for the generator.
3. Monthly audits will be completed for one year until a compliance history is established then quarterly review for timely execution of required generator tests and placement of results in the Life Safety Book. All audits will be shared with the QAPI committee for further recommendations.

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