Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carbondale Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with intact cognition and Medicaid coverage was overcharged for care costs due to billing errors, resulting in a $100 discrepancy in personal funds management. The facility failed to properly apply the Personal Needs Allowance when deducting care costs, leading to inaccurate accounting of the resident's finances.
A resident with severe cognitive impairment and high risk for pressure ulcers was not consistently provided with required heel-lift boots as ordered, despite a care plan and physician orders specifying their use. Observations showed the resident without the boots on multiple occasions, with staff confirming the resident often removed them and was instead given slippers. There was no documentation of refusals or interventions to address this, and staff records inaccurately reflected that the boots were in use. The DON confirmed the facility did not consistently follow planned interventions to promote healing or prevent worsening of a pressure ulcer.
A resident with decreased mobility and a history of lung cancer did not receive restorative ambulation services as planned after discharge from PT, despite care plan interventions and documentation indicating otherwise. Both the resident and a nurse aide confirmed that the ambulation program was not implemented, and the DON acknowledged the failure to provide and accurately document the required restorative nursing services.
Surveyors observed unsanitary conditions in the kitchen and resident pantries, including a build-up of black substances under the dishwasher and on ice machine hoses, as well as undated and unmarked resident food items in a refrigerator. Staff confirmed that food items should be dated and that cleaning of equipment was not performed frequently enough to prevent contamination.
A resident developed a blister on the heel, which the facility failed to investigate or communicate about with the family. Initial assessments showed no skin issues, but later documentation noted the blister. The care plan included interventions for skin integrity, but documentation was incomplete. A physician's evaluation identified the blister as a venous wound without supporting evidence. The family filed a grievance, but there was no resolution or discussion about the blister.
A resident experienced significant weight loss over one week, dropping 8.1 pounds despite consuming 70% to 100% of meals. The facility failed to conduct reweights or notify the physician promptly. The RD reviewed the weight loss six days later, but no additional interventions were documented. The DON confirmed the facility's lack of timely response, indicating a deficiency in nursing services.
The facility did not implement proper screening procedures for five employees, including a RN, LPN, and unit aides, as required by their abuse prohibition policy. The policy lacked procedures for obtaining references from previous employers, and there was no evidence that the facility contacted former employers for information. The NHA confirmed this oversight.
A resident with Parkinson's disease and dementia was prescribed Haldol for anxiety and terminal agitation without documented clinical necessity. Despite experiencing falls and dosage increases, there was no physician or hospice documentation justifying the medication's use. The pharmacist's request for a gradual dose reduction was met with insufficient documentation from the physician.
A resident with Parkinson's disease and dementia experienced multiple falls from a wheelchair, resulting in injuries, due to the facility's failure to implement an effective QAPI program. Despite interventions like occupational therapy, the falls continued, indicating insufficient strategies to address the root causes. The facility did not provide additional supervision or conduct thorough investigations, lacking documentation of corrective actions.
A facility failed to conduct a significant change MDS assessment for a resident who was placed on hospice care, as required by federal regulations. The resident experienced a significant decline in condition, but there was no documented evidence of the required assessment. The Nursing Home Administrator confirmed the oversight.
A resident with end-stage renal disease and dependent on dialysis was found without necessary emergency supplies in her room or on her wheelchair, despite her care plan requiring them. Interviews with the resident, an LPN, and the Nursing Home Administrator confirmed the absence of these supplies, indicating a failure by the facility to ensure their availability.
Failure to Accurately Manage and Account for Resident Personal Funds
Penalty
Summary
The facility failed to properly safeguard, manage, and accurately account for the personal funds of a resident who was admitted with a diagnosis of malignant neoplasm of the lung and was cognitively intact, as evidenced by a BIMS score of 15. The resident's payor source was Medicaid, which entitles individuals to a monthly Personal Needs Allowance (PNA). A review of the resident's fund ledger and financial documentation revealed that the facility made incorrect deductions for care costs, resulting in an overcharge. Specifically, the resident was charged a total of $10,025 for care costs from December 2024 through April 2025, when the correct total should have been $9,925 based on the resident's income and the applicable PNA for each month. The discrepancy was identified when the resident noticed a significant charge on his financial statement and brought it to the attention of facility staff. Further review confirmed that the facility was responsible for deducting only the monthly care cost balance after applying the PNA, but billing errors led to an overcharge of $100. The facility's failure to accurately manage the resident's personal funds constituted a violation of the resident's rights and state regulations regarding the management of resident finances.
Failure to Consistently Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to consistently implement planned interventions to promote healing and prevent the worsening or development of pressure ulcers for one resident. The resident in question was admitted with significant medical conditions, including diabetes and rheumatoid arthritis, and was assessed as being at high risk for pressure sore development due to severe cognitive impairment and dependence on staff for activities of daily living. The care plan and physician orders specified the use of heel-lift boots at all times, except during care, as well as the use of a specialized mattress and pressure redistribution cushion. Despite these documented interventions, multiple observations revealed that the resident was not wearing the required heel-lift boots on two separate occasions. Instead, the resident was found wearing slippers, and the heel-lift boots were observed lying unused in the room. Staff interviews confirmed that the resident often removed the boots, and staff would then put slippers on instead. However, there was no documentation in the care plan or task reports regarding the resident's refusal to wear the boots or any interventions taken to address these refusals. Additionally, staff documentation inaccurately indicated that the heel-lift boots were on the resident at times when direct observation showed otherwise. The Director of Nursing confirmed that the facility did not consistently implement the planned interventions to promote healing or prevent the progression of the resident's right heel pressure ulcer. This failure was found to be noncompliant with facility policy and regulatory requirements.
Failure to Provide and Accurately Document Restorative Ambulation Services
Penalty
Summary
The facility failed to consistently provide restorative nursing services as planned for a resident with decreased mobility and fatigue. The resident, who was cognitively intact and had a history of malignant neoplasm of the lung, was discharged from physical therapy with recommendations for a restorative ambulation program. The care plan specified that the resident should ambulate 50 feet with a rollator walker and the assistance of one caregiver, with interventions including proper footwear, instruction on device use, and wheelchair follow-along as recommended by therapy. Despite these documented interventions, the resident reported that after physical therapy services ended, no staff provided restorative ambulation services for over a month. Clinical records indicated that the resident received the intervention on multiple occasions, but during interviews, both the resident and the nurse aide responsible for the documentation confirmed that the ambulation program was not implemented as recorded. The DON acknowledged that the facility did not provide the planned restorative nursing services and that documentation was inaccurate.
Deficient Food Storage and Sanitation Practices
Penalty
Summary
Surveyors identified multiple failures in food storage and sanitation practices within the facility. During an initial kitchen tour, there was a heavy build-up of a black substance under the soiled side counter space of the dishwasher and debris under the ceiling light shield in the janitor's closet. The registered dietitian confirmed that the kitchen should be maintained in a clean and sanitary manner. In the Nursing B Hall Pantry, a refrigerator/freezer contained five undated and unmarked containers of resident food, as well as other undated items such as butter, bread, and ice cream. A registered nurse confirmed that staff are expected to date all food items when opened or received by residents or their families. Further observations in the A Hall and B Hall Nursing Unit pantries revealed a build-up of a black substance on the ends of the condensation hoses of the ice machines. The maintenance director confirmed that the ice machines and their condensation hoses were not cleaned and sanitized frequently enough to prevent this build-up. These findings indicate that the facility did not maintain acceptable practices for the storage and service of food, increasing the risk of contamination and microbial growth.
Failure to Investigate and Address Pressure Ulcer
Penalty
Summary
The facility failed to investigate the origin and promote the healing of a pressure sore for a resident, identified as Resident 1. The resident was admitted with diagnoses including weakness, history of falling, lumbar radiculopathy, and dementia. Initial assessments indicated no skin impairment, but later documentation noted a blister on the resident's left heel. Despite the presence of a blister, there was no evidence of an investigation into its development, and the facility did not provide information to the family regarding the cause of the blister. The care plan for the resident was initiated and updated to address the risk of skin integrity impairment, with interventions such as elevating the resident's heels and documenting skin breakdown. However, the facility's skin integrity report lacked complete documentation, including measurements and staging of the blister. A physician's evaluation later identified the blister as a venous wound, but there was no supporting evidence or collaboration with the physician to confirm this diagnosis. The resident's family expressed concerns about the blister and filed a grievance, but there was no resolution or documented discussion about the blister with the family. Interviews with facility staff revealed that the blister was not investigated because it was assumed to be a venous wound, without evidence to support this assumption. The facility's failure to investigate and communicate about the blister led to the deficiency noted in the report.
Failure to Monitor and Address Resident's Weight Loss
Penalty
Summary
The facility failed to consistently monitor and address a resident's weight loss, leading to a deficiency in providing adequate nutritional support. A resident, who was admitted with conditions including lumbar radiculopathy, dementia, and a history of falling, experienced a significant weight loss of 8.1 pounds, or 4.39%, over one week. Despite consuming between 70% to 100% of meals, the resident's weight dropped from 184.6 pounds to 176.5 pounds between August 1 and August 8, 2024. There was no evidence of reweights to confirm the initial weight loss, and no communication or notification was made to the physician regarding this significant change. The Registered Dietitian reviewed the resident's weight on August 14, 2024, six days after the weight loss was identified, and noted the significant weight loss. However, there was no documented evidence that the physician was notified of this change, nor were additional interventions such as reweights conducted. An interview with the Director of Nursing confirmed the facility's inability to demonstrate a timely response to the resident's weight loss, indicating a lapse in nursing services as per 28 Pa Code 211.12 (d)(3)(5).
Failure to Implement Employee Screening Procedures
Penalty
Summary
The facility failed to fully develop and implement established abuse prohibition procedures for screening prospective employees, as required by regulatory standards. The facility's Resident Abuse policy, last reviewed on January 3, 2023, did not include procedures for obtaining references from current or previous employers. This omission was identified during a review of the facility's abuse prohibition policy, employee personnel files, and staff interviews. The review revealed that five employees, including a Registered Nurse, a unit aide, an LPN, and another unit aide, were hired without the facility contacting their previous employers for references. The employees' applications indicated prior employment, but there was no evidence that the facility obtained information from former employers. The Nursing Home Administrator confirmed that no previous employers were contacted for information regarding the employees' past employment.
Lack of Documentation for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure the presence of current documented clinical necessity for the continued use of a psychotropic medication prescribed on an as-needed basis for a resident. The resident, who had diagnoses of Parkinson's disease, dementia, and a history of falling, was placed on hospice services for end-stage Parkinson's disease. A physician order was made for Haldol, an antipsychotic medication, to be administered sublingually every six hours for anxiety and terminal agitation. However, there was no corresponding physician or hospice staff documentation to justify the addition of this medication to the resident's regimen. Following the initiation of Haldol, the resident experienced additional falls, leading to an increase in the medication dosage. Despite further falls and dosage increases, there was still no physician documentation addressing the resident's behaviors and the rationale for the Haldol usage. The pharmacist requested a gradual dose reduction due to the lack of documented rationale for the increased dosage, but the physician only noted increased episodes of agitation without further documentation. The interim Director of Nursing confirmed the absence of necessary documentation regarding the initiation and dosage increases of Haldol.
Repeated Falls Due to Ineffective QAPI Program
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by repeated falls of a resident, identified as Resident 65, who was admitted with diagnoses including Parkinson's disease and dementia. The resident had a history of falls and was at risk due to cognitive impairment and mobility issues. Despite being on hospice care for end-stage Parkinson's disease, the resident experienced multiple falls from his wheelchair, resulting in injuries such as lacerations, abrasions, a scalp hematoma, and a lumbar fracture. The facility's QAPI plan, which was supposed to involve all staff and stakeholders in improving quality of care, did not effectively address the root causes of these falls. The resident's care plan acknowledged the risk of falls, but the interventions, including occupational therapy for wheelchair seating and propulsion, were insufficient to prevent further incidents. The resident continued to fall even after therapy sessions, indicating a lack of effective strategies to mitigate the risk. During the survey, it was noted that the facility did not provide additional supervision as a fall prevention measure, and there was no evidence of a thorough investigation or analysis of the adverse events. The facility's QAPI system failed to identify and address the underlying causes of the falls, and there was a lack of documentation to support any corrective actions taken. This deficiency highlights the facility's inability to maintain an active and effective QAPI program to ensure the safety and quality of care for its residents.
Failure to Conduct Significant Change MDS Assessment for Hospice Enrollment
Penalty
Summary
The facility failed to conduct a significant change Minimum Data Set (MDS) assessment for a resident who experienced a significant decline in condition and was placed on hospice care. According to the RAI User's Manual, a significant change in status MDS assessment is required within 14 days of the determination of a significant change, such as when a resident enrolls in a hospice program. The clinical record review revealed that the resident was placed on hospice care on May 6, 2024, but there was no documented evidence that a significant change MDS was completed to reflect the initiation of hospice services. An interview with the Nursing Home Administrator confirmed that a comprehensive significant change MDS assessment was not completed as required. This oversight was identified during a review of clinical records and staff interviews, indicating a failure to adhere to federally mandated assessment processes.
Failure to Provide Emergency Supplies for Dialysis Resident
Penalty
Summary
The facility failed to ensure the ready availability of necessary emergency supplies for a resident receiving hemodialysis. Resident 52, who was admitted to the facility with end-stage renal disease and dependence on renal dialysis, was found to lack emergency care supplies in her room and on her wheelchair. The resident's care plan, dated October 8, 2021, specified that 4 x 4 gauze pads and cloth tape should be available at her bedside, but observations on July 11, 2024, revealed that these supplies were not present. Interviews conducted with Resident 52 and Employee 6, an LPN, confirmed the absence of the required emergency supplies. The resident stated that she had never seen the supplies in her room, and the LPN verified their absence. The Nursing Home Administrator also confirmed the facility's failure to provide the necessary emergency supplies at the resident's bedside, as required by the care plan.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Carbondale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aventura At Creekside | 0.6 mi | — | 14 | 0 |
| Wayne Woodlands Manor | 5.2 mi | — | 16 | 0 |
| Forest City Nursing And Rehab Center | 5.3 mi | — | 0 | 0 |
| Mid-valley Health Care Center | 7.9 mi | — | 0 | 0 |
| Aventura At Terrace View | 8.6 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.