Barnes-kasson County Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Susquehanna, Pennsylvania.
- Location
- 2872 Turnpike Street, Susquehanna, Pennsylvania 18847
- CMS Provider Number
- 395285
- Inspections on file
- 14
- Latest survey
- January 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Barnes-kasson County Hospital during CMS and state inspections, most recent first.
A resident with a Foley catheter developed pressure sores due to inconsistent implementation of preventative measures. Despite being at risk, the facility failed to consistently alternate the catheter tubing and use protective barriers, leading to further skin issues. Documentation and timely interventions were lacking, contributing to the deficiency.
The facility failed to ensure clinical necessity for antibiotic use in two residents, leading to unnecessary medication prescribing. One resident with a history of psychotic disorder and UTIs received Macrobid without meeting criteria for a UTI diagnosis. Another resident with dementia received Macrobid and Rocephin despite not meeting criteria for antibiotic treatment. The facility did not adhere to prescribing guidelines, resulting in unnecessary medication use.
The facility failed to implement antibiotic stewardship protocols for two residents, leading to the initiation and continuation of antibiotic therapy without documented clinical necessity. One resident received Macrobid despite not meeting UTI criteria, while another was prescribed Macrobid and Rocephin without documented evidence of a UTI diagnosis. The nursing home administrator acknowledged the failure to adhere to infection prevention and control guidelines.
The facility failed to maintain an effective antibiotic stewardship program, leading to inappropriate and prolonged use of antibiotics among five residents. The lack of documented protocols and monitoring systems resulted in the administration of antibiotics without proper justification or physician support.
The facility failed to consult a resident's physician regarding repeated refusals of prescribed medication. The resident, who was moderately cognitively impaired and diagnosed with dementia, refused medication daily over a period of more than two months. There was no documented evidence of physician consultation, as confirmed by the DON.
The facility failed to timely assess declines in skin integrity for two residents with pressure ulcers. Initial assessments were conducted by an LPN, but there was no documented evidence of timely RN assessments. The care plans were not reviewed or revised, and the attending physicians were not promptly notified.
The facility failed to provide necessary behavioral health care for two residents. One resident with dementia exhibited physical aggression and medication refusals without receiving psychological services or physician notification. Another resident with bipolar disorder and anxiety did not receive psychological services despite increased anxiety and reported concerns to staff.
A deficiency was identified when a physician failed to act on multiple drug irregularities identified by a pharmacist for a resident with anxiety, depression, and delusional disorder. Despite recommendations for evaluating opioid use and considering gradual dose reductions for Duloxetine and Quetiapine, the physician did not respond, as confirmed by the DON.
The facility failed to ensure that several residents' drug regimens were free from unnecessary antibiotics. Multiple residents received antibiotics without proper documentation or justification, leading to the administration of unnecessary medications. The DON confirmed these deficiencies.
The facility failed to develop and implement infection control procedures for tracking and managing chronic infections among its residents. Infection control logs from July 2023 through February 2024 showed four residents with chronic infections treated with ongoing antibiotics, but there was no monitoring or reassessment of the need for continued antibiotic usage. The facility's infection control program lacked procedures for addressing lifelong/chronic infections and related monitoring activities.
A resident with bipolar disorder and anxiety was not afforded the right to make choices about her medication treatment options. Despite being cognitively intact and requesting specific medications that had previously helped her, the facility did not address her concerns, and she was not prescribed the requested medications or supplements.
The facility failed to evaluate the clinical necessity of an indwelling urinary catheter for a resident. Despite the resident being continent of urine, the catheter was not removed, and there was no documentation to support its continued use. The facility did not monitor the resident's hourly urine output as required.
The facility failed to ensure physician documentation of the clinical rationale for the continued dose of an antipsychotic drug for a resident and did not attempt a gradual dose reduction. The resident had been receiving Quetiapine (Seroquel) since July 2020, and a pharmacist's review requested a dose reduction or documented rationale, which was not provided.
Failure to Prevent Pressure Ulcers in Resident with Foley Catheter
Penalty
Summary
The facility failed to consistently provide care and services to prevent the development and promote healing of pressure sores for a resident. The resident, who was moderately cognitively impaired and at risk for developing pressure sores, developed a 2cm-by-2cm open area on the right labia and an excoriation in the vaginal area, presumed to be caused by the Foley catheter tubing. Although an intervention was put in place to alternate the Foley catheter tubing between the right and left legs daily, there was no evidence that this intervention was consistently documented or implemented. Further issues arose when a blister was identified on the resident's right inner thigh, again presumed to be caused by pressure from the Foley catheter. Despite preventative measures such as alternating the catheter tubing and using a protective barrier, there was no evidence these measures were consistently followed. The facility's failure to implement and document effective interventions contributed to the development of additional pressure-related skin issues, as evidenced by the lack of documentation and the director of nursing's inability to provide evidence of timely interventions.
Failure to Ensure Clinical Necessity for Antibiotic Use
Penalty
Summary
The facility failed to ensure documented evidence of clinical necessity for the administration of antibiotic medications for two residents, leading to unnecessary medication prescribing practices. Resident 14 was admitted with a history of psychotic disorder with delusions and a history of urinary tract infections (UTIs). Despite not meeting the Revised McGeer's Criteria for a UTI diagnosis, the resident was prescribed Macrobid, an antibiotic, and received 13 out of 14 doses without documented justification for its use. The Infection Preventionist confirmed that the prescribing physician was aware that the criteria were not met, yet the facility did not prevent unnecessary antibiotic use. Resident 34, admitted with dementia and a history of UTIs, exhibited increased lethargy and weakness, prompting orders for urinalysis and culture and sensitivity testing. The resident was prescribed Macrobid and later received Rocephin, both intramuscularly and intravenously, despite the 72-Hour Antibiotic Time-Out form indicating that the resident did not meet McGeer's criteria for antibiotic treatment. The culture results showed the presence of E. coli, but there was no documented evidence supporting the UTI diagnosis, and the resident received multiple doses of antibiotics without clinical necessity. Interviews with the Infection Preventionist and the Nursing Home Administrator confirmed that the prescribing physician and staff failed to adhere to prescribing guidelines, and the nursing staff inconsistently completed the infection surveillance checklist. This resulted in the administration of unnecessary medications and non-compliance with established guidelines for preventing unnecessary medication use, as confirmed by the Nursing Home Administrator.
Failure to Implement Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to consistently implement its antibiotic stewardship protocols for initiating antibiotic use in accordance with established infection prevention and control guidelines for two residents. For Resident 14, a Licensed Practical Nurse noted increased confusion and burning upon urination, leading to a urinalysis and culture and sensitivity test. Despite the culture results not meeting the diagnostic criteria for a urinary tract infection (UTI), Macrobid was prescribed, and the resident received 13 out of 14 doses without evidence of clinical necessity. The infection preventionist confirmed the failure to adhere to antibiotic stewardship protocols, including ensuring criteria were met before initiating treatment. Similarly, the facility did not follow its antibiotic stewardship protocol for Resident 34. The resident exhibited increased lethargy and weakness, prompting orders for urinalysis and culture and sensitivity testing. Macrobid was prescribed the same day, and the resident was transferred to the emergency room and returned with a UTI diagnosis. However, the infection surveillance checklist was incomplete, and there was no documented evidence supporting a UTI diagnosis before initiating Macrobid therapy. Additional orders for Rocephin were made, but the 72-hour antibiotic timeout form indicated the resident did not meet the criteria for antibiotic treatment. The nursing home administrator acknowledged the facility's failure to implement antibiotic stewardship protocols for both residents. This failure led to the initiation and continuation of antibiotic therapy without documented evidence of clinical necessity, inconsistent use of infection surveillance tools, and noncompliance with infection prevention and control guidelines.
Failure to Maintain Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program, as evidenced by the lack of documented protocols and monitoring systems for antibiotic use among five residents. Resident CR1 was administered Macrobid daily for chronic urinary tract infections without documented physician support or diagnostic criteria. Similarly, Resident 9 received Macrobid twice daily for chronic UTIs without proper documentation to justify the lifelong administration of the antibiotic. Resident 20's case revealed multiple failures, including the administration of Macrobid at incorrect dosages and the concurrent use of antibiotics that were not supported by culture and sensitivity reports. The nursing staff also failed to transcribe a physician's order to reduce the Macrobid dosage, leading to prolonged inappropriate antibiotic use. Resident 10 was prescribed Doxycycline for lifelong prophylactic measures against MRSA without documented clinical necessity. The orthopedic consult recommended lifelong antibiotic therapy, but subsequent reviews and consults did not support the continued use of Doxycycline. Despite this, the resident continued to receive the antibiotic daily. Resident 3 was also administered Doxycycline for lifelong suppressive therapy for an abdominal wound, but there was no documented evidence to justify the need for such prolonged antibiotic use. The facility's records failed to show ongoing purulent drainage or other symptoms that would necessitate continued antibiotic therapy. During an interview, the Director of Nursing confirmed that the facility did not have protocols to monitor antibiotic use effectively. This lack of monitoring increases the risk of adverse events, including the development of antibiotic-resistant organisms. The facility's failure to implement a comprehensive antibiotic stewardship program led to the inappropriate and prolonged use of antibiotics among the residents, as evidenced by the clinical records and staff interviews.
Failure to Consult Physician on Medication Refusals
Penalty
Summary
The facility failed to timely consult with the resident's physician regarding the potential need to alter treatment due to repeated refusals of medication administration prescribed for one resident. Resident 8, who was admitted with dementia and was moderately cognitively impaired, refused at least one prescribed medication daily from January 1, 2024, through March 7, 2024. There was no documented evidence that the facility had consulted the resident's attending physician about these repeated refusals. This deficiency was confirmed during an interview with the Director of Nursing on March 7, 2024.
Failure to Timely Assess Pressure Ulcers
Penalty
Summary
The facility failed to timely assess declines in skin integrity for two residents with pressure ulcers. Resident 15, who had multiple comorbidities including hypertension and type II diabetes, developed a new wound on the sacrum and a pressure ulcer on the right great toe. These areas were initially identified by an LPN, but there was no documented evidence that a registered nurse (RN) assessed these wounds in a timely manner. Additionally, the resident's care plan was not reviewed or revised to address these new skin impairments, and the attending physician was not promptly notified of the changes in the resident's condition. Resident 27, who was admitted with chronic pain, developed a new reddened area on the left second toe, which later progressed to an unstageable pressure ulcer. Similar to Resident 15, the initial assessment was conducted by an LPN, and there was no documented evidence of an RN's timely assessment. The facility also failed to promptly review and revise the resident's care plan to ensure effective interventions for maintaining or improving skin integrity. The Director of Nursing (DON) confirmed that new pressure injuries and skin impairments should be immediately assessed and their origin investigated to plan care accordingly. The DON acknowledged that the facility did not ensure timely assessment of newly identified skin impairments by a registered nurse and failed to assess the healing progress by a registered nurse, as required by professional nursing standards and facility policy.
Failure to Provide Necessary Behavioral Health Care
Penalty
Summary
The facility failed to ensure that Resident 8 received necessary behavioral health care in a timely manner. Resident 8, who was admitted with dementia and was moderately cognitively impaired, exhibited multiple behaviors including physical aggression and medication refusals almost daily from January 2024 through March 7, 2024. Despite these behaviors, there were no documented visits from psychological services or indications that the resident's physician had been notified of the medication refusals, as required by the care plan initiated on February 24, 2023. Similarly, the facility did not provide necessary behavioral health care for Resident 30, who was admitted with diagnoses including bipolar disorder, anxiety, and opioid dependence. Despite the resident's increased anxiety and the need for psychosocial interventions, there was no documented evidence of psychological services or community substance use services being provided. The resident reported not receiving any psychological services since admission and mentioned her concerns to several staff members without resolution. Interviews with the DON and NHA confirmed the lack of psychological services for both residents.
Physician's Failure to Act on Pharmacist's Drug Irregularity Recommendations
Penalty
Summary
A deficiency was identified in the care of Resident 4, who was admitted with diagnoses of anxiety disorder, depression, and delusional disorder. The pharmacist conducted monthly drug regimen reviews and identified several drug irregularities that required the attending physician's attention. On May 20, 2023, the pharmacist recommended evaluating the use of Tramadol, an opioid prescribed for chronic pain, but the physician did not act on this recommendation. Similarly, on June 10, 2023, the pharmacist suggested a gradual dose reduction (GDR) for Duloxetine, prescribed for depression, but the physician again failed to respond. Lastly, on July 23, 2023, the pharmacist recommended a GDR for Quetiapine, prescribed for delusional disorder, but no action was taken by the physician. An interview with the Director of Nursing (DON) on March 7, 2024, confirmed that the attending physician did not act on any of the identified drug irregularities in Resident 4's medication regimen. This failure to address the pharmacist's recommendations constitutes a deficiency in the facility's compliance with drug regimen review and physician response protocols, as outlined in the relevant state codes and regulations.
Failure to Ensure Drug Regimen Free from Unnecessary Antibiotics
Penalty
Summary
The facility failed to ensure that several residents' drug regimens were free from unnecessary antibiotic drugs. Resident CR1 was administered Macrobid daily for chronic urinary tract infections without documented physician support or diagnostic criteria. Similarly, Resident 9 received Macrobid twice daily for lifelong chronic urinary tract infections without proper documentation to justify the necessity of this treatment. Resident 20 was prescribed Macrobid for chronic urinary tract infections, but the nursing staff failed to transcribe a physician's order to decrease the dose, resulting in the resident continuing to receive an unnecessary higher dose. Additionally, the resident was concurrently treated with Macrobid and other antibiotics despite culture reports indicating resistance to Macrobid. Resident 10 was prescribed Doxycycline for lifelong chronic suppression of an MRSA infection without documented evidence of the clinical necessity for continued use. Resident 3 was also given Doxycycline for lifelong suppressive therapy for an abdominal wound, but there was no follow-up documentation to justify the ongoing need for this antibiotic. Resident 30 received Ceftin and Rifampin for MRSA in wounds, despite not meeting the McGeer criteria for infection, and was later given Vancomycin and Septra DS for suspected SSTI without proper documentation to support the necessity of these antibiotics. The Director of Nursing confirmed that the residents mentioned were not free from unnecessary medications, specifically antibiotics. The facility's failure to ensure proper documentation and justification for the continued use of these antibiotics led to the administration of unnecessary drugs to multiple residents, violating regulatory standards for medication management in long-term care facilities.
Failure to Implement Infection Control Procedures for Chronic Infections
Penalty
Summary
The facility failed to develop and implement infection control procedures for tracking and managing chronic infections among its residents. A review of the facility's infection control logs from July 2023 through February 2024 revealed that four residents had chronic infections treated with ongoing antibiotics. However, these logs did not include any attempt to monitor the need for the ongoing use of the antibiotic medications, nor was there evidence that these specific lifelong or chronic infections were reassessed and tracked to determine the need for ongoing antibiotic usage. Additionally, there was no descriptive information on the resident listings to include diagnostic criteria used. The facility's infection control program did not include procedures to address residents diagnosed with lifelong/chronic infections and clinical criteria to determine best practices for treatment and any monitoring or surveillance related activities that may be required. This was confirmed during an interview with the facility Infection Control Nurse. The lack of re-evaluation or scheduled monitoring for residents with chronic infections to evaluate the effectiveness and continued appropriateness of prophylactic antibiotic therapy was evident, indicating a significant gap in the facility's infection prevention and control program.
Failure to Honor Resident's Medication Choices
Penalty
Summary
The facility failed to ensure that Resident 30 was afforded the right to make choices about significant aspects of her life, including medication treatment options. Resident 30, who was admitted with diagnoses including bipolar disorder, anxiety, and vitamin deficiency, was cognitively intact with a BIMS score of 14. Despite her cognitive status, the resident's requests for specific medications she had previously received, such as Neurontin for bipolar disorder, Ativan for anxiety, and vitamin supplements, were not addressed. The resident expressed that she felt better when on these medications and had voiced her concerns to multiple staff members, but her medication administration record for March 2024 showed that she was not prescribed any of the mentioned medications or supplements. Interviews with staff confirmed that the resident had communicated her medication concerns, but these were not acted upon. A nurse aide acknowledged being aware of the resident's complaints but did not know about her increased anxiety. The Director of Nursing confirmed that the resident was scheduled to see a behavioral health specialist in the community, but this appointment was not until April 18, 2024. The Nursing Home Administrator and the Director of Nursing admitted that the facility failed to timely afford the resident the right to participate in making choices about her healthcare and treatment options.
Failure to Evaluate Clinical Necessity of Indwelling Urinary Catheter
Penalty
Summary
The facility failed to evaluate the clinical necessity of an indwelling urinary catheter for one resident. The resident was admitted with an indwelling Foley catheter and a diagnosis of atrial fibrillation and heart failure. The facility's policy requires daily evaluation of the need for urinary catheters and prompt removal when no longer necessary. However, the resident's monthly physician progress notes for January and February did not address the ongoing clinical necessity for the catheter. Additionally, the resident's admission urinary continence evaluation indicated that the resident was continent of urine, contradicting the initial justification for the catheter's use. The facility's documentation revealed that the resident's hourly urine output was not being monitored and documented as required. The Director of Nursing confirmed that there was no physician documentation to support the continued use of the indwelling Foley catheter for accurate hourly urine output measurement. This lack of documentation and evaluation led to the deficiency, as the facility did not adhere to its policy on urinary catheterization care and maintenance.
Failure to Document Clinical Rationale for Antipsychotic Drug Dosage
Penalty
Summary
The facility failed to ensure the presence of physician documentation of the clinical rationale for the continued dose of an antipsychotic drug prescribed for one resident and failed to attempt a gradual dose reduction of the antipsychotic drug. Resident 4 was admitted with diagnoses including anxiety disorder and delusional disorder. The resident had been receiving Quetiapine (Seroquel) 75 mg in the morning and 50 mg at bedtime since July 2020. A pharmacist's medication review requested a gradual dose reduction or a documented clinical rationale if the reduction was not appropriate. However, there was no documentation from the physician to support the lack of attempts at a gradual dose reduction for Resident 4's antipsychotic drug dosage. An interview with the Director of Nursing confirmed that the facility could not provide documented evidence that Resident 4's attending physician had documented an individualized clinical rationale for the ongoing need for the current dosage of Seroquel. Additionally, the physician had not attempted a gradual dose reduction. This deficiency was identified during a survey ending on March 7, 2024.
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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