Armstrong Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kittanning, Pennsylvania.
- Location
- 265 South Mckean Street, Kittanning, Pennsylvania 16201
- CMS Provider Number
- 395471
- Inspections on file
- 54
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 65 (1 serious)
Citation history
Health deficiencies cited at Armstrong Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with bipolar disorder, diabetes, moyamoya disease, moderate cognitive impairment, and a Wanderguard order was left unsupervised near an elevator after a first-floor group activity while staff transported other residents in small groups. The resident, previously identified as an elopement risk and care planned for wandering behaviors, left the supervised area without staff knowledge, used an elevator leading to the parking lot, and wheeled herself off facility premises toward a nearby store she often visited on LOA with family. Staff realized she was missing, initiated a code white, and conducted an internal and external search, ultimately locating her in an alley along the road and returning her to the unit, where assessment showed no injury. Staff interviews and record review showed that activities staff had left residents waiting by the elevator without continuous supervision and did not have ready access to an elopement-risk list, leading surveyors to determine that the facility failed to provide adequate supervision to prevent elopement for this resident and that this created immediate jeopardy for multiple residents at risk for elopement.
The facility failed to maintain a full-time DON (at least 35 hours per week) as required. Although an RN was hired as DON, review of daily Stand-Up sheets over several weeks showed the DON was frequently documented as not present, often did not sign the sheets (making presence unknown), and some sheets were missing. Additional undated Stand-Up sheets also showed the DON was not present. After the Asst DON’s employment ended, no RN was designated as an interim DON. The NHA later confirmed there was no documentation that the DON worked full-time hours in the DON role, resulting in noncompliance with state requirements for nursing services and management.
Facility administration, including the NHA and DON, did not effectively manage operations to ensure compliance with elopement-prevention regulations and facility policies. Although their job descriptions required them to direct care and nursing services in accordance with local, state, and federal standards, they failed to implement and oversee measures to prevent residents identified as elopement risks from leaving the building unsupervised. As a result, a known elopement-risk resident exited the facility without supervision, creating an Immediate Jeopardy situation for multiple residents documented as elopement risks.
Staff failed to follow physician orders for BiPAP therapy for a resident with cancer, HTN, and COPD. Facility policy required practitioner orders for immediate care and proper administration of oxygen therapies, including BiPAP. The resident had orders for BiPAP use during hours of sleep with specified parameters, but review of the TAR showed the treatment was not provided on three documented occasions, and an RN confirmed the device was not initiated until the day after the initial order. Notations on the TAR directing staff to “see nursing note” for two missed BiPAP treatments were not supported by any corresponding nursing documentation, demonstrating noncompliance with ordered respiratory treatment and documentation requirements.
A resident with a history of constipation, HTN, and neck pain was admitted with documentation showing no bowel movement for about eight days. Throughout one day, the resident repeatedly complained of abdominal pain and lack of bowel movement and repeatedly requested to go to the hospital. A NA and an LPN reported notifying the RN Supervisor, who did not go to assess the resident, stated she had already done his paperwork, and declined to send him out, even as the call bell continued and the resident stated he had been asking all day. The resident ultimately called 911 himself. Staff interviews indicated that facility bowel protocol should have been initiated after several days without a BM and that the resident had an order for magnesium citrate from a prior facility that likely was not given. The DON and administrator confirmed the RN Supervisor refused to assess or send the resident out, resulting in a finding that the facility failed to protect the resident from neglect.
The facility failed to follow its abuse/neglect reporting policy when a resident with constipation, HTN, and neck pain repeatedly requested transfer to the hospital for abdominal pain and constipation. According to documentation, the resident asked to be sent out, an LPN and NA relayed this to the RN supervisor, and the RN supervisor refused to assess the resident or arrange hospital transfer, leading the resident to call 911 independently. This situation constituted an allegation of neglect that, under facility policy, required reporting to the state and other agencies within a defined timeframe, but the allegation was not reported to the local state field office within 24 hours, as later confirmed by the DON and the administrator.
A resident admitted with constipation and other diagnoses went at least eight days without a documented bowel movement, despite facility policy and physician orders for a bowel protocol including Milk of Magnesia, Dulcolax suppository, and Fleet enema. The MAR showed no evidence that ordered constipation medications were administered, and staff interviews confirmed that bowel protocols should be initiated when a resident has no bowel movement for several days and that changes in condition require assessment and physician notification. The resident repeatedly used the call bell and requested to see the RN supervisor and be sent to the hospital for abdominal pain and lack of bowel movement, but the RN supervisor did not assess the resident and stated she had already done his paperwork. The resident ultimately called 911 himself and was hospitalized for rectal fecal impaction and severe constipation requiring laxatives, disimpaction, and enemas, and the administrator acknowledged the facility’s failure to provide necessary care and services.
The facility did not follow up on a vendor-provided building structural assessment quote that was part of an ongoing plan of correction, as confirmed by document review and interview with the maintenance supervisor. This failure potentially affected the building's structural integrity.
A deficiency was identified when the facility did not provide documentation that the main control board of one emergency generator, flagged for replacement during annual maintenance, had been corrected. This issue was confirmed by the maintenance supervisor.
The facility did not obtain required approvals for converting resident rooms to storage on one floor and failed to provide accurate, portable Life Safety Code floor plans that included all required rated partitions and exits. These deficiencies were confirmed by facility leadership and repeated from a prior survey.
Stair tower doors on two building levels were found blocked by a caution retractable rope and signage instructing that the stairs were only for emergency use, which could delay resident egress. The maintenance director confirmed this setup during the survey.
Surveyors found combustible decorations on two floors, including items obstructing a corridor egress pathway and santa banners pinned to a fire and smoke door near a nurse station, with no fire retardant documentation available and the integrity of the fire door compromised. The maintenance director confirmed these deficiencies.
A three-to-one outlet multiplier was found in use in the first floor salon, with a hair dryer, hair straightener, and hair curler plugged into it, in violation of electrical equipment requirements. The maintenance director confirmed this setup during an interview.
Surveyors found that more than 12 E-sized oxygen cylinders, exceeding 300 cubic feet, were improperly stored in the basement activities room. The storage did not meet NFPA requirements for construction, ventilation, and separation, as confirmed by the maintenance supervisor.
The facility did not provide or document annual emergency preparedness training for all staff and volunteers, as confirmed by both document review and interviews with facility leadership.
Armstrong Rehabilitation and Nursing Center did not conduct or document a full-scale exercise to test its emergency preparedness plan, as confirmed by a lack of records and staff interviews during a survey.
A two-step lock, including a dead bolt, was observed on the environmental services office door next to the salon, potentially impeding emergency egress. This was confirmed by the administrator and maintenance director.
The facility did not conduct required annual performance evaluations for five nurse aides, as confirmed by personnel record review and staff interview. Documentation of these evaluations was missing for all affected staff, in violation of regulatory requirements.
Expired and undated insulin vials and pens, as well as other expired medications and medical supplies, were found in several medication rooms and carts. Staff confirmed these items were expired, and required labeling and storage procedures were not followed, despite facility policies and routine pharmacist inspections.
A resident with cerebral palsy, anxiety disorder, and gait abnormalities was unable to attend a scheduled eye surgery after the facility canceled the appointment due to unpaid transportation bills. Staff interviews and facility records confirmed that multiple appointments were canceled over several months because the transportation vendor was not paid on time, impacting residents' access to necessary medical care.
Surveyors found that staff failed to use appropriate PPE in droplet isolation rooms, did not properly clean and disinfect resident rooms after isolation was discontinued, and lacked a comprehensive water management program to monitor for Legionella. These deficiencies were confirmed through staff interviews, observations, and review of facility policies.
A review of personnel files and facility policy revealed that several direct care staff, including an RN, multiple NAs, and an LPN, did not receive required annual training on Effective Communication. The facility's HR confirmed the absence of this training for these staff members, as mandated by regulations.
Six staff members, including multiple nurse aides and an LPN, did not receive required annual training on Resident Rights as mandated by facility policy. Personnel file reviews and staff interviews confirmed the absence of this training within the specified period.
Four staff members, including three nurse aides and an LPN, did not receive required annual training on abuse, neglect, and exploitation as mandated by facility policy and federal regulations. Personnel file reviews and staff interviews confirmed the absence of this training within the specified timeframes.
The facility did not provide mandatory QAPI program training to a RN, three NAs, and an LPN, as required by policy and federal regulations. Personnel files lacked documentation of annual QAPI training for these staff, and HR confirmed the omission.
Four staff members, including three nurse aides and an LPN, did not receive mandatory annual infection control training as required by facility policy and regulations. Personnel file reviews and staff interviews confirmed the absence of this training within the specified timeframes.
The facility did not provide required annual Compliance and Ethics training to several staff members, including an RN, multiple NAs, and an LPN, as confirmed by personnel file reviews and staff interviews. This failure was in direct violation of facility policy and regulatory requirements for staff development and compliance training.
Three nurse aides did not receive the required 12 hours of annual in-service training, as confirmed by a review of personnel records and staff interview. The facility was unable to provide documentation showing completion of the mandated training hours for these staff members.
The facility did not provide required behavioral health training to a RN, three NAs, and an LPN, as evidenced by missing documentation in their personnel files and confirmed by HR. This failure was identified through review of training records and staff files, in violation of regulatory requirements for staff development.
Two residents did not receive care that maintained their dignity: one had a catheter drainage bag left uncovered in violation of facility policy, and another, who was totally dependent for eating, was left without assistance when her meal tray was delivered. These deficiencies were confirmed by staff and the DON.
The facility did not document that two residents with significant medical conditions were given the opportunity to formulate an advance directive, as required by policy and regulation. Clinical records lacked evidence that these residents or their representatives were informed about or offered the chance to create an advance directive, and this was confirmed by the facility's social worker.
A resident with diagnoses of suicidal ideation, schizophrenia, and anxiety disorder did not have a comprehensive, person-centered care plan addressing her mental health needs. The care plan only listed the use of plastic silverware as an intervention, despite the resident expressing suicidal thoughts and attempting self-harm with plastic utensils. No additional interventions were documented or implemented.
A resident with multiple chronic conditions developed a stage 3 pressure injury, but the facility failed to complete required weekly wound documentation, did not update the Braden Scale risk assessment after the injury, and did not timely update the care plan to reflect the resident's current skin status. These failures were confirmed by the DON and NHA, indicating noncompliance with professional standards and facility policy.
A resident with a history of suicidal ideation, schizophrenia, and anxiety disorder expressed a desire not to be alive and attempted self-harm on two occasions using plastic utensils. Despite facility policy requiring one-on-one supervision and removal of potential self-harm items, the resident was not adequately supervised, allowing these incidents to occur.
A resident with multiple chronic conditions and a Stage 3 pressure ulcer did not receive a comprehensive nutritional assessment or an updated care plan following a significant change in condition. The required assessment and care plan updates to address the resident's nutritional needs related to the pressure ulcer were not completed or documented, as confirmed by the RD and facility leadership.
Two residents requiring respiratory care did not have their oxygen and nebulizer equipment stored according to facility policy, with items such as nasal cannulas and nebulizer tubing left out and not placed in protective bags when not in use. An LPN and the DON confirmed these lapses in proper respiratory care procedures.
A resident with a history of suicidal ideation, schizophrenia, and anxiety disorder did not receive timely or sufficient social services after therapy was discontinued due to cognitive decline. Despite expressing suicidal thoughts and attempting self-harm, the facility did not provide further therapeutic interventions or contact clinical staff for medication management.
A resident with diabetes did not receive their prescribed dose of Insulin Aspart with their meal as ordered. An LPN administered the insulin significantly after breakfast, and the DON confirmed this was a significant medication error, failing to ensure residents are free from such errors.
Surveyors found that the facility did not post complete contact information, including email addresses, for the State Survey Agency, Adult Protective Services, and Medicaid Fraud Unit on all floors, and also failed to display a required statement about residents' rights to file complaints with the State Survey Agency.
The facility did not ensure that all required nine multidisciplinary members, including the Medical Director, lab, and pharmacy representatives, attended quarterly Infection Control Committee meetings for three of four quarters, as confirmed by meeting logs and the DON.
Personnel files for a dietary aide and a nurse aide did not contain documentation from a licensed health care practitioner confirming that each employee was free from communicable diseases or conditions at the start of employment. The health forms were only signed by the employees, not by a qualified practitioner, as confirmed by HR staff.
The facility did not provide required annual Accident Prevention training to six staff members, including several nurse aides and an LPN, as confirmed by personnel file reviews and a Human Resources interview.
The facility did not provide required Restorative Nursing training to seven staff members, including an RN, an LPN, and several NAs, as confirmed by personnel file reviews and staff interviews. This failure was in direct violation of the facility's policy mandating annual and role-specific training for all staff.
The facility did not provide annual Emergency Preparedness training to six staff members, including several nurse aides and an LPN, as required by facility policy. Personnel files lacked documentation of this training within the required timeframe, and this was confirmed by Human Resources during the survey.
The facility did not provide annual Fire Prevention and Safety training to several staff members, including multiple nurse aides and an LPN, as required by facility policy. Personnel files lacked documentation of this training for the relevant annual periods, and this was confirmed by Human Resources.
A resident with dementia and other medical conditions experienced a fall from bed that was not documented or reported by staff. An LPN responded to the incident but did not assess the resident, instead forcefully placing the resident back onto the bed and leaving without further care or documentation. The incident was only discovered later when the resident complained of pain and was found to have a hip fracture.
Two residents with persistent rashes and itching did not receive physician-ordered hydroxyzine HCL for several days, despite visible symptoms and staff awareness. Staff interviews and observations confirmed the ongoing discomfort and lack of medication administration, and facility leadership acknowledged the failure to follow physician orders.
Two residents with persistent itching and rashes were not tested for scabies nor placed on contact precautions, despite facility policy and staff awareness of a possible outbreak. Both residents remained in shared rooms without isolation signage, and no physician orders for diagnostic testing were found. The infection preventionist confirmed knowledge of symptoms but did not ensure appropriate infection control measures were implemented.
A resident with moderate cognitive impairment and anxiety was moved to a different floor for safety reasons without prior written notice to the resident or their responsible party. Staff confirmed that the responsible party was not consulted or given options before the transfer, and the required notification was not documented.
A resident with moderate cognitive impairment and a history of anxiety and muscle weakness was identified as high risk for wandering and elopement. Despite facility policy requiring individualized care plans, the resident's plan included only generic interventions and lacked person-centered strategies tailored to their specific needs. The DON confirmed the absence of individualized interventions for this high-risk resident.
Elopement Due to Inadequate Supervision After First-Floor Group Activity
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for one resident who had been assessed as at risk for elopement. The facility’s own policy defined elopement as a resident leaving a safe area without staff knowledge or entering an unsafe area without staff presence. The resident at the center of the incident had a history that included bipolar disorder, diabetes, moyamoya disease, and moderate cognitive impairment per the MDS. Elopement risk assessments for this resident had fluctuated, with the resident identified as an elopement risk on one assessment and not at risk on two others. The physician had ordered an electronic monitoring bracelet (Wanderguard), and the care plan for behavior symptoms such as wandering and suicidal ideations included checking the Wanderguard placement, providing the device, and using diversions. On the day of the incident, the resident participated in a first-floor group activity (cooking club). After the activity concluded, activities staff began transporting residents back to their home units using an elevator that could only hold four people at a time. One activities aide reported that while transporting residents from the first floor to the upper floors, the resident left the first-floor area near the elevator where she had been waiting to return to her third-floor room. Another statement from the same aide indicated that she had to leave some residents waiting by the elevator due to capacity limits, and when she returned to the first floor, the resident was no longer there. The aide then sought help from other staff to locate the resident. An environmental services employee confirmed seeing the resident and another resident sitting by the elevator, then later finding the resident gone and assuming she had been taken back to her floor before learning she was missing. A code white was called when staff realized the resident could not be found in nearby rooms, restrooms, or on the unit. Multiple staff statements described searching inside and outside the building, including the basement, surrounding doors, parking lot, and nearby alleyways. Staff obtained information from bystanders outside who reported seeing a woman in a wheelchair and pointed out the direction she had traveled. Staff ultimately found the resident outside in a nearby alley, wheeling herself along the berm of the road toward a local convenience store she frequently visited with family during authorized leaves of absence. Progress notes documented that the resident was returned to the facility, was alert and oriented, tearful, and stated she had not intended to cause trouble but wanted to go to the store. A head-to-toe assessment and vital signs check revealed no injuries or distress. During subsequent interviews, staff confirmed that the resident had been left unsupervised near the elevator after the activity and that activities staff did not have ready access to or awareness of an elopement binder listing residents at risk for elopement, contributing to the failure to provide adequate supervision. The surveyors determined this failure created an immediate jeopardy situation for ten residents identified by the facility as at risk for elopement.
Removal Plan
- Resident was returned to the facility.
- Full body assessment was completed with no negative findings.
- Physician and family were notified.
- Resident care plan will be updated to include that resident will be supervised at all times outside of her living unit.
- Nursing Home Administrator completed Elopement/Accidents and Hazards education with Activities Staff that residents coming to the first floor dining room for activities that have a Wanderguard device or are deemed at risk for elopement will not be unsupervised at any time (before, during, or after the activity) until they are returned safely to their respective living area.
- Whole house education on Elopement/Accidents and Hazards was initiated and completed.
- Elopement assessments were completed on current residents and are under evaluation in the resident medical chart.
- Elopement binders were verified for accuracy and completion.
- Activities on the first floor will continue with an implemented plan to ensure resident safety and decreased risk of elopement.
- Facility leadership will assist during large group activities planned for the first floor dining room to ensure direct supervision support.
- Leadership will support activities staff in transporting residents to/from the first floor dining room and provide additional supervision during the activity.
- Activity Director will verbalize the need for help in morning standup meeting and provide a sign-up sheet for leadership to secure.
- Residents with a Wanderguard device or residents at risk of elopement will not be left unsupervised.
- Four people will be used for coverage: one in the room, one transporting in the hallway, one transporting the elevator, and one observing the hallway.
- Facility reduced the number of activities in the first-floor dining room to larger primary activities (auction, birthday party, cooking club, special events).
- Once all residents are in the first-floor dining room, the door will be closed.
- A bell was placed on the dining room door to alert staff if someone is attempting to open the door.
- Other activities will be modified to be completed on the resident floors in the dayrooms.
- Smaller integrated activities (e.g., Church and Resident Council) will be scheduled in the 3A dayroom moving forward.
- New admissions will be evaluated for elopement and findings discussed during the morning meeting process.
- If a resident is deemed an elopement risk, elopement binders will be updated, a Wanderguard will be placed, and the interdisciplinary team will be made aware.
- Audits of group activities occurring in the first-floor dining room will be completed by the Nursing Home Administrator for proper supervision of residents.
- All education, care plan updates, and activity modifications will be completed.
- Audits will begin with the next large group activity scheduled.
Failure to Maintain a Full-Time DON
Penalty
Summary
The deficiency involves the facility’s failure to ensure the consistent services of a full-time Director of Nursing (DON), defined as 35 or more hours per week, as required by regulation. The DON job description indicated that the position was responsible for planning, organizing, developing, and directing the overall operations of the Nursing Service Department in accordance with applicable standards, regulations, and facility policies, and required a current unrestricted RN license. The DON began employment on 1/15/26, but review of facility “Stand-Up” sheets from early February through late March showed that the DON was either documented as not present, had not signed the sheets (making presence unknown), or there were no sheets available for multiple business days. Specifically, the DON was documented as not present in the building on numerous listed dates, and several additional undated Stand-Up sheets also documented that the DON was not present. Further review showed that the Assistant DON’s employment ended on 2/16/26, and after that date no other RN was placed in an interim DON role. The Nursing Home Administrator confirmed on 3/23/26 that the DON was not in the building and was using paid time off through her last day of employment on 3/24/26. In a subsequent interview on 3/25/26, the Administrator confirmed there was no documented evidence that the DON worked 35 or more hours per week in the facility in the capacity of DON. The cited deficiency references 28 Pa Code 201.3 (Definitions), 201.14(a) (Responsibility of Licensee), 201.18(e)(6) (Management), and 211.12(b)(c)(d) (Nursing Services).
Failure of Administration to Prevent Elopement of High-Risk Residents
Penalty
Summary
Facility administration, specifically the Nursing Home Administrator (NHA) and the Director of Nursing (DON), failed to effectively manage operations to protect residents identified as elopement risks from exiting the building unsupervised. The NHA job description required leading, guiding, and directing facility operations in accordance with local, state, and federal regulations and facility policies to provide appropriate care. The DON job description required planning, organizing, developing, and directing the overall operations of the nursing service department in accordance with applicable standards, regulations, and facility policies, as directed by the Administrator and Medical Director, to provide appropriate care and services to residents. Despite these defined responsibilities, the NHA and the previously employed DON did not ensure that federal and state guidelines and regulations related to elopement prevention were followed. As a result, a resident who was a known elopement risk exited the building without supervision. This failure created an Immediate Jeopardy situation for 10 of 94 residents who were documented as elopement risks. During an interview, the NHA and current DON confirmed that facility administration failed to effectively manage the facility to protect residents from elopement. The deficiency was cited under 28 Pa. Code 201.14(a) Responsibility of licensee, 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management, and 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.
Failure to Follow Physician Orders for BiPAP Therapy
Penalty
Summary
Facility staff failed to follow physician orders for BiPAP therapy for one discharged resident. Facility policies required that a physician or other qualified practitioner provide written and/or verbal admission orders for residents’ immediate care and that oxygen, including BiPAP, be administered consistent with professional standards, the care plan, and resident goals and preferences. The resident, who had diagnoses including cancer, hypertension, and COPD, had a physician order dated 11/12/25 for BiPAP at hours of sleep at present parameters at bedtime with removal per schedule, with a start date of 11/13/25. A subsequent order dated 11/13/25 specified BiPAP at hours of sleep at present parameters of 45% and 6.0 cm H2O, with removal per schedule. Review of the Treatment Administration Record for November 2025 showed that the ordered BiPAP treatment was not provided on three occasions: 11/12/25, 11/19/25, and 11/20/25. During an interview, an RN stated that the BiPAP was not applied until 11/13/25, explaining that although the orders were entered on 11/12/25, the treatment was not scheduled until 11/13/25. When asked about a “9” notation on the TAR for 11/19/25 and 11/20/25, the RN stated it meant “see nursing note,” but confirmed there were no corresponding nursing notes to explain why the BiPAP was not used on those dates. This established that staff did not follow the physician’s BiPAP orders and did not document reasons for the missed treatments.
Failure to Assess and Respond to Resident’s Repeated Requests for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not assessing and responding to repeated complaints of abdominal pain and constipation and requests to go to the hospital. The facility’s abuse, neglect, and exploitation policy defined neglect as the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The RN Supervisor (Employee E1), whose job description required ensuring compliance with policies, assessing changes in resident status, notifying the physician and family, and documenting accordingly, was on duty when the resident repeatedly requested to be sent to the hospital. The resident had been admitted with diagnoses including constipation, hypertension, and cervicalgia, and admission documentation and the discharge transition packet showed his last bowel movement had been approximately eight days prior to admission. On the day of the incident, progress notes documented that the resident’s last bowel movement was on 2/5 and that later that day he requested to go to the hospital for abdominal pain and constipation, ultimately calling 911 himself. A NA (Employee E2) reported that around mid-afternoon the resident rang and asked to see the RN Supervisor to go to the emergency room; the NA notified the RN Supervisor, who stated she had done his paperwork and was not going back, and the NA did not see her go to the resident’s room. The NA further stated that the RN Supervisor told the resident he could not come back to the facility while the ambulance workers were there. An LPN (Employee E3) corroborated that the resident had been asking all day to be sent to the hospital, reported that the RN Supervisor was made aware, and described hearing the RN Supervisor say she had done his paperwork and did not know what else she could do, and later, when the call bell rang again, saying from the desk that she already knew what the resident wanted. The LPN (Employee E3) stated that when she returned to the resident’s room, he was on the phone with 911, and that the RN Supervisor later asked if she should send the resident out if he wanted to go, with the LPN responding yes and telling the resident she would call 911 after dinner. Another LPN (Employee E4) explained that the facility’s bowel protocol should be initiated if a resident has not had a bowel movement in three days, that last bowel movements are assessed on admission, and that medications for the bowel protocol are automatically put in place upon admission, with staff able to review discharge paperwork for this information. LPN E3 also stated the resident was having abdominal pain from a bowel obstruction and that the resident had an order for citrate of magnesium from the prior facility, which she did not believe he received. The DON and Nursing Home Administrator confirmed that the RN Supervisor refused to assess the resident and refused to send him to the hospital despite staff reports that he was requesting to be sent out, and confirmed the facility failed to protect the resident from neglect.
Failure to Timely Report Allegation of Neglect to State Authorities
Penalty
Summary
The facility failed to report an allegation of neglect within 24 hours to the local state field office for one of two residents. Facility policy dated 7/1/25 on Abuse, Neglect, and Exploitation required that all alleged violations be reported to the Administrator, state agency, adult protective services, and other required agencies immediately but no later than two hours if the allegation involved abuse or serious bodily injury, or no later than 24 hours if it did not. Neglect was defined in the policy as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of clinical records showed that one resident, admitted and later readmitted with diagnoses including constipation, hypertension, and cervicalgia, was involved in the incident. Progress notes for this resident dated 2/12/26, entered by RN Employee E1, documented that the resident requested to go to the hospital for abdominal pain and constipation and ultimately called 911 personally. Information later submitted to the State Agency by the DON on 2/16/26 indicated that on 2/13/26 the resident had requested transfer to the hospital, and an LPN and NA reported this request to the RN Supervisor, Employee E1. The RN Supervisor allegedly refused to assess the resident and refused to send the resident to the hospital. This sequence of events constituted an allegation of neglect that, per policy, required reporting within 24 hours to the appropriate agencies, including the local state field office. Interviews with the DON and the Nursing Home Administrator on 2/25/26 confirmed that such allegations must be reported within 24 hours and that the facility did not meet this requirement for this resident, resulting in noncompliance with multiple cited state regulations.
Failure to Implement Bowel Protocol and Respond to Resident’s Constipation Complaints
Penalty
Summary
The deficiency involves the facility’s failure to follow its bowel routine policy and physician orders to provide appropriate treatment and care for a resident with constipation. The facility’s Bowel Routine Policy required that each resident have routine bowel elimination, with Milk of Magnesia given if no bowel movement occurred in 72 hours, followed by Dulcolax suppository, then a Fleet enema, and physician notification if these were ineffective. The resident was admitted with diagnoses including constipation, high blood pressure, and cervicalgia, and admission documentation and the discharge transition packet later confirmed the last bowel movement was on 2/4/26. A progress note on 2/12/26 documented that the resident’s last bowel movement had been on 2/5/26, and the clinical record for that date did not show any bowel movement. On 2/12/26, physician orders were in place for a bowel regimen: Milk of Magnesia 30 ml by mouth as needed if no bowel movement in 48 hours, Dulcolax suppository if Milk of Magnesia was ineffective, and a Fleet enema if there was still no bowel movement after the suppository. Review of the February 2026 MAR showed no evidence that these medications were administered as ordered on 2/12/26. Staff interviews indicated that for newly admitted residents, last bowel movement is assessed upon admission, bowel protocol medications are automatically put in place, and staff can review discharge paperwork to determine the last bowel movement. An LPN stated that if a resident has not had a bowel movement in three days, the bowel protocol should be initiated, and that if a resident has a change in condition, they must be assessed, vitals obtained, and the physician notified. Multiple staff accounts and the resident’s own statements described repeated requests for help and for transfer to the hospital due to abdominal pain and lack of bowel movement, without appropriate nursing assessment or timely response. A nurse aide reported that the resident rang the call bell requesting to see the RN supervisor to go to the emergency room, that the RN supervisor was notified, and that the RN supervisor stated she had done his paperwork and was not going back, and did not go to the resident’s room. An LPN reported overhearing the resident say he wanted to go to the hospital and that he had been asking all day, complaining of not having a bowel movement in 7–10 days, and that the RN supervisor commented she did his paperwork and did not know what else she could do. The resident ultimately called 911 himself from his room. The hospital discharge summary documented that he was hospitalized for rectal fecal impaction and severe constipation requiring oral laxatives, disimpaction, and soap suds enema. The Nursing Home Administrator confirmed that the facility failed to provide care and services needed for the resident to attain or maintain the highest practicable well-being.
Failure to Follow Up on Building Structural Assessment
Penalty
Summary
The facility failed to maintain compliance with NFPA 101 requirements regarding building construction type and height. Specifically, the facility did not follow up on a building structural assessment quote that was provided by a vendor as part of an ongoing plan of correction. This quote was initially obtained in response to a previous survey, but no further action was taken to address the structural assessment needs. During document review and an interview with the maintenance supervisor, it was confirmed that the facility did not proceed with the necessary follow-up on the structural assessment. This inaction potentially affected the structural integrity of the building, as the required evaluation and any subsequent actions were not completed.
Plan Of Correction
The building structural assessment quote from February 27, 2025, will be reviewed with the Regional team and vendor for availability for service completion. The Director of Maintenance will follow up once a date is confirmed that the work will be completed. The Director of Maintenance will report to the monthly Quality Assurance meeting on the progress of the work.
Failure to Maintain Emergency Generator Control Board
Penalty
Summary
The facility failed to maintain the emergency generator as required by NFPA standards. During a document review, it was found that the annual planned maintenance inspection report for the 35 kW generator indicated that the unit's main control board needed to be replaced to prevent a possible no start condition. However, there was no documentation available to show that this issue had been corrected. This deficiency was confirmed during an interview with the maintenance supervisor, who acknowledged the lack of corrective documentation for the emergency generator. The report specifically notes that this failure affected one of two generators at the facility, and the required maintenance action was not completed or recorded as resolved.
Plan Of Correction
The systematic change will be to contact vendor to get the unit main control board replaced. The Director of Maintenance will monitor service needs to generator and have vendor repair onsite as needed. The Director of Maintenance will report this findings to the Administrator and Monthly Quality Assurance meeting.
Failure to Obtain Required Approvals and Maintain Accurate Life Safety Floor Plans
Penalty
Summary
The facility failed to maintain compliance with general requirements of the Life Safety Code (LSC) on one of its six building levels. Specifically, the facility did not obtain the required approval from the Department of Health State Plan Review or a granted occupancy from the Life Safety Division for converting resident rooms to storage rooms on the fifth floor. This deficiency was observed during a site visit and is a repeat finding from the previous year's survey. Additionally, the facility was unable to provide accurate floor plans that identified the fifth floor rooms as storage locations, and both the administrator and maintenance director confirmed that the necessary paperwork had not been submitted. Further deficiencies were identified regarding the facility's failure to maintain and provide accurate, portable floor plans that outlined designated rated partitions throughout the building. During document review and interviews, it was found that the facility did not have a Life Safety Code Floor Plan on-site that included required elements such as smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits, and shaft walls. The maintenance supervisor confirmed that the floor plan provided during the survey did not accurately contain these required items.
Plan Of Correction
The systematic change will be to get a copy of portable floor plans for the facility. A copy will be kept in the Administrator's office and the Director of Maintenance's office. The Administrator will review annually portable copies with the Director of Maintenance to assure there's a complete set for use. Monthly Quality Assurance meetings will review floor plans.
Stairway Exits Blocked by Caution Rope and Signage
Penalty
Summary
During an observation, it was found that stair tower doors on two of five building levels were blocked by a caution retractable rope with signage stating, "STOP!! DO NOT USE STAIRS ONLY FOR EMERGENCY." This setup prevented residents from using the stairways as exits except in emergencies, which could impede their ability to exit promptly. The maintenance director confirmed the presence of the rope and signage at the time of the survey. No additional information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
The systematic change will be to have the retractable rope become a breakaway rope so not to impede progress through the stair tower door. The Director of Maintenance will audit all stairwell doors to assure there a retractable rope in place and report findings to Monthly Quality Assurance meeting.
Combustible Decorations Obstruct Egress and Compromise Fire Door Integrity
Penalty
Summary
Surveyors observed that the facility failed to properly maintain combustible decorations on two of its five floors. On the first floor, combustible decorations were found plugged into the corridor, obstructing the full use of the egress pathway. Additionally, there was no documentation available at the time of the survey to confirm that these decorations were treated with fire retardant. On the second floor, santa banners were pinned to a fire and smoke door near the nurse station, which compromised the integrity of the door. These deficiencies were confirmed during an interview with the maintenance director, who acknowledged the issues with the combustible decorations. The observations were made during a survey conducted between 9:04 a.m. and 10:03 a.m. on December 19, 2025. No information about specific residents or their conditions was provided in the report.
Plan Of Correction
The systematic change will be to have the Christmas decorations that were in the hallway and covering doors be removed in total. The Administrator or designee will limit holiday materials in the hallway and doors, and the Administrator or designee will review holiday materials prior to placing them in the facility.
Improper Use of Outlet Multiplier in Salon
Penalty
Summary
The facility failed to comply with electrical equipment requirements as outlined by NFPA 101 and related standards. During an observation, it was found that in the first floor salon, a three-to-one outlet multiplier was plugged into the wall, with a hair dryer, hair straightener, and hair curler all connected to it. This setup does not meet the specified requirements for the use of power strips and outlet multipliers in patient care areas, as only certain types of equipment and UL-listed devices are permitted, and extension cords or outlet multipliers are not to be used as substitutes for fixed wiring. The maintenance director confirmed the use of the three-to-one outlet multiplier in the salon during an interview. The report does not mention any specific residents or patients involved, nor does it provide details about their medical history or condition at the time of the deficiency. The deficiency was identified based on direct observation and staff interview, indicating a failure to adhere to established electrical safety protocols in the facility.
Plan Of Correction
The systematic change was removing the three-to-one outlet immediately. The Director of Maintenance will monitor the beauty shop for appropriate use of electrical outlets. The Director of Maintenance will report this findings to the Administrator and Monthly Quality Assurance meeting.
Improper Oxygen Cylinder Storage Exceeding 300 Cubic Feet
Penalty
Summary
Surveyors observed that the facility failed to maintain proper oxygen cylinder storage on one of its building levels. Specifically, during an inspection of the basement activities room, it was found that the room contained more than 300 cubic feet of oxygen, with over 12 E-sized cylinders stored within the space. This storage arrangement did not comply with the requirements for oxygen storage as outlined by NFPA 101 and NFPA 99, which specify construction, ventilation, and separation standards for quantities exceeding 300 cubic feet. The maintenance supervisor confirmed during the interview that the observed storage practice constituted a deficiency. The report did not mention any specific residents or patient care areas directly affected at the time of the observation, nor did it provide details about any adverse events related to the deficiency. The focus of the deficiency was solely on the improper storage of oxygen cylinders in the basement activities room.
Plan Of Correction
The systematic change was removing the E-sized cylinders to make sure there were 12 or fewer in the basement activity room. The Director of Maintenance will monitor the basement activity room for appropriate storage of E-sized oxygen cylinders. The Director of Maintenance will report these findings to the Administrator and at the Monthly Quality Assurance meeting.
Failure to Provide Annual Emergency Preparedness Training to All Staff and Volunteers
Penalty
Summary
The facility failed to provide annual emergency preparedness training to all staff and volunteers as required by federal regulations. During a document review, it was found that there was no documentation confirming that all staff and volunteers had received the required annual emergency preparedness training based on the facility's emergency preparedness plan. An interview with the administrator and maintenance supervisor confirmed the absence of documentation verifying that all staff and volunteers had completed the annual emergency preparedness training. This lack of documentation indicated noncompliance with the requirement to maintain an up-to-date emergency preparedness training and testing program for all personnel.
Plan Of Correction
E 0036 The systematic change will be an emergency preparedness training will be held so all employees receive the required training for stated deficiency. The Administrator or designee will monitor the training to make sure it occurs and all employees have signed off receiving the training. An annual training will then be established so all employees received the Emergency Preparedness training required. Monthly Quality Assurance meeting will review training guidelines. Education will be completed by January 31, 2026.
Failure to Conduct and Document Required Emergency Preparedness Exercise
Penalty
Summary
Armstrong Rehabilitation and Nursing Center failed to maintain compliance with federal emergency preparedness requirements by not conducting, testing, and evaluating a full-scale exercise of its emergency plan. During a documentation review, surveyors found that the facility lacked records to verify that such an exercise had been planned or executed as required by regulation. The deficiency was confirmed through interviews with both the administrator and the maintenance supervisor, who acknowledged the absence of documentation related to the full-scale emergency exercise. This lack of evidence indicated that the facility did not meet the annual requirement to participate in a community-based or facility-based functional exercise to test its emergency preparedness plan. No information was provided in the report regarding specific residents, their medical histories, or their conditions at the time of the deficiency. The deficiency was identified during a Medicare/Medicaid Recertification Survey, and the finding was based solely on the facility's failure to document and perform the required emergency preparedness testing.
Plan Of Correction
The systematic change will be to have a full-scale exercise and training so the emergency plan can be tested and evaluated. The Administrator or designee will monitor the training to make sure it occurs and all employees have signed off receiving the training. Going forward, a planned full-scale exercise will be scheduled with local emergency personnel so the emergency plan can be tested and evaluated. Monthly Quality Assurance meetings will review training guidelines. The full-scale exercise will be completed by January 31, 2026. E 0039
Means of Egress Obstructed by Two-Step Lock on Office Door
Penalty
Summary
During an observation on December 19, 2025, it was found that the first floor environmental services office, located next to the salon, had a two-step lock on its door. This included a dead bolt, which could potentially slow down egress in the event of an emergency. The presence of this locking mechanism was confirmed in an interview with the administrator and maintenance director at the time of the observation. No information regarding residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
The systematic change was removing the deadbolt lock after the surveyor left the building. The Director of Maintenance will audit all office doors to assure there isn't a two-step locking mechanism in place. The Director of Maintenance will audit office doors for a two-step lock and report findings to the Monthly Quality Assurance meeting.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for five nurse aides, as required by federal regulations. Personnel records for these nurse aides, with hire dates ranging from 2011 to 2023, did not contain documentation of annual performance reviews based on their respective dates of hire. This deficiency was confirmed during an interview with a Human Resources employee, who acknowledged that the required annual evaluations had not been conducted for these staff members. No information regarding residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
For Nurse Aide (NA) Employee's 4, 5, 6, 7, and 8, the annual evaluations were completed. Nurse Aides' employment files will be reviewed to make sure annual evaluations have been completed. Evaluations will be completed annually based on hired date. Human Resource Director will educate the Director of Nursing on protocol for annual evaluations. Human Resource Director or designee will audit employee evaluations and set a schedule for the upcoming year. Results will be turned into the monthly Quality Assurance meeting.
Failure to Properly Store and Label Medications and Biologicals
Penalty
Summary
The facility failed to properly store medications and biologicals in multiple medication rooms and carts, as evidenced by observations and staff interviews. Specifically, expired and undated insulin vials and pens were found in two medication carts, with several items marked with opened dates well beyond the recommended 28-day usage period. Additionally, some insulin products were missing required opened and expiration dates. Staff confirmed that these items were expired at the time of observation. Further deficiencies were identified in three medication rooms, where expired medications, supplements, and medical supplies were found. Items such as expired fish oil, zinc, vitamin C, B12, iron, probiotics, IV tubing, and blood collection sets were observed. Some items were also undated, and staff interviews confirmed the expired status of these products. The facility's policies require medications to be stored according to manufacturer recommendations and for insulin to be dated upon opening, but these procedures were not followed. The facility's consultant pharmacist is responsible for routine inspections to identify and destroy discontinued, outdated, or deteriorated medications, but the presence of expired and improperly labeled items indicates that these inspections were either not conducted as required or were ineffective. The Nursing Home Administrator and the Director of Nursing confirmed the failure to properly store medications and biologicals in the affected medication rooms.
Plan Of Correction
During the survey, all medication and supplies that were expired were removed from med carts and supply rooms. All insulins in all medication carts and supplies in supply rooms will be checked for expiration dates and removed if expired. The Director of Nursing or designee will educate licensed nurses on the protocol for insulin dating and supply expiration dates. The Director of Nursing or designee will audit insulin dates and supply expiration dates weekly, three times, and monthly, two times. Results will be turned into the monthly Quality Assurance meeting.
Failure to Pay Transportation Vendor Resulting in Canceled Resident Appointments
Penalty
Summary
The facility failed to pay its transportation vendor in a timely manner, resulting in the cancellation of multiple resident appointments, including a critical eye surgery appointment for a resident with cerebral palsy, anxiety disorder, and gait abnormalities. The resident and their family reported that an initial eye appointment was canceled and rescheduled, but the rescheduled appointment was also canceled by the facility. The family was informed that the cancellation was due to the facility's inability to provide transportation. Interviews with staff, including the scheduler responsible for arranging transportation, confirmed that the appointment was canceled because the transportation company had not been paid by the facility. The scheduler indicated that this issue had occurred previously, but this was the longest period during which transportation was unavailable. Facility documentation showed that twelve appointments were canceled between October and December due to the lack of available transportation. The Nursing Home Administrator acknowledged that the facility failed to pay the transportation vendor on time, which directly led to the disruption of necessary medical appointments for residents. The facility's contract with the transportation provider required timely payment, and the failure to meet this obligation resulted in residents being unable to attend scheduled medical appointments.
Plan Of Correction
The invoices for transportation have been paid, and resident 57's appointment is scheduled for January 9, 2026. Invoices for transportation will be submitted timely and paid based on the due date. The administrator or designee will review weekly invoices with Accounts Payable for payment status. Audit of transportation invoices for payment will be conducted weekly (3 times) and monthly (2 times). Results will be presented at the monthly Quality Assurance meeting.
Infection Control Deficiencies: PPE Use, Room Cleaning, and Water Management
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices within the facility. Staff did not use personal protective equipment (PPE) appropriately in rooms under droplet isolation precautions, which were required due to the presence of COVID-19 on the third floor. Observations included nurse aides and an LPN entering and working in isolation rooms wearing only surgical masks or incomplete PPE, despite signage indicating the need for gowns, N95 respirators, gloves, and eye protection. Additionally, a visitor was not properly educated or equipped with the necessary PPE before entering a droplet isolation room, as confirmed by staff interviews. The facility also failed to ensure proper cleaning of resident rooms after discontinuation of isolation precautions. Housekeeping staff reported that residents remained in their beds during the deep cleaning process, which prevented thorough disinfection of beds, mattresses, and bedframes, and bedding was not laundered as required. This was confirmed by both housekeeping and administrative staff, who acknowledged that the cleaning procedures did not align with facility policy for post-isolation room cleaning. Furthermore, the facility did not maintain a comprehensive water management program to monitor and mitigate the risk of Legionella bacteria in the water system. The nursing home administrator was unable to provide documentation of a Legionella water management plan, including monitoring, auditing, or mapping of high-risk areas within the facility's water pipes. This deficiency persisted for a full year, as confirmed by the administrator during the survey.
Plan Of Correction
Resident weren't directly affected with Personal Protective Equipment (PPE) usage. The residents were removed from their beds and rooms cleaned, and the water management plan will be completed. All residents will be removed from their beds when rooms are cleaned. Employees will be instructed on what the protocol is for infection control signs hanging on the doors. The Director of Nursing or designee will educate nursing staff on the protocol for entering and leaving an infectious room and on educating a visitor on the protocol when the resident units or rooms have the infectious signs posted. The Director of Environmental Services will educate their staff on cleaning an infectious room post-isolation and the proper protocol of removing the resident from the bed. The Director of Nursing or designee will audit infectious rooms and proper PPE usage weekly times 3 and monthly times 2. The Director of Environmental Services will audit room cleans for removal of residents weekly times 3 and monthly times 2. Results will be turned into the monthly Quality Assurance meeting.
Failure to Provide Effective Communication Training to Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory training on Effective Communication to five out of seven direct care staff members, as required by both federal and state regulations. Review of personnel files for a registered nurse, three nurse aides, and a licensed practical nurse revealed that none had documentation of receiving Effective Communication training within the required annual period following their respective hire dates. The facility's own policy mandates that all staff must complete this training prior to independently providing services to residents, annually, and as necessary based on the facility assessment. During an interview, the Human Resources employee confirmed that the required training had not been provided to these staff members. The deficiency was identified through review of facility policies, training records, and staff interviews, with no evidence found that the affected staff had completed the necessary training within the specified timeframes.
Plan Of Correction
Employee's 3, 5, 6, 8, and 9 will receive the communication training in January 2026. All employees will receive an annual communication training during a set month of the year. Human Resource Director will educate all Department Directors on the annual education requirements for communication training. Human Resource Director or designee will audit the training to assure all staff have been educated on the training topic. Audit results will be turned into the Quality Assurance meeting monthly.
Failure to Provide Annual Resident Rights Training to Staff
Penalty
Summary
The facility failed to provide required training on Resident Rights to six out of seven reviewed staff members, including five nurse aides and one LPN. According to the facility's own policy, all staff, contractors, and volunteers must receive training on Resident Rights prior to independently providing services, annually, and as necessary based on the facility assessment. Personnel file reviews for these staff members showed no documentation of Resident Rights training within the required annual period. During an interview, the Human Resources employee confirmed that the identified staff members did not receive the mandated Resident Rights training. This deficiency was identified through review of facility policy, personnel files, and staff interviews, and it was determined that the facility did not meet the regulatory requirement to ensure staff are educated on resident rights and facility responsibilities.
Plan Of Correction
Employee's 4, 5, 6, 7, 8 and 9 will receive the resident rights training in January 2026. All employees will receive an annual resident rights training during a set month of the year. Human Resource Director will educate all Department Directors on the annual education requirements for resident rights training. Human resource Director or designee will audit the training to assure all staff have been educated on resident rights training topic. Audit results will be turned into the Quality Assurance meeting monthly.
Failure to Provide Annual Abuse, Neglect, and Exploitation Training to Staff
Penalty
Summary
The facility failed to provide required training on Abuse, Neglect, and Exploitation to four out of seven reviewed staff members, including three nurse aides and one LPN. According to the facility's own policy, all staff, contractors, and volunteers must receive training on these topics prior to independently providing services, annually, and as needed based on the facility assessment. Personnel file reviews revealed that these four staff members did not have documentation of having completed the required training within the specified annual timeframes following their hire dates. This deficiency was confirmed during an interview with a Human Resources employee, who acknowledged that the required training had not been provided to the identified staff members. The lack of training was identified through a review of facility policy, staff personnel files, and staff interviews, and it was determined that the facility did not meet the regulatory requirements for staff development and training on abuse, neglect, and exploitation prevention.
Plan Of Correction
Employee's 5, 6, 8, and 9 will receive the Abuse and Neglect training in January 2026. All employees will receive an annual Abuse and Neglect training during a set month of the year. Human Resource Director will educate all Department Directors on the annual education requirements for abuse and neglect training. Human Resource Director or designee will audit the training to assure all staff have been educated on Abuse and Neglect training topic. Audit results will be turned into the Quality Assurance meeting monthly.
Failure to Provide Required QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to five out of seven reviewed staff members, including a registered nurse, three nurse aides, and a licensed practical nurse. Review of personnel files for these employees showed no documentation of QAPI training within the required annual period, as specified by the facility's own policy and federal regulations. The policy mandates that all staff, including those under contract and volunteers, must receive training on the QAPI program prior to independently providing services, annually, and as necessary based on the facility assessment. During an interview, the Human Resources employee confirmed that the required QAPI training was not provided to these staff members. The deficiency was identified through review of training records and personnel files, which lacked evidence of completed QAPI training for the specified period for each of the five staff members. No information about residents or their conditions was included in the report.
Plan Of Correction
Employee's 5, 6, 8, and 9 will receive Quality Assurance and Performance Improvement training in January 2026. All employees will receive an annual Quality Assurance and Performance Improvement training during a set month of the year. The Human Resource Director will educate all Department Directors on the annual education requirements for Quality Assurance and Performance Improvement training. The Human Resource Director or designee will audit the training to assure all staff have been educated on Quality Assurance and Performance Improvement training topics. Audit results will be turned into the Quality Assurance meeting monthly. F 0944
Failure to Provide Required Infection Control Training to Staff
Penalty
Summary
The facility failed to provide mandatory infection control training to four out of seven reviewed staff members, including three nurse aides and one LPN. According to the facility's own policy, all staff, including those under contractual arrangements and volunteers, are required to complete infection prevention and control training prior to independently providing services, annually, and as necessary based on the facility assessment. Personnel file reviews revealed that these four staff members did not have documentation of infection control training within the required annual period following their respective hire dates. This deficiency was confirmed during an interview with a Human Resources employee, who acknowledged that the required infection control training had not been provided to the identified staff members. The lack of training was found to be inconsistent with both federal and state regulations, as well as the facility's internal policies regarding staff development and infection prevention.
Plan Of Correction
Employee's 5, 6, 8, and 9 will receive the Infection Control training in January 2026. All employees will receive an annual Infection Control training during a set month of the year. Human Resource Director will educate all Department Directors on the annual education requirements for Infection Control training. Human resource Director or designee will audit the training to assure all staff have been educated on Infection Control training topic. Audit results will be turned into Quality Assurance meeting monthly.
Failure to Provide Annual Compliance and Ethics Training to Staff
Penalty
Summary
The facility failed to provide required Compliance and Ethics training to five out of seven reviewed staff members, including a registered nurse, three nurse aides, and a licensed practical nurse. Review of personnel files showed that these employees did not have documentation of annual Compliance and Ethics training within the required timeframes, despite the facility's policy mandating such training for all staff, contractors, and volunteers. The policy also specifies that training must be completed prior to staff independently providing services and must be conducted annually and as necessary based on the facility assessment. During an interview, the Human Resources employee confirmed that the facility did not provide the required Compliance and Ethics training to these staff members. The deficiency was identified through review of facility policies, personnel files, and staff interviews, and it was determined that the facility did not meet the federal and state requirements for staff development and compliance training.
Plan Of Correction
Employee's 3, 5, 6, and 8 will receive the Compliance and Ethics training in January 2026. All employees will receive an annual Compliance and Ethics training during a set month of the year. Human Resource Director will educate all Department Directors on the annual education requirements for Compliance and Ethics training. Human Resource Director or designee will audit the training to assure all staff have been educated on Compliance and Ethics training topic. Audit results will be turned into Quality Assurance meeting monthly.
Failure to Provide Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that three out of five sampled nurse aides received the required minimum of 12 hours of in-service education per year. Personnel records and training documentation for these nurse aides (identified as E5, E6, and E8) did not contain evidence that they had completed the mandated annual in-service training. The review of facility nurse aide training records confirmed the absence of documentation for the required training hours for each of these employees. During an interview, the Human Resources staff member confirmed that the facility could not provide evidence that the three nurse aides had received the necessary yearly in-service training. The deficiency was cited under both federal and state regulations, specifically referencing requirements for ongoing staff development and the responsibility of the licensee to ensure compliance.
Plan Of Correction
Employee's 5, 6, and 8 will receive their 12 hours of in-service training in January 2026. All Nurse Aides will receive their 12 hours of in-service training during a set month of the year. Human Resource Director will educate all Director of Nursing on the annual 12 hours of in-service for Nurse Aides. Human Resource Director or designee will audit the training to ensure all nurse aides have been educated on the required topics for 12 hours of in-service annually. Audit results will be turned into Quality Assurance meeting monthly. F 0947
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide required behavioral health training to five out of seven reviewed staff members, including a registered nurse, three nurse aides, and a licensed practical nurse. According to the facility's own policy, all staff are to receive training in behavioral health annually and as necessary based on the facility assessment. Personnel files for these staff members showed no evidence of behavioral health training within the required timeframes following their respective hire dates. This deficiency was confirmed during an interview with a human resources employee, who acknowledged that the required behavioral health training had not been provided to the identified staff members. The lack of training was found through a review of facility policies, training records, and staff files, and was cited as a violation of both federal and state regulations regarding staff development and the responsibility of the licensee.
Plan Of Correction
Employee's 3, 5, 6, 8, and 9 will receive the Behavioral Health training in January 2026. All employees will receive an annual Behavioral Health training during a set month of the year. Human Resource Director will educate all Department Directors on the annual education requirements for Behavioral Health training. Human resource Director or designee will audit the training to ensure all staff have been educated on Behavioral Health training topic. Audit results will be turned into Quality Assurance meeting monthly.
Failure to Maintain Resident Dignity During Catheter Care and Meal Assistance
Penalty
Summary
The facility failed to provide care in a manner that maintained resident dignity for two residents. For one resident with a history of depression, neurogenic bladder, and quadriplegia, the clinical record indicated the use of an indwelling urinary catheter. Observation revealed that the resident's catheter drainage bag was left uncovered and hanging on the bed frame, contrary to the facility's catheter care policy, which requires privacy covers to be used at all times. This was confirmed by an LPN, who acknowledged that the lack of a privacy cover did not maintain the resident's dignity. For another resident with diagnoses including high blood pressure, cerebral infarction, and dementia, the clinical record and care plan indicated the resident was totally dependent on staff for self-feeding. During a lunch service, staff placed the resident's meal tray in front of her but did not provide the required assistance, leaving the resident without help to eat. This was confirmed by an LPN, who stated that the resident should have been assisted with lunch at the time the tray was delivered. The Director of Nursing confirmed that the facility failed to ensure care was provided in a manner that maintained the dignity of both residents. The findings were based on review of facility policies, clinical records, direct observation, and staff interviews, and were found to be inconsistent with both federal and state requirements for resident rights and nursing services.
Plan Of Correction
Resident R 3 had a catheter dignity bag placed on their catheter bag and resident R44 was fed their meal that day of survey. All residents with catheters will be reviewed to assure dignity bags are placed on catheter bags and residents with an order for assisted feeding will be reviewed and fed their meals. The Director of Nursing will educate nursing staff on placement of dignity bags on the catheter bags and all residents that are assisted with meals will be fed when their tray is delivered. The Director of Nursing or designee will audit catheter bags for dignity bag placement 3 times a week for 3 weeks, then 3 times a week for 2 weeks and 3 times a week for 1 week. Residents with orders for assistance to be fed will be reviewed and audited during mealtime that assistance was provided weekly times 3 and monthly times 2. Results will be turned into the monthly Quality Assurance meeting.
Failure to Document Opportunity for Advance Directives
Penalty
Summary
The facility failed to provide documentation that residents or their representatives were given the opportunity to formulate an advance directive, as required by federal regulations. Specifically, for two of four residents reviewed, there was no evidence in the clinical records that the residents were informed about or offered the chance to create an advance directive, such as a living will or durable power of attorney for health care. The facility's policy states that upon admission, staff should determine if a resident has an advance directive and, if not, offer information and the opportunity to formulate one, but this was not documented for the affected residents. One resident had diagnoses including depression, neurogenic bladder, and quadriplegia, while another had chronic obstructive pulmonary disease (COPD), muscle weakness, and cancer. Despite these significant medical conditions, their records did not contain an advance directive or documentation of being given the opportunity to create one. The facility's social worker confirmed during an interview that this documentation was missing for these residents.
Plan Of Correction
Resident R3 and Resident R44 were both given the opportunity for Advanced Directives, and the Social Worker documented they were provided. The Social Worker will look back for the past 30 days and review documentation of advanced directives with new Admissions. The Administrator educated the Social Worker on the need to document that advanced directives were given to new admissions. The Social Worker or designee will document new admission advanced directives weekly times 3 and monthly times 2. Results will be turned into the monthly Quality Assurance meeting.
Failure to Develop Person-Centered Care Plan for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to develop and implement a person-centered care plan with appropriate interventions for a resident who had documented mental health diagnoses, including suicidal ideation, schizophrenia, and anxiety disorder. The resident's care plan listed 'suicidal ideations' as a focus but did not include a specific goal related to this issue, and the only intervention documented was the use of plastic silverware. No additional interventions or strategies to address the resident's suicidal ideation were included in the care plan or clinical record. Clinical progress notes revealed that the resident expressed feelings of purposelessness and made statements about not wanting to be alive. On two separate occasions, the resident attempted to harm herself using plastic utensils. Despite these incidents and the resident's mental health history, the care plan was not updated to include further interventions to address her suicidal ideation. The deficiency was identified through clinical record review and staff interviews, confirming the lack of a comprehensive, person-centered care plan for this resident.
Plan Of Correction
Resident R7 was at hospital and care plan was corrected upon her return. December 22, 2025. All residents with suicide ideations care plans were reviewed to make sure they were person-centered care plans. The Director of Nursing or designee will educate Nursing Administration staff on person-centered care plans for residents with suicide ideation. The Director of Nursing or designee will audit care plans with suicide ideations weekly times 3 and monthly times 2. Results will be turned into the monthly Quality Assurance meeting.
Failure to Assess and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with a pressure ulcer was properly assessed and provided with necessary treatment and services in accordance with professional standards of practice. The facility's policy requires prompt assessment and treatment of pressure injuries, including regular risk assessments, full body skin assessments, and documentation of findings in the medical record. However, for one resident who was admitted with multiple diagnoses including COPD, diabetes mellitus, and bipolar disorder, a new stage 3 pressure injury to the coccyx was identified, but the required weekly wound documentation was not completed from the time the wound was discovered. Additionally, the Braden Scale for Predicting Pressure Sore Risk, which is intended to be updated regularly and after significant changes in a resident's condition, had not been updated for this resident since several months prior to the identification of the pressure injury. The care plan for pressure ulcer development was also not updated in a timely manner to reflect the resident's current skin status. These lapses were confirmed by both the DON and the NHA during interviews, who acknowledged the lack of updated assessments and documentation. The deficiency was identified through review of facility policies, clinical records, and staff interviews, which revealed that the facility did not follow its own protocols for pressure injury prevention and management. The absence of timely wound documentation, risk reassessment, and care plan updates for the resident with a stage 3 pressure injury constituted a failure to provide care consistent with professional standards and the facility's stated procedures.
Plan Of Correction
Resident 8 was given a skin assessment during survey week. All residents with newly reported skin issues were reviewed to make sure they have the weekly skin notes. The Director of Nursing or designee will educate Nursing Administration staff on proper skin issue documentation. The Director of Nursing or designee will audit reports of new skin issues for skin assessments weekly, three times, and monthly, two times. Results will be turned into the monthly Quality Assurance meeting.
Failure to Provide Adequate Supervision for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide adequate supervision for a resident with significant mental health concerns, resulting in multiple suicide attempts. The resident, who had diagnoses of suicidal ideation, schizophrenia, and anxiety disorder, expressed feelings of hopelessness and made statements about not wanting to be alive. On two consecutive days, the resident attempted self-harm using plastic utensils—a fork and a spoon—despite staff being aware of her mental health status and recent expressions of suicidal ideation. Facility policies required immediate safety interventions for residents with suicide ideation or attempts, including one-on-one observation, removal of potential means for self-harm, and urgent mental health evaluation. However, the clinical record and staff interviews confirmed that these measures were not adequately implemented for this resident, as she was able to access items to attempt self-harm and was not under continuous supervision as required by policy.
Plan Of Correction
Resident R7 was sent to hospital on December 6, 2025, and escorted by a staff member during transport. No other residents presented with suicide ideations currently that needed one-to-one care. The Director of Nursing or Designee will educate nursing staff on protocol when a resident with suicide ideation starts to act on them. The Director of Nursing or Designee will audit resident prevention with suicide ideations weekly times 3 and monthly times 2. Results will be turned into the monthly Quality Assurance meeting.
Failure to Assess and Update Nutritional Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to accurately assess the nutritional status and update the individualized care plan for a resident with significant health concerns. According to the facility's own policy, a comprehensive nutritional assessment by a dietitian is required within 72 hours of admission, annually, and upon a significant change in condition. However, for a resident admitted with chronic obstructive pulmonary disease, diabetes mellitus, and bipolar disorder, and who developed a Stage 3 pressure ulcer, the required comprehensive nutritional assessment was not completed following a significant change in condition as documented in the Minimum Data Set (MDS) assessment. The clinical record review did not show evidence that the dietitian completed the necessary assessment to address the resident's current nutritional status in relation to the Stage 3 pressure ulcer. Specifically, there was no documentation of updated nutrient needs, evaluation of laboratory or diagnostic values, or assessment of the need for additional nutritional interventions to support pressure ulcer repair. The absence of this assessment was confirmed by the registered dietitian during an interview. Additionally, the resident's nutritional care plan, which was last updated after the significant change in condition, did not include any focus, goals, or interventions related to the newly identified Stage 3 pressure ulcer. This lack of care plan update was acknowledged by both the registered dietitian and facility leadership, confirming that the resident's specific nutritional concerns were not addressed as required.
Plan Of Correction
Resident 8 received an updated nutritional assessment and updated care plan. All residents in the last 30 days that have a nutritional concern will be reviewed for having a nutritional assessment and updated care plan based on their needs. Administrator or designee will educate the Registered Dietician and Certified Dietary Manager on the need to do accurate nutrition assessment and updating the care plans based on their nutritional needs. Registered Dietician or designee will audit 3 resident nutrition assessments and care plans weekly times 3 and monthly times 2. Results will be turned into monthly Quality Assurance meeting.
Failure to Follow Respiratory Care Protocols for Oxygen and Nebulizer Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents who required oxygen and nebulizer treatments. For one resident with diagnoses including depression, neurogenic bladder, and quadriplegia, physician orders specified oxygen administration as needed. However, during observation, the nasal cannula was found lying on top of the oxygen concentrator and not stored in a plastic bag when not in use, contrary to facility policy. An LPN confirmed that the cannula was not properly stored. For another resident with depression, heart failure, and COPD, physician orders required nebulizer treatments as needed. Observation revealed that the nebulizer machine and tubing were left on the bedside table, with the tubing undated and not stored in a bag as required by policy. An LPN confirmed these findings. The Director of Nursing acknowledged that the facility did not provide appropriate respiratory care for these residents.
Plan Of Correction
F 0695 Resident 3 and Resident 65 had their nasal cannula bagged and dated immediately when found. All residents that have a nasal cannula will be reviewed to assure they are bagged when not in use and all tubing is dated. The Director of Nursing or Designee will educate Nursing staff on protocol for bagging the oxygen equipment and dating the tubing. The Director of Nursing or designee will audit bagging the oxygen equipment and dating the tubing weekly times 3 and monthly times 2. Results will be turned into the monthly Quality Assurance meeting.
Failure to Provide Timely Social Services for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide sufficient and timely medically-related social services to a resident with a known history of suicidal ideation, schizophrenia, and anxiety disorder. The resident was admitted with these diagnoses and had previously received therapeutic services, which were discontinued in October due to reported cognitive decline and lack of communication with the therapist. After the discontinuation of therapy, there was no evidence of further clinical therapeutic services or psychotropic medication management for the resident from October through December. In early December, staff documented that the resident expressed feelings of purposelessness and made statements indicating suicidal ideation. The resident also attempted self-harm using plastic utensils on two occasions. Despite these incidents and the resident's ongoing expressions of distress, there was no documentation that the facility contacted the clinical therapist or nurse practitioner for further evaluation or intervention. Interviews with staff confirmed awareness of the resident's recurring distressing dreams and mental health concerns, yet no additional social services or therapy were provided during this period.
Plan Of Correction
Resident R7 was sent to hospital on December 6, 2025, and Social Services needs would be addressed when she returned. No other residents currently present with suicide ideations that need further social service interventions. The Director of Nursing or Designee will educate Social Services on protocol when a resident with suicide ideation discusses dreams to provide the necessary therapy or interventions. Social Services or designee will audit resident prevention with suicide ideations weekly times 3 and monthly times 2. Results will be turned into monthly Quality Assurance meetings.
Significant Medication Error: Insulin Not Administered With Meal
Penalty
Summary
A deficiency occurred when a resident with diagnoses of arthritis, depression, and diabetes did not receive their prescribed insulin as ordered. The facility's policy requires that medications be administered by licensed nurses according to physician orders and professional standards, specifically following the six rights of medication administration. The resident had a physician order for eight units of Insulin Aspart to be administered subcutaneously with meals. However, during a medication pass observation, an LPN administered the insulin at 9:42 a.m., which was after the resident's breakfast tray had already been delivered at 7:55 a.m. The LPN acknowledged that the medication was given late and not in accordance with the order to administer it with meals. The Director of Nursing confirmed that the resident did not receive the medication as ordered, resulting in a significant medication error. This event demonstrated a failure to ensure that residents are free from significant medication errors, as required by facility policy and regulatory standards.
Plan Of Correction
Resident R36 was assessed by the RN. Resident R36 has had no ill effects due to the medication error. Employee E18 was re-educated on the Facility Medication Policy by the Director of Nursing. The Director of Nursing or designee will re-educate Licensed nurses on the Facility Medication Policy. The Director of Nursing or designee will audit 3 medication passes for 3 weeks. Then 2 medication passes weekly for 4 weeks. Results will be reviewed monthly by the Quality Assurance Committee.
Incomplete Required Postings for State Agencies and Complaint Procedures
Penalty
Summary
The facility failed to post complete and required contact information for the State Survey Agency, Adult Protective Services, and the Medicaid Fraud Unit on all three floors. Specifically, the postings did not include email addresses for these agencies as mandated by regulation. Additionally, the facility did not display a statement informing residents that they may file a complaint with the State Survey Agency regarding any suspected violation of state or federal nursing facility regulations. These deficiencies were identified during observations conducted on all three floors, and the absence of the required postings was confirmed in an interview with the Nursing Home Administrator. No information was provided in the report regarding specific residents or their medical conditions in relation to this deficiency.
Plan Of Correction
No residents were directly affected by the posting, but they were corrected the week of survey. All postings were corrected so residents and families have the correct information available for their use if needed. Administrator or designee will educate administration staff on proper signage for state survey agencies, adult protective services, and the Medicaid fraud unit. Administrator or designee will audit the three postings weekly times 3 and monthly times 2. Results will be turned into the monthly Quality Assurance meeting.
Infection Control Committee Lacked Required Multidisciplinary Attendance
Penalty
Summary
The facility failed to ensure that all required nine multidisciplinary members were present at the quarterly Infection Control Committee meetings for three out of four quarters. Specifically, attendance records for the first, second, and third quarterly meetings showed that the Medical Director, a laboratory representative, and a pharmacy representative were not present at various meetings. The facility's policy requires a risk assessment using an all-hazard approach to prioritize infection prevention and control activities, and these meetings are intended to support that process. Interviews with the Director of Nursing confirmed that the required members were not in attendance for the specified quarters. The absence of these key members was documented in the meeting attendance logs, and the deficiency was acknowledged by facility leadership during the survey process. No information about specific residents or their medical conditions was provided in the report.
Plan Of Correction
Required signatures couldn't be obtained since meetings have passed. Infection preventionist will have the Medical Director, lab, and pharmacy attend 1 meeting each quarter of the year. Director of Nursing or Designee will educate all team members of Infection Prevention on required meeting attendance. Director of Nursing or designee will audit the Infection Control meetings to assure all required attendance is met quarterly. Audit results will be turned into Quality Assurance meeting monthly.
Missing Practitioner Verification of Employee Health Status
Penalty
Summary
The facility failed to ensure that personnel records for two employees, a dietary aide and a nurse aide, included documentation from a licensed health care practitioner verifying that each employee was free from communicable diseases or conditions as of their start date. Review of the personnel files showed that the required health forms were present but were only signed by the employees themselves, not by a physician, nurse practitioner, or physician's assistant. This omission was confirmed during an interview with a human resources staff member, who acknowledged that the necessary practitioner verification was missing from the files reviewed.
Plan Of Correction
Employe 1 and 2 had their physical forms reviewed and signed by health care practitioners. Human Resource Director will make review the last 10 new hires physical form to verify they were signed prior to starting employment clearing them form communicable diseases. Director of Nursing or Designee will Human Resources on required physical form signed prior to starting employment clearing them form communicable diseases. Human Resources or designee will audit the New hire employee files to assure all required signatures are completed. Audit results will be turned into Quality Assurance meeting monthly.
Failure to Provide Required Accident Prevention Training to Staff
Penalty
Summary
The facility failed to provide required Accident Prevention training to six out of seven reviewed staff members, including five nurse aides and one LPN. According to the facility's own policy, all staff, including those under contractual arrangements and volunteers, must receive training on accident prevention prior to independently providing services, annually, and as necessary based on the facility assessment. Personnel file reviews for these staff members showed no documentation of Accident Prevention training within the required annual period for each individual. This deficiency was confirmed during an interview with a Human Resources employee, who acknowledged that the required training had not been provided to the identified staff members. The lack of documented training was specifically noted for each staff member based on their hire dates and the corresponding annual training periods.
Plan Of Correction
Employee's 4, 5, 6, 7, 8, and 9 will receive the Accident Prevention training in January 2026. All employees will receive an annual Accident Prevention training during a set month of the year. Human Resource Director will educate all Department Directors on the annual education requirements for Accident Prevention training. Human resource Director or designee will audit the training to assure all staff have been educated on Accident Prevention training topic. Audit results will be turned into Quality Assurance meeting monthly.
Failure to Provide Restorative Nursing Training to Staff
Penalty
Summary
The facility failed to provide required training on Restorative Nursing techniques to seven staff members, including RNs, LPNs, and NAs. According to the facility's own policy, all staff, including those under contractual arrangements and volunteers, must receive training relevant to their roles before independently providing services to residents, annually, and as necessary based on the facility assessment. Personnel file reviews for the identified staff members showed no evidence of Restorative Nursing training within the required annual period following their respective hire dates. During an interview, the Human Resources representative confirmed that none of the seven staff members received the mandated Restorative Nursing training. This lack of training was identified through a review of facility policy, staff personnel files, and direct staff interviews, establishing that the facility did not meet its own training requirements for staff competency in Restorative Nursing.
Plan Of Correction
Employee's 3, 4, 5, 6, 7, 8, and 9 will receive the Restorative Nursing training in January 2026. All employees will receive an annual Restorative Nursing training during a set month of the year. Human Resource Director will educate all Department Directors on the annual education requirements for Restorative Nursing training. Human Resource Director or designee will audit the training to assure all staff have been educated on Restorative Nursing training topic. Audit results will be turned into Quality Assurance meeting monthly.
Failure to Provide Annual Emergency Preparedness Training to Staff
Penalty
Summary
The facility failed to provide required Emergency Preparedness training to six out of seven reviewed staff members, including five nurse aides and one LPN. According to the facility's own policy, all staff, contractors, and volunteers must complete training on emergency preparedness prior to independently providing services, annually, and as needed based on the facility assessment. Personnel file reviews for these six employees showed no documentation of Emergency Preparedness training within the required annual period following their respective hire dates. This deficiency was confirmed during an interview with a Human Resources employee, who acknowledged that the required training had not been provided to these staff members. The lack of documented training was identified through a review of facility policies, staff files, and direct staff interviews.
Plan Of Correction
Employee's 4, 5, 6, 7, 8, and 9 will receive the Emergency Preparedness training in January 2026. All employees will receive an annual Emergency Preparedness training during a set month of the year. Human Resource Director will educate all Department Directors on the annual education requirements for Emergency Preparedness training. Human resource Director or designee will audit the training to assure all staff have been educated on Emergency Preparedness training topic. Audit results will be turned into Quality Assurance meeting monthly.
Failure to Provide Annual Fire Prevention and Safety Training to Staff
Penalty
Summary
The facility failed to provide required training on Fire Prevention and Safety to six out of seven reviewed staff members, including five nurse aides and one LPN. According to the facility's own 'Training Requirements' policy, all staff, contractors, and volunteers must receive training in key areas, including fire prevention and safety, prior to independently providing services, annually, and as needed based on the facility assessment. Personnel file reviews for the identified staff members showed no documentation of Fire Prevention and Safety training within the required annual period. During an interview, the Human Resources employee confirmed that the required training had not been provided to these staff members. The deficiency was identified through a review of personnel files and facility policy, with specific hire dates and missing training periods noted for each affected staff member. No information about residents or their conditions was included in the report.
Plan Of Correction
Employees 4, 5, 6, 7, 8, and 9 will receive the Fire Prevention training in January 2026. All employees will receive an annual Fire Prevention training during a set month of the year. Human Resource Director will educate all Department Directors on the annual education requirements for Fire Prevention training. Human resource Director or designee will audit the training to assure all staff have been educated on Fire Prevention training topic. Audit results will be turned into Quality Assurance meeting monthly.
Failure to Protect Resident from Neglect Following Fall and Inadequate Staff Response
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not follow proper procedures after the resident experienced a fall. The resident, who had diagnoses including high blood pressure, dementia, and impulse disorder, was admitted to the facility and later complained of increased hip pain. An X-ray revealed an acute displaced fracture of the left proximal femur. Investigation revealed that the fall was not documented in the clinical record, and there was no notification or documentation of the incident. Staff interviews and witness statements indicated that after the resident fell out of bed, an LPN responded but did not assess the resident appropriately and instead forcefully placed the resident back onto the bed without proper evaluation or assistance, then left the room without further care or documentation. The incident was not reported or documented as required by facility policy, and the staff involved did not follow established protocols for post-fall assessment and notification. The Director of Nursing was unaware of the fall until after the injury was discovered, and only learned of the incident through staff interviews during the subsequent investigation. The lack of immediate assessment, failure to notify appropriate personnel, and absence of documentation contributed to the facility's failure to protect the resident from neglect.
Failure to Administer Physician-Ordered Medications for Itching
Penalty
Summary
The facility failed to administer medications as ordered by physicians for two residents with documented skin conditions and persistent itching. One resident, with diagnoses including hypertension, COPD, and urinary retention, developed a generalized rash with excoriations and was observed repeatedly scratching, resulting in blood-stained bedding. Despite a physician's order for hydroxyzine HCL to be given every eight hours as needed for itching, the medication was not administered for several days. Staff interviews confirmed awareness of the resident's ongoing itching and the failure to provide the ordered medication. Another resident, diagnosed with a rash, COPD, and depression, also experienced persistent itching and visible rashes on multiple body areas. This resident had physician orders for hydrocortisone cream and hydroxyzine HCL for itching, but the oral medication was not administered as ordered over several days. The resident reported that staff did nothing to help with the itching, and staff interviews, as well as observations, confirmed the lack of medication administration. The Director of Nursing and Nursing Home Administrator acknowledged the failure to provide medications as ordered for both residents.
Failure to Implement Transmission-Based Precautions and Scabies Testing
Penalty
Summary
The facility failed to implement transmission-based precautions and conduct appropriate testing for scabies for two residents who exhibited symptoms consistent with a possible infestation. According to the facility's own policy, residents with signs and symptoms of scabies, such as itching and rash, should be assessed, isolated, and tested to prevent further transmission. However, despite multiple documented instances of residents presenting with generalized itching, rashes, and excoriations, there were no physician orders for skin scrapings to rule out scabies, nor were contact precautions initiated for these residents. Resident records revealed that one resident had a persistent, generalized rash with linear excoriations and continued to scratch, resulting in bedding stained with blood. Another resident reported itching and developed a rash on multiple body areas, with no evidence of diagnostic testing for scabies being performed, despite being told it would be. Both residents were observed in shared rooms without any contact isolation signage or precautions in place, and staff interviews confirmed ongoing concerns about scabies and the lack of appropriate interventions. The infection preventionist acknowledged a previous outbreak of scabies in the facility and confirmed that while some residents had been treated, others with symptoms were not tested or placed on precautions. Staff interviews further indicated awareness of the symptoms and concerns about scabies, but there was a lack of follow-through in implementing the facility's infection control policy. The deficiency was identified through review of records, staff and resident interviews, and direct observation during the facility tour.
Failure to Provide Written Notice Prior to Resident Room Change
Penalty
Summary
The facility failed to provide written notice, including the reason for a room change, to a resident and their responsible party prior to moving the resident to a different floor. According to the facility's policy, residents and their representatives must be notified in writing before any room change occurs. In this case, the clinical record review showed that the resident, who had a diagnosis of anxiety and muscle weakness and was assessed as moderately cognitively impaired with a BIMS score of 12, was transferred from the second to the third floor. The progress notes indicated the resident was not happy with the move but was willing to try the change. There was no documentation in the clinical record that the responsible party was notified of the room change before it occurred. Staff interviews confirmed that the move was made for safety reasons and that the responsible party was neither asked for input nor given options prior to the transfer. The Director of Nursing acknowledged that the required written notice, including the reason for the room change, was not provided to the resident or their representative in advance.
Lack of Person-Centered Care Plan for Resident at Risk of Wandering
Penalty
Summary
The facility failed to ensure that a resident identified as high risk for wandering and elopement had a person-centered care plan individualized to their specific needs. Review of the resident's clinical record showed diagnoses of anxiety and muscle weakness, with a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. The resident's elopement evaluation identified them as a risk for elopement, and the care plan noted wandering behavior. However, the interventions listed in the care plan were generic, such as administering medication and initiating psychiatric or psychological evaluations, without any individualized or person-centered strategies tailored to the resident's unique needs or behaviors. Facility policies require that care plans be reviewed and revised upon status changes and that residents at risk for wandering or elopement receive care in accordance with person-centered planning. Despite these policies, the care plan for this resident did not include specific interventions or goals addressing the resident's individual risk factors or behaviors related to wandering. This deficiency was confirmed by the Director of Nursing during an interview, who acknowledged the lack of individualized, person-centered interventions in the care plan for the resident at high risk for wandering or elopement.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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