Beacon Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Indiana, Pennsylvania.
- Location
- 1515 Wayne Avenue, Indiana, Pennsylvania 15701
- CMS Provider Number
- 395702
- Inspections on file
- 22
- Latest survey
- May 28, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Beacon Ridge during CMS and state inspections, most recent first.
The facility did not maintain required inspection and testing documentation for its fire alarm system. During surveyor review, no records could be produced to show that semi-annual visual inspections or the two-year smoke detector sensitivity testing had been completed, and the maintenance supervisor confirmed that this documentation was unavailable at the time of the survey. This deficiency affected the entire facility.
The facility did not comply with NFPA 101 fire drill requirements when document review showed that, in most quarters reviewed, second and third shift fire drills were conducted within the same hour slot instead of at varied times. Fire drills are required to occur at expected and unexpected times under varying conditions on each shift, and the administrator and maintenance supervisor confirmed this scheduling deficiency during the survey.
Surveyors observed that the generator room contained an electrical breaker panel labeled "Panel HC" with an open breaker slot, indicating the electrical system was not maintained per NFPA 70 and NFPA 99 requirements. During an interview, the maintenance supervisor confirmed this electrical system deficiency in one of the facility’s smoke compartments.
The facility failed to maintain and provide an accurate, portable Life Safety Code (LSC) floor plan during surveyor review. Surveyors requested the on-site LSC floor plan and found it was unavailable, and an interview with the administrator confirmed that the plan could not be produced. The required floor plan was to clearly indicate smoke barrier walls, 2-hour fire barrier walls, horizontal exits, rated rooms (including storage rooms, soiled utility rooms, and designated medical gas rooms), required exits, and shaft walls.
Surveyors found that the facility failed to maintain required documentation for its fire sprinkler system. During review and interview, the facility could not provide records of semi-annual inspections for valve supervisory switches or annual inspections for control valves. The maintenance supervisor confirmed that these sprinkler system inspection records were not available when requested by surveyors.
A resident with cognitive impairment, dependence for mobility and ADLs, incontinence, and a history of CVA with hemiparesis was admitted with a Stage 3 pressure ulcer to the right hip and prior hospital treatment for an infected wound with cellulitis. An initial physician order to cleanse the wound with normal saline, apply adaptic, and cover with a bordered dressing was not transcribed to the TAR, and there was no documentation that this treatment was provided for several days, despite a later wound consult showing significant worsening and slough requiring debridement. Over the following months, multiple wound care orders involving Dakin’s solution, Plurogel, calmoseptine, acetic acid, Flagyl powder, and calcium alginate dressings were in place, but on numerous specified dates there was no documented evidence on the TAR that these treatments were completed, including missed treatments on night shifts, as confirmed by the ADON.
The facility did not ensure that breakfast meals were held and served at safe, palatable temperatures in accordance with its dietary policy. Breakfast trays were delivered to a unit and left undelivered on a cart for an extended period, with some trays only partially covered, leaving eggs exposed. When the Regional Dietary Manager later checked the trays, temperatures of the eggs were below required hot-holding standards, and the manager confirmed the food was cold, not palatable, and should not be served.
Surveyors found multiple food safety violations in the kitchen, including a walk-in cooler operating above the required 41°F, numerous expired milk cartons left in storage, and pies stored on Styrofoam plates left uncovered in a prep cooler. They also observed a fan blowing directly on uncovered pans of apple crisp in a food prep area. Dietary leadership confirmed that the cooler temperature, presence of expired food, uncovered desserts, and use of a fan in the food prep area were not consistent with facility policy and professional food service standards.
Surveyors found that the facility failed to provide and document required written notices explaining the reasons for hospital transfers for multiple residents. In several cases, a resident had falls resulting in fractures, stroke‑like symptoms, respiratory changes, or positive blood cultures leading to transfer and hospital admission for conditions such as sepsis, bacteremia, atrial fibrillation, UTI, stroke, and a femoral neck fracture. These residents were often cognitively impaired, required extensive ADL assistance, and had complex medical histories including dementia, post‑CVA hemiplegia/hemiparesis, indwelling catheters, feeding tubes, and pressure ulcers. Despite physician orders for transfer and subsequent hospital admissions, the clinical records did not contain written notifications to the residents or their representatives describing the reasons for the transfers, and the NHA confirmed that written transfer letters were not being completed.
Surveyors found multiple instances where MDS assessments did not match clinical records. An LPN Assessment Coordinator coded several residents’ MDS sections inaccurately, including medication use (antipsychotics, antianxiety agents, diuretics, anticonvulsants, antibiotics), restraint use (bedrails), IV medications, and pressure ulcer risk. In each case, physician orders and MAR/TAR documentation showed that treatments or risk factors were present during the required look‑back periods, but the corresponding MDS sections were either left unchecked or coded inconsistently with the documented care.
The facility did not develop or implement individualized care plans for several residents with significant clinical needs and medication regimens. One resident with dementia, severe depression with psychosis, cognitive impairment, and antipsychotic use had no care plans addressing either the antipsychotic therapy or cognitive impairment. Another cognitively impaired resident receiving a diuretic for edema had no diuretic care plan. A third cognitively impaired resident with hemiparesis, an indwelling catheter, a feeding tube, and a Stage 3 pressure ulcer was receiving long-term prophylactic antibiotic therapy for UTIs without a corresponding care plan. These omissions were confirmed by facility leadership, including the ADON, an LPN assessment coordinator, and the NHA.
Surveyors found that the facility failed to follow physician orders for anticoagulant medications for two residents. One resident on hospice with atrial fibrillation had Jantoven orders that were not clarified, resulting in three missed doses. Another resident with a right tibia fracture, ordered to receive 70 mg of Enoxaparin daily for DVT prophylaxis, was observed receiving an 80 mg prefilled Enoxaparin injection from an LPN, who acknowledged administering the incorrect dose; the DON confirmed both medication errors.
A resident receiving hospice services, with dementia, psychotic disorder, anxiety, and depression, had a care plan stating that the facility would coordinate care with the hospice provider. The hospice contract required regular communication and documentation to ensure resident needs were met and specified processes for resolving inconsistencies between physician orders and the hospice plan of care. The resident had an existing physician order for ABHR cream with a specific drug formulation and dosing, while subsequent hospice orders changed the ABHR formulation and application instructions. These hospice orders were not transcribed into the resident’s physician orders, and facility leadership confirmed they should have been, resulting in a failure to coordinate hospice medication orders as required.
Surveyors found that two residents who required staff assistance for daily care and had cognitive and neurological conditions, including dementia, Parkinson’s disease, and stroke, did not consistently have their call pendants within reach as required by facility policy and their care plans. On observation, each resident was lying in bed with the call pendant placed on a nightstand out of reach, despite care plan directions to encourage call bell use and ensure pendants were in place. One resident later had both a pendant and a tap bell, but the tap bell was not within reach. Staff, including an aide and the DON, acknowledged that residents able to use call pendants should have them within reach, confirming that the observed situations did not meet facility expectations.
Two residents’ care plans were not revised to match their current treatment orders. One cognitively impaired resident with paralysis and edema had a care plan stating they were receiving diuretic therapy, but the MAR showed no diuretics were being administered. Another cognitively impaired resident with hemiparesis, an indwelling catheter, a feeding tube, and a Stage 3 pressure ulcer had a care plan indicating ongoing IV medications for an ESBL urinary infection, while the clinical record contained no evidence of IV therapy. The DON and NHA acknowledged that the care plans should have been updated when these treatments were discontinued.
Surveyors found that the facility did not meet professional standards when staff failed to clarify and implement provider orders for two residents. One cognitively impaired resident with dementia had a provider note for routine Tylenol for pain, but only a PRN acetaminophen order was in place and the routine order was never entered or administered. Another cognitively impaired resident with diabetes and a right great toe ulcer had an original order for daily Mupirocin ointment and a later wound consultant–driven order for daily Iodosorb treatment, yet both treatments were administered concurrently to the same wound instead of discontinuing the earlier regimen.
A resident with cognitive impairment, intellectual disabilities, and an ostomy did not receive colostomy care in accordance with facility policy and professional standards. The facility’s policy required colostomy care per physician orders, including attention to stoma and peristomal skin. However, the resident’s clinical record lacked physician orders specifying the colostomy size and instructions for changing the colostomy appliance, and there was no documentation that the appliance was being changed. The NHA confirmed the absence of these orders and documentation, resulting in a deficiency related to colostomy care.
A resident with cognitive impairment, hemiparesis, a feeding tube, an indwelling urinary catheter, and a Stage 3 pressure ulcer had physician orders for daily cleansing of the feeding tube site with normal saline, drying, and application of a drain sponge, consistent with facility policy requiring LPNs to perform and document daily tube dressing changes. Review of Treatment Administration Records over several months showed multiple dates with no documented evidence that the ordered feeding tube site care was completed, and the Assistant DON confirmed the absence of documentation for those dates.
Surveyors found that a medication room refrigerator on one unit contained five bottles of liquid Ativan, a controlled medication used to treat anxiety, stored together with non-narcotic medications without a separately locked, permanently affixed compartment. An LPN and the Nursing Home Administrator both confirmed that the Ativan was not secured in a distinct locked area as required for controlled substances.
A resident with a history of UTI reported dysuria, and the physician ordered a UA flex to culture and later prescribed Macrobid pending urine C&S results. Facility policy required timely laboratory services and specified that the day shift nurse complete and send lab requests. Although the UA was completed and results communicated to the physician, review of lab records showed no urine C&S was ever performed. The NHA confirmed that the lab order was transcribed incorrectly, so the C&S test was not completed as ordered.
Multiple residents were found living in rooms with chipping paint, broken drywall, water damage, and deteriorating windowsills. Some residents reported ongoing drafts and wet conditions, with maintenance staff unaware of or not addressing the issues despite facility policy requiring a clean and homelike environment.
Care plans for three residents were not updated to reflect their current care needs and interventions. One resident's care plan listed a diuretic that was not being administered, another had outdated code alert bracelet information, and a third had an intervention for antibiotic therapy without evidence of a current infection or antibiotic use. The Nursing Home Administrator confirmed that these care plans should have been revised to match the residents' actual conditions and treatments.
Three residents with indwelling urinary catheters did not receive proper care: one had a drainage bag dragging on the floor during transport, another did not have documented evidence of a required catheter change, and a third had catheter tubing in direct contact with the floor and the drainage bag partially uncovered. Staff interviews confirmed awareness of proper catheter care protocols, but these were not consistently followed.
A resident with Parkinson's disease, who was cognitively intact and required assistance with daily care, did not have a care plan developed to address their specific care needs related to the condition. Facility policy requires comprehensive, individualized care plans, but documentation and staff interviews confirmed this was not completed.
A resident who required moderate assistance and a gait belt for transfers was moved by a nurse aide using the back of his pants instead of the gait belt, despite the device being available and the aide being aware of the resident's transfer requirements. The administrator confirmed the transfer should have been performed with the gait belt.
A resident receiving opioid pain medication had multiple doses of Hydrocodone-Acetaminophen signed out on the controlled drug record, but there was no documentation in the MAR or clinical record to confirm administration of these doses. The DON confirmed the absence of required documentation for the signed-out medications.
Three medication administration errors were observed, including crushing an extended-release tablet, opening a capsule against manufacturer instructions, and administering an incorrect aspirin dose. These actions by LPNs resulted in a medication error rate exceeding five percent, in violation of facility policy and regulatory requirements.
The QAPI committee did not effectively address or correct recurring deficiencies related to safety hazards, catheter care, and controlled substance accountability, as the same issues were cited in consecutive surveys despite previous plans of correction.
The facility failed to maintain professional standards for food service safety, with deficiencies in food storage and preparation. Danishes and dinner rolls were not dated, and a roll of ground hamburger lacked proper labeling. In the Bayside Nourishment Center, a microwave was found unclean, and an ice machine lacked an air gap, risking contamination. Interviews confirmed these lapses.
The facility failed to follow physician orders for nutritional supplements, hypoglycemic protocols, and bowel medications for several residents. A resident did not receive prescribed nutritional supplements, while two residents with diabetes did not receive required glucose interventions. Additionally, insulin was improperly administered to a resident, and bowel protocols were not followed for two residents, as confirmed by staff interviews.
The facility failed to document the administration of controlled medications for two residents. One resident, who was cognitively impaired, had doses of Oxycodone signed out but not documented as administered. Another resident, with anxiety, had doses of Lorazepam signed out without documentation of administration. The Assistant DON confirmed the lack of documentation.
A facility failed to attempt non-pharmacological interventions before administering Lorazepam to a resident with anxiety, despite having a care plan that included such strategies. The resident received the medication multiple times without documented evidence of trying alternative interventions first, as confirmed by the Assistant DON.
The facility failed to date opened medications and discard expired supplies in two medication rooms. An opened and undated Ativan bottle was found in the Landing room, while an undated insulin vial and expired blood collection tubes were observed in the Bayside room. Staff confirmed these deficiencies, acknowledging the need for proper dating and disposal.
The facility's QAPI committee failed to maintain compliance with regulations, resulting in repeated deficiencies in professional standards, quality of care, accident hazards, catheter care, oxygen therapy, medication accountability, food storage, and infection control. Despite having plans of correction, these issues persisted, indicating ineffective implementation.
A cognitively impaired resident with a Foley catheter was observed with her drainage bag visibly attached to her bed without a privacy cover, contrary to her care plan. This was confirmed by both a nurse and the DON, indicating a failure to maintain the resident's dignity.
A resident with moderate cognitive impairment and a history of stroke had a pressure-induced deep tissue injury on the right heel. The physician's order to apply skin prep was incorrectly documented, leading to treatment on the left heel instead. The discrepancy was not clarified with the physician, resulting in a deficiency in care.
A resident with moderate cognitive impairment and a history of stroke had a Stage III pressure ulcer. A wound consultation recommended applying Santyl twice daily, but the Treatment Administration Record showed no evidence of this treatment being administered. This was confirmed by the DON.
The facility failed to follow care plans and physician orders for several residents, leading to unsafe conditions. A resident with a history of falls was not wearing shoes as required, another resident with dysphagia was served inappropriate food, a resident with frail skin was not wearing protective sleeves, and a resident at risk for falls was unsafely transported in a wheelchair.
A facility failed to prevent urinary tract infections for a resident with an indwelling urinary catheter. The facility's policy required catheter tubing to be kept off the floor, but an observation revealed the tubing was under a fall mat and in contact with the floor. The resident had moderate cognitive impairment and a neurogenic bladder. Interviews with a nurse aide and the DON confirmed the tubing should not have been on the floor, indicating non-compliance with the facility's policy.
A facility failed to keep a resident's oxygen tubing and nasal cannula off the floor, contrary to its policy and physician's orders. The resident, who was cognitively impaired and had chronic respiratory failure, required continuous oxygen while sleeping. Observations showed the tubing and cannula on the floor, confirmed by staff interviews.
A facility failed to obtain a physician's order for catheterization to collect urine specimens for a resident. Despite the facility's policy requiring verification of a physician's order for intermittent catheterization, there was no documented order for the procedures performed on specific dates. The resident's care plan noted a potential for discomfort due to urinary retention, and staff were instructed to perform catheterization as needed.
A resident with a history of CVA and dysphagia was not provided the correct food consistency as ordered by the physician. Instead of a mechanical soft/chopped diet, the resident was served a full chicken nugget, leading to difficulty swallowing. The incident was confirmed by the DON, indicating a failure to follow dietary orders.
An LPN failed to follow proper infection control practices during wound care for two residents with peripheral vascular disease. The LPN did not perform hand hygiene between glove changes, contrary to the facility's policy. This was confirmed by interviews with the LPN and the DON.
Missing Required Fire Alarm System Inspection and Testing Documentation
Penalty
Summary
The facility failed to ensure that its fire alarm system was inspected and tested at the required intervals in accordance with NFPA 70 and NFPA 72. During document review, surveyors found that the facility could not provide documentation showing that semi-annual visual inspections of the fire alarm system had been completed. In addition, the facility was unable to produce records confirming that the required two-year smoke detector sensitivity testing had been performed. An interview with the maintenance supervisor confirmed that the documentation for these required inspections and tests was not available at the time of the survey, and this deficiency affected the entire facility. No residents or specific patient conditions were mentioned in the report, and the deficiency centered solely on the lack of required fire alarm system inspection and testing documentation.
Plan Of Correction
Maintenance department was educated on the need for the fire alarm system to be inspected and tested at regular intervals that includes semi annual visual inspections and a two year smoke detector test. The semi annual inspection will be scheduled to be completed according to NFPA- 0100 70 and 72. The smoke detector sensitivity will be scheduled to be completed according to NFPA-0100 70 and 72. Random audits will be completed by the Administrator and/or designee monthly for 6 months to assure that semi annual inspections are completed and the smoke detector test was completed. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Vary Fire Drill Times Across Shifts
Penalty
Summary
The facility failed to meet NFPA 101 fire drill requirements by not varying the times of fire drills across work shifts as required. Document review showed that for three of four testing quarters, the second and third shift fire drills were conducted within the same hour slot, rather than at different, varying times. Fire drills are required to be held at expected and unexpected times under varying conditions at least quarterly on each shift, including between 9:00 p.m. and 6:00 a.m. when a coded announcement may be used. During an interview, the administrator and maintenance supervisor confirmed this fire drill deficiency at the time of the survey. No residents or specific patient conditions were mentioned in the report, and the deficiency pertains solely to the scheduling and conduct of fire drills for staff and facility safety procedures.
Plan Of Correction
Formatted text (without <text> tags or quotes): Maintenance department was educated on the need for fire drills – quarterly on each shift at varying hour time slots. Random audits will be completed by the Administrator and/or designee monthly for 6 months to assure that monthly inspections are completed at varying timeframes and hour time slots. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Open Breaker Slot Found in Generator Room Electrical Panel
Penalty
Summary
The facility failed to maintain and inspect its electrical system in accordance with NFPA 70 and NFPA 99 requirements in one of four smoke compartments. During an observation of the generator room on April 30, 2026, at 1:00 p.m., surveyors identified an open breaker slot in the electrical breaker panel labeled "Panel HC." This condition was noted as a deficiency under NFPA 70-408.7, which requires proper closure of unused openings in electrical equipment. In an interview conducted at the same time, the maintenance supervisor confirmed the existence of this electrical system deficiency. No residents or patient-specific information was provided in the report, and no additional events beyond the observed open breaker slot and the maintenance supervisor’s confirmation were described.
Plan Of Correction
Maintenance department was educated on the need to maintain and inspect electrical system per NFPA 70 and NFPA 99 with respect to having no open breakers slots in the panel box. The open breaker was replaced 4/30/2026 following the identification of the missing breaker. Random audits will be completed by the Administrator and/or designee monthly for 6 months to assure that there are no open breakers in the panel boxes. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Maintain Required Portable Life Safety Code Floor Plans
Penalty
Summary
The facility failed to maintain and provide accurate, portable Life Safety Code (LSC) floor plans as required by the Division of Safety Inspection, affecting the entire facility. During document review on April 30, 2026, at 12:54 p.m., surveyors requested the facility’s portable LSC floor plan and found it was unavailable at the time of the survey. The required LSC floor plan was to include clearly identified smoke barrier walls extending from outside wall to outside wall, 2-hour fire barrier walls, horizontal exits, rated rooms such as storage rooms, soiled utility rooms, and designated medical gas rooms, as well as required exits and shaft walls. Interview with the administrator at the exit conference on the same date and time confirmed that the facility’s LSC floor plan was not available for surveyor use.
Plan Of Correction
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Indiana Skilled Nursing INC dba Beacon Ridge agrees with the allegations and citations listed on the statement of deficiencies. Indiana Skilled Nursing INC dba Beacon Ridge maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Indiana Skilled Nursing INC dba Beacon Ridge written credible allegation of compliance. By submitting this plan of correction, Indiana Skilled Nursing INC dba Beacon Ridge does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Indiana Completion Date: 05/29/2026 Status: APPROVED Date: 05/20/2026 Skilled Nursing INC dba Beacon Ridge reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. Maintenance department was educated on the need for the floor plan to include the designated items required on the Life Safety Code Floor Plan. Random audits will be completed by the Administrator and/or designee monthly for 2 months to assure that the floor plan is compliant. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Missing Documentation for Required Sprinkler System Inspections
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain required documentation for its automatic sprinkler system. During document review and interview on April 30, 2026, at 10:50 a.m., the facility was unable to provide records showing that semi-annual inspections of valve supervisory switches had been completed, as required. At the same time, the facility also could not produce documentation of annual inspections for the sprinkler system control valves. The maintenance supervisor confirmed during the interview that the sprinkler system documentation for these required inspections was unavailable at the time of the survey. No residents or specific patient conditions were mentioned in the report, and the deficiency centered solely on missing inspection and maintenance records for the fire sprinkler system components.
Plan Of Correction
Completion Date: 05/29/2026 Status: APPROVED Date: 05/20/2026 Maintenance department was educated on the need for the sprinkler system to be inspected and tested at regular intervals that includes semi annual for valve supervisory switches and annual control valves. The semi annual inspection will be scheduled to be completed per NFPA-0100 25. The annual control valve inspection will be scheduled to be completed per NFPA-0100 25. Random audits will be completed by the Administrator and/or designee monthly for 6 months to assure that semi annual valve supervisory switched and annual control valve testing was completed. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Provide and Document Ordered Treatment for Stage 3 Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide and document ordered treatment and services for a resident’s Stage 3 pressure ulcer to the right hip, consistent with professional standards and the facility’s own pressure ulcer policy. The policy required that residents with pressure ulcers receive necessary treatment and that wound care be documented in the clinical record and Treatment Administration Record (TAR). On admission, the resident had a Stage 3 pressure ulcer to the right lateral hip measuring 2.5 cm x 1.5 cm x 0.1 cm, with a physician’s order to cleanse with normal saline, apply adaptic, and cover with a bordered dressing daily and as needed. This order, dated August 19, 2025, was not transcribed onto the TAR, and there was no documented evidence that the ordered treatment was completed from August 19 through August 26, 2025. The resident’s clinical background included cognitive impairment, dependence on staff for mobility and ADLs, bowel and bladder incontinence, and diagnoses of CVA with hemiparesis/hemiplegia and wound infection. Hospital records prior to admission documented a right hip wound with purulent drainage, surrounding erythema and warmth, and CT findings consistent with cellulitis; the resident had been treated with vancomycin for suspected MRSA. Despite this history, a weekly skin assessment on August 23, 2025, indicated no open areas or skin issues, which conflicted with other documentation noting a Stage 3 pressure ulcer. A wound consultation on August 26, 2025, identified the right hip ulcer as a Stage 3 pressure ulcer present on admission, with 40% slough and requiring surgical debridement; at that time, the wound measured 7.5 cm x 6 cm x 0.3 cm, showing deterioration from the admission measurements. Following the initial lapse, multiple subsequent physician orders for wound care to the right hip were not consistently documented as completed on the TAR. Orders included various regimens over time, such as cleansing with 0.125% Dakin’s solution and packing with Dakin’s-soaked gauze, use of Plurogel with normal saline–moistened gauze and calmoseptine to the periwound, and later irrigation with acetic acid 0.25% plus Flagyl powder and packing with acetic acid–moistened gauze, as well as calcium alginate rope with super absorbent bordered dressings. On specific dates listed in November and December 2025, and in March and April 2026, there was no documented evidence that these ordered treatments were completed, including missed treatments on particular night shifts. The Assistant DON confirmed that the initial order was not transcribed to the TAR and that there was no documented evidence of treatment completion on the identified dates, supporting the finding that the facility failed to ensure necessary wound care treatment and documentation for the resident’s Stage 3 pressure ulcer.
Plan Of Correction
Resident 43 pressure injury resolved as of 4/29/2026. Skin evaluations were completed 05/08/2026 for current in-house facility residents which resulted in no new findings and no declines in existing wounds. An audit of the last 30 days of residents with pressure injuries was completed ensure treatment orders were signed for administration. The Director of Nursing and/or designee re-educated current in-house and agency Nursing Staff on completing treatments and services with timely documentation of administration per physician order for pressure injuries. Newly hired and agency Nursing staff will be educated upon on boarding on completing treatments and services with timely documentation of administration per physician order for pressure injuries. An approved directed inservice provider was secured to provide the directed in-service training to facility in-house and agency licensed nursing and nurse aide staff regarding the federal regulation and accompanying guidance for treatment and services to prevent and heal pressure injuries on May 27, 2026. The Director of Nursing and/or designee will complete random audits of the Treatment Administration Record (TAR) to ensure treatments are complete and administration documented timely by nursing staff weekly for 4 weeks and then monthly for 2 weeks. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Improper Holding and Service Temperatures for Breakfast Trays
Penalty
Summary
The facility failed to provide palatable food at safe and appetizing temperatures when breakfast trays were not properly covered and were left on a cart for an extended period before delivery. Facility policy dated January 22, 2026, required all hot foods to be held at greater than 135°F and cold foods at less than 41°F. A dietary tracking form showed that breakfast trays for the Bayside unit were delivered to the unit at 7:40 a.m. on April 20, 2026. At 8:09 a.m., surveyors observed a breakfast cart on Bayside containing nine undelivered breakfast trays, with two trays having protective lids only partially covering the dishes, leaving the eggs exposed. At 8:18 a.m., the Regional Dietary Manager arrived on the unit and the trays were still on the cart; temperature checks showed the uncovered eggs at 103°F and the covered eggs at 112.8°F. The Regional Dietary Manager confirmed that the trays should have been fully covered and that the eggs were cold, not palatable, and should not be served to residents.
Plan Of Correction
Eggs were immediately discarded upon discovery of temperatures less than 135-degrees with fresh breakfast items offered to the residents. The Dietary Manager and/or designee will re-educate current in-house dietary department staff as well as newly hired and agency dietary staff regarding proper placement of dome covers for maintenance of food temperatures. The Director of Nursing and/or designee will re-educate current in-house nursing staff as well as newly hired and agency staff to monitor dome cover placement upon meal delivery with need to take temperatures for palatability and/or have the food items replaced. Random audits will be completed by the Dietary Manager and/or designee weekly for 4 weeks then every other week for 4 weeks to assure palatability. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Improper Food Storage and Handling in Kitchen Food Service
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to storage, preparation, and handling of food in the facility’s kitchen. The facility’s policies required potentially hazardous cold foods to be held at or below 41°F and food to be stored to prevent contamination and maintain safety. During an observation in the main kitchen walk-in cooler, the temperature was found to be 42°F, which was documented as being in the danger zone and not in compliance with policy. In the same cooler, surveyors observed 56 cartons of milk that had expired the previous day and had not been discarded, contrary to the facility’s food storage policy. Additional observations showed improper handling and protection of prepared foods. In the main kitchen prep cooler, six pies were stored on Styrofoam plates and left open to the air, rather than being sealed to prevent air from entering the food. On a separate observation date, a fan was found blowing directly on three uncovered pans of apple crisp dessert in a food preparation area. The Regional Dietary Manager confirmed that the walk-in cooler should have been below 41°F, that the pies should have been sealed, and that expired food should have been removed from the cooler. The Dietary Manager also confirmed that a fan should not be blowing on the food preparation area.
Plan Of Correction
The facility is unable to retroactively correct the observations in the kitchen. Upon discovery of the temperature of the main cooler, a sample of refrigerated foods were tested for appropriate temperature with no issues noted. No expired milk was distributed to residents as they were discarded upon discovery. The pie and apple crisp deserts observed were immediately discarded and not served to residents. The fan was removed from the food prep area. The Regional Dietary Manager reviewed the policy for discarding expired foods and revised the policy to discard food items the day before the expiration date. The Dietary Manager and/or designee will re-educate current in-house and agency the dietary department staff as well as newly hired and agency dietary department staff on the revised policy for discarding expired foods and proper storage and preparation for food services safety. Random audits will be completed by the Dietary Manager and/or designee five times a week for 4 weeks then weekly for four weeks to ensure proper storage and preparation of food. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Provide Required Written Notice of Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide written notice to residents and/or their representatives regarding the reasons for transfers to the hospital, as required by 42 CFR 483.15(c)(2)-(6), (8), (d)(1)-(2) and 483.21(c)(2), and 28 Pa. Code 201.29(j). Surveyors reviewed clinical records and found that for multiple residents who were transferred to the hospital, there was no documented evidence that written notification of the reason for transfer was provided to the resident or the resident’s representative. The Nursing Home Administrator confirmed during interview that written transfer letters explaining the reason for transfer were not being completed for the families of the affected residents. For one resident with an unwitnessed fall on February 11, 2026, staff found her on the floor near her dresser with right arm pain and obtained an order to send her to the emergency department for evaluation and treatment. On April 2, 2026, x‑ray results showed a subacute displaced fracture of the right humerus, and the resident was again ordered to be sent to the emergency department. In both instances, review of the clinical record revealed no documentation that the resident’s representative or emergency contact was notified in writing of the purpose for the transfers. Another resident, who was cognitively impaired and required assistance with daily care and had a history of paralytic syndrome following cerebral infarction, developed increased shortness of breath and abdominal pain. The physician was notified and ordered a hospital transfer, and the resident was later admitted with sepsis; however, there was no documented written notification to the resident or responsible party regarding the reason for this transfer. Additional residents were similarly affected. One cognitively impaired resident with dementia, who required staff assistance for daily care, was noted to have abnormal lung sounds and irregular breathing; the physician ordered a hospital transfer, and the resident was admitted with atrial fibrillation and a urinary tract infection, but there was no documented written notice of the reason for transfer to the resident or responsible party. Another cognitively impaired resident with hemiplegia/hemiparesis after a stroke experienced stroke‑like symptoms, was evaluated by a physician, and was transferred and admitted to the hospital with a diagnosis of stroke, again without documented written notification of the reason for transfer. A resident with significant impairments including cognitive impairment, hemiparesis/hemiplegia, limited range of motion, an indwelling catheter, a feeding tube, and a Stage 3 pressure ulcer had positive blood cultures for Staphylococcus epidermidis reported from the hospital emergency room; the physician ordered transfer and the resident was admitted with bacteremia, but the record lacked written notice of the transfer reason to the resident or responsible party. Another resident experienced a witnessed fall without immediate injury, later complained of left hip pain during therapy, and had an x‑ray that revealed a left femoral neck fracture, leading to an order to send the resident to the local hospital. Review of this resident’s record showed no documented evidence that the resident and legal guardian were notified in writing of the purpose of the hospitalization. Across all these cases, the surveyors determined that the facility did not provide or document the required written notices explaining the reasons for hospital transfers, constituting noncompliance with federal discharge/transfer notice and documentation requirements and state resident rights regulations.
Plan Of Correction
The facility is unable to retroactively correct that the resident and/or representative was notified in writing as follow up to the verbal notification regarding the reason for their transfer to the hospital for Residents 7, 8, 9, 43, 67 and 81. The Administrator will re-educate the Business Office Manager, Social Service Director and Admissions Coordinator on the need to notify the resident and/or resident representative in writing as follow up to the verbal notification regarding the reason(s) for transfer to the hospital. The Administrator will complete random audits to ensure written notification to the resident and/or resident representative as follow-up to the verbal notification of transfer, with reason(s), to hospital is completed for 4 weeks and then monthly for 2 weeks. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Inaccurate MDS Coding for Medications, Restraints, IV Therapy, and Pressure Ulcer Risk
Penalty
Summary
Surveyors identified that the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents’ clinical status, as required by the RAI User’s Manual and federal regulations. For one resident with an order for Divalproex Sodium 500 mg twice daily for seizure disorder, the March Medication Administration Record (MAR) showed the anticonvulsant was administered throughout the month, yet the quarterly MDS coded Section N0415K1 as if no anticoagulant/anticonvulsant had been given during the seven‑day look‑back period. The LPN Assessment Coordinator confirmed this MDS was coded inaccurately. Another resident’s side rail/enabler bar assessments documented that side rails were not indicated, and there was no evidence of side rail use during the seven‑day look‑back period, but the quarterly MDS coded Section P0100A as “used daily.” A different resident had physician orders and MAR documentation for Seroquel (antipsychotic), Buspirone and Clonazepam (antianxiety/anticonvulsant), and Furosemide (diuretic) administered consistently during the look‑back period, yet the MDS left Sections N0415A1, N0415B1, N0415G1, and N0415K1 unchecked, indicating no such medications were received. For another resident, physician orders and MAR/TAR entries showed Doxycycline and topical Mupirocin (antibiotics) were administered during the look‑back period, but Section N0415F1 on the MDS was not checked, indicating no antibiotic use. Surveyors also found discrepancies in coding for IV medications and pressure ulcer risk. One resident received IV Meropenem every eight hours over several days as documented on the MAR, but the quarterly MDS Section O0110H1B was coded to indicate IV medications were received during the 14‑day look‑back period in error, as confirmed by the LPN Assessment Coordinator. For the same resident, Section M0100A, M0100B, and M0100C were all checked, indicating the resident was at risk for pressure ulcer/injury development, yet Section M0150 was coded “0 – no,” indicating the resident was not at risk. Another resident had physician orders and MAR documentation for Seroquel administered multiple times daily for bipolar disorder during the seven‑day look‑back period, but Section N0415A1 on the quarterly MDS was coded “no,” indicating no antipsychotic use. In each of these cases, staff interviews confirmed the MDS assessments were coded inaccurately.
Plan Of Correction
Minimum Data Set (MDS) modifications were completed for Residents 2, 10, 12, 34, 43, and 57 to reflect correct coding. The Clinical Reimbursement Consultant re-educated the MDS Coordinator related to MDS accuracy with specifics on sections M, N, O and P items. An Initial audit review will be completed for section M, N, O and P items for residents with MDS Assessment Reference Dates of 4/23/26 through 5/8/26 for coding accuracy. The Director of Nursing and/or designee will complete random audits for MDS accuracy for sections M, N, O and P items weekly for 4 weeks and then monthly for 2 weeks. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Develop Care Plans for Key Diagnoses and High-Risk Medications
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans addressing specific clinical conditions and medication regimens for multiple residents. For one resident with a significant change MDS, the assessment documented cognitive impairment, dependence on staff for daily care, use of antipsychotic medication, and diagnoses of dementia, depression with severe psychosis, and obsessive-compulsive disorder. Physician orders directed administration of risperidone 0.25 mg twice daily for severe depression with psychotic features, yet there was no documented care plan addressing the resident’s antipsychotic use or her dementia and cognitive impairment. The Assistant Director of Nursing confirmed the absence of these care plans. Another resident’s quarterly MDS showed cognitive impairment, need for assistance with daily care, and diagnoses including dementia and hypertension, with physician orders for furosemide 40 mg for edema; however, there was no documented diuretic care plan, which the LPN Assessment Coordinator confirmed was missing. A third resident’s quarterly MDS documented cognitive impairment, limited range of motion on one side, dependence on staff for daily care, an indwelling urinary catheter, a feeding tube, a Stage 3 pressure ulcer present on admission, and diagnoses including cerebrovascular accident with right-sided hemiparesis/hemiplegia. Physician orders included long-term prophylactic nitrofurantoin 50 mg via feeding tube three times weekly for UTI prevention, but there was no documented care plan addressing this long-term antibiotic therapy. The Nursing Home Administrator confirmed the lack of a care plan for the resident’s prophylactic antibiotic use.
Plan Of Correction
Individualized care plans will be reviewed, developed, and implemented as needed for Residents 1, 2, and 43 to accurately reflect care and services provided. The Clinical and Clinical Reimbursement Consultants re-educated the Minimum Data Set (MDS) Coordinator, Interdisciplinary Team, and Administrative Nurses (Director of Nursing, Assistant Director of Nursing, Staff Development/Infection Control Nurse Coordinator, and Nursing Supervisor) regarding developing and implementing a comprehensive person-centered care plan on May 14 and May 15, 2026. Director of Nursing and/or designee will educate all Licensed Nursing staff regarding development of care plans. An initial audit review will be completed by the Director of Nursing and/or designee to assure the development and implementation of a comprehensive person-centered care plan to reflect current in-house residents with anticoagulants, cognitive impairments, diuretic(s), and prophylactic antibiotics. The Director of Nursing and/or designee will complete random audits for a comprehensive person-centered care plan reflecting current in-house residents with anticoagulants, cognitive impairments, diuretic(s), and prophylactic antibiotics weekly for 4 weeks and then monthly for 2 weeks. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Follow Anticoagulant Medication Orders for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to administer anticoagulant medications as ordered by physicians for two residents, contrary to its policy that medications be given in accordance with prescriber orders. For one resident admitted for hospice respite care with atrial fibrillation and cognitive impairment, hospice medication orders specified Jantoven 5 mg once daily three times a week and 7.5 mg four times a week. The Medication Administration Record showed that the facility did not clarify the specific dosing schedule with the physician and the resident did not receive Jantoven on three consecutive days. The DON confirmed that the Jantoven order had not been clarified and that three doses were missed. For another resident who was cognitively intact, required assistance with daily care, and had a nondisplaced right tibia fracture, physician orders required a 70 mg daily dose of Enoxaparin Sodium injection for DVT prophylaxis. During an observation, an LPN administered an 80 mg prefilled Enoxaparin syringe into the resident’s abdomen instead of the ordered 70 mg dose. The LPN confirmed that the syringe from the pharmacy was 80 mg and that she administered the incorrect dose, and the DON confirmed that the LPN did not follow the physician’s order, resulting in a medication error.
Plan Of Correction
The facility is unable to retroactively correct the observation for Resident 44 and 73. There were no ill effects noted. The Director of Nursing and/or designee will complete medication pass competency for Licensed Practical Nurse 3 to ensure competence with medication administration. The Director of Nursing and/or designee will re-educate in-house and agency Nursing Staff on safe medication administration and clarifying and following physician orders. Newly hired and agency Nursing staff will be educated on safe medication administration and clarifying and following physician orders. Random audits will be completed by the Director of Nursing or designee weekly for 4 weeks and monthly for 2 months to assure that anticoagulants were clarified and administered per physician order. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Transcribe and Coordinate Hospice Medication Orders
Penalty
Summary
Surveyors identified a deficiency in the facility’s coordination of hospice services for one resident receiving hospice care. The hospice contract effective June 3, 2022, required regular and as-needed communication between the hospice and the facility, with each party responsible for documenting such communications to ensure resident needs were met 24 hours per day. The contract also specified that if physician orders were inconsistent with the hospice plan of care or hospice protocols, facility nursing staff were to notify hospice so that hospice could resolve differences with the physician and secure necessary orders. Resident 38 had a quarterly MDS dated March 20, 2026, indicating cognitive impairment, need for staff assistance with daily care, receipt of antipsychotic and antianxiety medications, and enrollment in hospice services, with diagnoses including dementia, psychotic disorder, anxiety, and depression. A care plan dated January 8, 2025, stated that the facility would coordinate care with the resident’s hospice provider. Physician orders dated June 18, 2024, documented that the resident was receiving hospice services effective June 19, 2024. For symptom management, the resident had a current physician order dated March 14, 2025, for ABHR cream containing 1 mg Ativan per 12.5 mg Benadryl per 2 mg Haldol per 10 mg Reglan, to be applied topically twice daily for anxiety and psychosis. Hospice orders dated February 16, 2026, and April 13, 2026, specified a different ABHR formulation (1 mg Ativan per 25 mg Benadryl per 2 mg Haldol per 10 mg Reglan) and directions to apply one syringe to the wrist or neck every morning and evening for anxiety and agitation with care. There was no documented evidence that these hospice orders were transcribed into the resident’s physician orders, and the Nursing Home Administrator confirmed that the hospice orders were not transcribed and should have been, demonstrating a failure to coordinate care with the hospice provider as required.
Plan Of Correction
Resident 38 ABHR gel order was clarified and updated per physician on 4/24/26. Initial audit of current in-house resident Hospice recommendations will be reviewed to ensure orders are in place. Director of Nursing and/or designee will re-educate current in-house facility and agency nursing staff as well as newly hired or agency staff regarding the requirement to review hospice recommendations with visits and transcribing orders appropriately to the Medication Administration Record. Director of Nursing/designee will complete random audits of Hospice recommendations to ensure orders are generated and transcribed correctly weekly for 4 weeks and monthly for 2 months. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Call Bells Not Kept Within Reach for Two Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident call bells were within reach for two residents, contrary to facility policy and care plan interventions. The facility’s call system policy dated January 22, 2026, states that each resident must be provided with a means to call staff directly for assistance from the bed and other areas. Resident 32 had a quarterly MDS showing she was sometimes understood and sometimes able to understand others, required staff assistance for daily care, and had Parkinson’s disease and dementia. Her care plan, initiated in 2019 with an intervention added in 2021, directed staff to encourage her to use the call bell and to assure the call pendant was in place and functioning properly. On observation, she was found lying in bed with her call pendant placed on the nightstand out of reach. The DON stated at that time that the resident was unable to use the call pendant, then placed it around her neck. In interviews, the resident first indicated she would push the button on her pendant to call a nurse, and later stated she had been told there was a bell somewhere to use; at that later observation, she was wearing the pendant and had a tap bell on her overbed table that was not within reach. Resident 78’s annual MDS indicated he was usually understood and usually able to understand others, required staff assistance for daily care, and had dementia and a history of stroke. His care plan directed staff to encourage him to use the call bell for assistance. During observation, he was found lying in bed with his call pendant on the nightstand out of reach. At the time of this observation, a nurse aide acknowledged that the resident should have had his call pendant within reach. In a subsequent interview, the resident demonstrated his call pendant hanging around his neck when asked how he would call for a nurse. The DON stated that all residents who are able to use their call pendants should have them within reach, confirming that the observed placement of the pendants on the nightstands, out of reach, was inconsistent with facility expectations and policy.
Plan Of Correction
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Indiana Skilled Nursing INC dba Beacon Ridge agrees with the allegations and citations listed on the statement of deficiencies. Indiana Skilled Nursing INC dba Beacon Ridge maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Indiana Skilled Nursing INC dba Beacon Ridge written credible allegation of compliance. By submitting this plan of correction, Indiana Skilled Nursing INC dba Beacon Ridge does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Indiana Skilled Nursing INC dba Beacon Ridge reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. The facility is unable to retroactively correct the observation for Resident 32 and 78; when it was identified it was corrected at that time. There were no ill effects noted. The Director of Nursing and/or designee will re-educate current facility staff, including agency staff, on assuring the call pendants and/or tap bells are within reach. New/agency Nursing staff will be educated upon onboarding, assuring the call pendants and/or tap bells are within reach of residents. The Director of Nursing and/or designee will complete random audits 3 times a week for 2 weeks, weekly for 2 weeks and then monthly for 2 months to assure the call pendants and/or tap bells are within reach. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Update Care Plans to Reflect Discontinued Treatments
Penalty
Summary
The deficiency involves the facility’s failure to revise comprehensive care plans to reflect current treatment orders for two residents. For one resident with cognitive impairment, paralysis following a cerebral infarction, and dependence on staff for daily care, a quarterly MDS assessment documented ongoing needs and a care plan dated March 18, 2026, stated that the resident was receiving diuretic therapy for edema and that staff were to administer the diuretic as ordered. However, review of the April 2026 MAR showed that the resident was not receiving any diuretic medication during the survey period, indicating that the care plan was not updated when the diuretic was discontinued. For another cognitively impaired resident with hemiparesis/hemiplegia, limited range of motion, an indwelling urinary catheter, a feeding tube, and a Stage 3 pressure ulcer present on admission, the quarterly MDS assessment documented multiple complex care needs. A care plan dated March 24, 2026, indicated that this resident was receiving IV medications for an ESBL urinary infection. Review of the clinical record revealed no documentation that the resident was actually receiving IV medications at that time. The NHA confirmed that the care plan should have been revised to show that IV medications were no longer being administered.
Plan Of Correction
F 0657 Comprehensive care plans will be revised for Residents 18 and 43 to reflect current status of diuretic and intravenous medications. The Clinical and Clinical Reimbursement Consultants re-educated the Minimum Data Set (MDS) Coordinator, Interdisciplinary Team and Administrative Nurses (Director of Nursing, Assistant Director of Nursing, Staff Development/Infection Control Nurse Coordinator, and Nursing Supervisor) regarding care plan timing and revision to the comprehensive care plan, to reflect specific care, on May 14 and May 15, 2026. Director of Nursing and/or designee will educate all Licensed Nursing staff regarding updating and maintaining comprehensive care plans. An initial audit review will be completed for current in-house residents to assure revisions to the comprehensive care plans for diuretic and intravenous medication(s) were accurately reflected. The Director of Nursing and/or designee will complete random audits for revisions to the comprehensive person-centered care plan reflecting use of diuretic and intravenous medication(s) weekly for 4 weeks and then monthly for 2 weeks. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Clarify and Update Provider Orders for Pain Management and Wound Care
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by not clarifying and implementing provider orders for two residents. For one resident with dementia who was cognitively impaired and required staff assistance for daily care, a physician progress note documented that the resident was to receive routine Tylenol for pain control. However, the existing physician order listed acetaminophen 500 mg, two tablets every eight hours as needed for pain, and there was no documented evidence that a routine Tylenol order was ever implemented. The Assistant Director of Nursing stated that the routine Tylenol order in the physician’s progress note was missed and therefore was not added to the resident’s medication orders. For another cognitively impaired resident with diabetes mellitus and cellulitis of the right lower limb, the physician initially ordered 2% Mupirocin ointment to be applied once daily to a right great toe ulcer. A subsequent wound consultant note recommended cleansing the right great toe wound with wound cleanser, applying Iodosorb ointment to the wound bed and surrounding callus, and covering it with a dry dressing secured with rolled gauze daily, and a later physician order reflected this Iodosorb-based treatment. Review of the Treatment Administration Record showed that the resident was receiving both the original Mupirocin treatment and the newer Iodosorb treatment to the same right great toe wound. The Director of Nursing confirmed that two wound treatment orders were being carried out concurrently and that the Mupirocin order should have been discontinued in favor of the wound consultant’s recommendation.
Plan Of Correction
Physician orders for R9 Tylenol was addressed on 4/20/2026 upon return from the hospital. R34 treatment orders for toe wound clarified on 4/12/2026. No ill effects noted to either resident. The Clinical and Clinical Reimbursement Consultants re-educated the Minimum Data Set (MDS) Coordinator, Interdisciplinary Team and Administrative Nurses (Director of Nursing, Assistant Director of Nursing, Staff Development/Infection Control Nurse Coordinator, and Nursing Supervisor) regarding resident services provided meeting professional standards, to reflect resident orders for care and services being provided, on May 14 and May 15, 2026. Initial review of physician/provider progress notes for current in-house residents will be completed to ensure resident orders are present per recommendations from 4/23/26 to 5/8/26. The Director of Nursing and/or designee will complete random audits of current in-house resident physician/provider progress notes to ensure orders are present per recommendations as needed weekly for 4 weeks and then monthly for 2 weeks. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Obtain Orders and Document Colostomy Care for a Resident
Penalty
Summary
Surveyors identified a deficiency in colostomy care for one resident when the facility failed to ensure care was provided in accordance with professional standards, the care plan, and physician orders. The facility’s colostomy care policy, dated January 22, 2026, required that colostomy care be provided per physician orders to maintain good skin care and monitor the condition of the stoma and surrounding skin. An annual MDS for Resident 16, dated March 17, 2025, showed the resident was cognitively impaired, required staff assistance for daily care needs, had intellectual disabilities, and had an ostomy. Review of the resident’s clinical record revealed there was no physician order specifying the colostomy size and no orders for changing the colostomy appliance, and there was no documented evidence that the colostomy appliance was being changed. In an interview, the Nursing Home Administrator confirmed the absence of a physician order for the ostomy size and the lack of documentation that the colostomy appliance was being changed for this resident. These findings demonstrate that the facility did not follow its own policy or obtain and implement necessary physician orders for colostomy care for this resident, resulting in a failure to provide and document appropriate ostomy services as required.
Plan Of Correction
The physician orders for Resident 16 were updated to include colostomy size with orders to change the appliance on 4/21/2026 with no ill effects noted. An audit of current in-house resident colostomy orders will be completed to ensure specification of size with orders to change appliance present. The Director of Nursing and/or designee will re-educate the Nursing Staff on verifying that resident colostomy orders specify size with orders to change the appliance. Newly hired and agency Nursing staff will be educated upon on boarding on verifying that resident colostomy orders specify size with orders to change the appliance. The Director of Nursing and/or designee will complete random audits weekly for 4 weeks and then monthly for 2 weeks to assure resident colostomy orders are present and specify size with orders to change appliance. with colostomy's have corresponding orders on the Treatment Administration Record (TAR). Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Provide and Document Ordered Enteral Feeding Tube Site Care
Penalty
Summary
The deficiency involves the facility’s failure to provide and document ordered enteral feeding tube site care for a resident receiving enteral nutrition. Facility policy dated January 22, 2026, required LPNs to change feeding tube dressings at least every 24 hours unless otherwise ordered and to document the dressing change in the resident’s chart. Physician’s orders dated August 19, 2025, directed that the resident’s feeding tube site be cleansed with normal saline, patted dry, and a drain sponge applied daily and as needed for soilage or dislodgement. Review of the Treatment Administration Records (TARs) from August 2025 through December 2025 and March and April 2026 showed multiple dates on which there was no documented evidence that the ordered feeding tube site care was completed. The resident involved had a quarterly MDS dated February 20, 2026, indicating cognitive impairment, limited range of motion of upper and lower extremities on one side, dependence on staff for daily care, an indwelling urinary catheter, a feeding tube, and a Stage 3 pressure ulcer present on admission, with diagnoses including cerebrovascular accident and hemiparesis/hemiplegia affecting the right dominant side. Despite these conditions and the specific physician’s orders for daily feeding tube site care, the TARs lacked documentation of this care on numerous identified dates across several months. In an interview, the Assistant DON confirmed there was no documented evidence that the feeding tube site care was completed as ordered on those dates.
Plan Of Correction
The facility is unable to retroactively correct the lack of documentation for enteral feeding site care administration to Resident 43 as verified during survey on the Treatment Administrative Record (TAR). There were no ill effects noted to the resident. An audit of the last 30 days of current in-house residents with enteral feeding sites will be completed to ensure order for site care are present with documentation of administration. The Director of Nursing and/or designee will re-educate current in-house and agency Nursing Staff on the importance of documenting administration of enteral feeding site care as ordered. Newly hired and agency Nursing staff will be educated upon boarding on providing and completing the documentation on the necessary treatment and services per physician order for enteral feeding care. The Director of Nursing and/or designee will complete random audits of enteral feeding care to verify that the treatment is completed and documented on the TAR weekly for 4 weeks and then monthly for 2 weeks. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Improper Refrigerator Storage of Controlled Liquid Ativan
Penalty
Summary
Surveyors identified a deficiency related to the labeling and storage of drugs and biologicals, specifically the failure to provide a separately locked, permanently affixed compartment in a medication room refrigerator for controlled drugs. During an observation of the Landings unit medication room, surveyors noted that a small locked refrigerator contained five bottles of liquid Ativan, a controlled medication used to treat anxiety. These bottles were stored together with non-narcotic medications and were not placed in a distinct, separately locked compartment as required for controlled substances. At the time of the observation, an LPN confirmed that the five bottles of liquid Ativan were not secured in a separate locked compartment from other non-narcotic medications. Later, the Nursing Home Administrator also confirmed that the liquid Ativan was not stored in a separately locked, permanently affixed compartment within the refrigerator. The deficiency was cited under federal requirements for storage of controlled drugs and the related state pharmacy services regulation.
Plan Of Correction
Upon identification, the controlled drugs were relocated to another nursing unit secured medication refrigerator and housed in a separately locked, permanently affixed compartment in the refrigerator. Medication room refrigerator controlled drug box was secured and medications returned to the refrigerator on the assigned unit. The Director of Nursing and/or designee will re-educate current in-house and agency Nursing Staff on the requirement for storage of controlled drugs in a separately locked, permanently affixed compartment in the refrigerator separate from other non-narcotic medications. Newly hired and agency Nursing staff will be educated on the storage of controlled drugs in a separately locked, permanently affixed compartment in the refrigerator separate from other no- narcotic medications. Random audits will be completed by the Director of Nursing or designee weekly for 4 weeks and monthly for 2 months to assure that controlled drugs are stored in a separately locked, permanently affixed compartment in the refrigerator separate from other non-narcotic medications. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Obtain Ordered Urine Culture and Sensitivity Test
Penalty
Summary
The facility failed to obtain ordered laboratory services for a resident when a urine culture and sensitivity (C&S) test was not completed as ordered by the physician. Facility policy dated January 22, 2026, stated that the facility would provide or obtain laboratory services to meet residents' needs and ensure quality and timeliness, with the day shift unit nurse responsible for filling out and sending laboratory requests for newly ordered tests. A quarterly MDS for the resident, dated March 29, 2026, documented that the resident was cognitively intact, independent with daily care needs, and had a history of urinary tract infection. On February 24, 2026, at 1:31 p.m., nursing documentation showed that the resident complained of burning and pain on urination, the physician was notified, and an order was received for a UA flex to culture to rule out a urinary tract infection. Later that day at 5:58 p.m., a nurse's note indicated that the physician was notified of the urinalysis results and ordered Macrobid 100 mg twice daily for seven days pending the urine C&S results. Review of the February 2026 lab results revealed no evidence that a urine C&S was obtained from the February 24 urine sample as ordered. In interviews, the Nursing Home Administrator confirmed that a urine C&S was not obtained as ordered and explained that the laboratory order for the resident’s urine sample had been transcribed incorrectly, resulting in the C&S not being completed by the lab.
Plan Of Correction
The facility is unable to retroactively correct the observation of a Urinalysis (UA) being completed when a Urinalysis with Culture and Sensitivity (UA C&S) was ordered. There were no ill effects noted. The Director of Nursing and/or designee will re-educate the current in-house and agency Nursing Staff regarding obtaining laboratory services per physician order and assuring that the laboratory requisition is completed correctly and per physician order. Newly hired and agency Nursing staff will be educated regarding obtaining laboratory services per physician order and assuring that the laboratory requisition is completed correctly and per physician order. Random audits will be completed by the Director of Nursing or designee weekly for 4 weeks and monthly for 2 months to assure that UA and UA C&S specimen laboratory requisitions are accurate per physician order. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment in several resident rooms, as evidenced by multiple observations of physical damage and lack of timely repairs. In one room, a large area of dried, chipping paint was found above the heating/cooling unit, and the Maintenance Director was unaware of the issue, attributing it to recent moisture from rain. In another room shared by two residents, there was broken drywall near the air conditioning unit, bubbling paint, a loose and deteriorating windowsill, and a black/grey removable substance in the window corner. The residents reported placing a blanket on the windowsill to block a cold draft and stated that maintenance had not returned to complete repairs after initially cleaning up fallen wall pieces. Subsequent observation revealed the blanket was wet and the conditions remained unaddressed. Additional deficiencies were observed in other rooms, including broken drywall below a window and more areas of chipping paint above heating/cooling units. The Maintenance Director confirmed the presence of water damage, loose wall trim, and the need for repairs, but was not aware of these issues prior to the survey and indicated that no work orders had been submitted for these concerns. The facility's policy required maintaining a clean, sanitary, and orderly environment, but these conditions were not met for the affected residents, some of whom were cognitively intact and able to communicate their needs and concerns.
Care Plans Not Updated to Reflect Residents' Current Needs
Penalty
Summary
The facility failed to ensure that care plans were updated or revised to accurately reflect the current care needs and interventions for three residents. For one resident with a history of hypertension and previously documented as receiving a diuretic for edema and hypertension, the care plan continued to indicate diuretic use despite no evidence in the clinical record or Medication Administration Record (MAR) that the medication was being administered. Another resident, identified as an elopement risk with a history of dementia, anxiety, depression, and bipolar disorder, had a care plan that listed an outdated code alert bracelet number and expiration date, which did not match the current physician order or the bracelet observed on the resident. A third resident, who was cognitively impaired and required assistance with care needs, had a care plan intervention for antibiotic therapy related to a urinary tract infection, but there was no documentation in the clinical record or MAR of a current infection or antibiotic administration. In each case, interviews with the Nursing Home Administrator confirmed that the care plans should have been revised to reflect the residents' current conditions and interventions, but this was not done in a timely manner as required by facility policy and regulatory standards.
Failure to Maintain Proper Catheter Care and Documentation
Penalty
Summary
The facility failed to provide proper care for residents with indwelling urinary catheters, as evidenced by multiple observations and record reviews. For one resident with severe cognitive impairment and neuromuscular bladder dysfunction, staff were observed transporting the resident in a wheelchair while the catheter drainage bag, attached beneath the chair, dragged on the floor. Staff interviews confirmed that the drainage bag should not have been in contact with the floor, but noted challenges in keeping the bags elevated due to the design of some chairs. Another resident, who was cognitively intact and required assistance with daily care, had a physician's order for the indwelling catheter to be changed every 30 days. However, there was no documented evidence that the catheter change was completed as ordered. Additionally, a third resident with obstructive uropathy was observed with catheter tubing in direct contact with the floor, and the drainage bag partially exposed and not fully covered for dignity. Staff interviews confirmed awareness of the requirement to keep catheter equipment off the floor and properly covered, but these standards were not maintained during the observed incidents.
Failure to Develop Care Plan for Resident with Parkinson's Disease
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed the specific needs of a resident diagnosed with Parkinson's disease. According to facility policy, care plans must include measurable objectives and timetables to meet each resident's physical, psychosocial, and functional needs, and should be revised as the resident's condition changes. Review of the clinical record for this resident, who was cognitively intact and required assistance with daily care, showed no documented evidence of a care plan targeting care needs related to Parkinson's disease. This deficiency was confirmed by the Nursing Home Administrator during an interview.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
A review of clinical records and interviews revealed that a resident who was alert, oriented, and required moderate assistance for daily care, including transfers with a wheeled walker and gait belt, was not safely transferred according to his care plan. During an observed transfer, a nurse aide moved the resident from a seated position to his wheelchair by holding the back of his pants, despite a gait belt being available on the wheelchair. The nurse aide acknowledged awareness of the resident's transfer requirements but did not use the gait belt as specified. The nursing home administrator confirmed that the resident should have been transferred using the gait belt, but this was not done.
Failure to Document Administration of Controlled Medication
Penalty
Summary
The facility failed to maintain proper accountability for controlled medications for one resident. According to facility policy, staff are required to initial the Medication Administration Record (MAR) after administering each medication. Review of the clinical record for a resident who was cognitively intact and receiving opioid medication for pain management revealed that multiple doses of Hydrocodone-Acetaminophen were signed out on the controlled drug record over several months. However, there was no documented evidence in the resident's clinical record, including the MAR, to confirm that these signed-out doses were actually administered to the resident on the specified dates and times. This lack of documentation was confirmed by the Director of Nursing, who acknowledged that the records did not show administration of the medication as required.
Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy and regulation. During medication administration observations, three errors were identified out of 29 opportunities, resulting in a 10.34 percent error rate. The errors included improper handling and administration of medications by nursing staff. Specifically, one nurse crushed an extended-release tablet of Metoprolol Succinate before administering it to a resident with hypertension, despite manufacturer instructions and facility policy prohibiting this practice. Another nurse opened a Tamsulosin HCL capsule and administered its contents in applesauce to a resident with obstructive uropathy and benign prostatic hyperplasia, contrary to manufacturer instructions that the capsule should not be opened, crushed, or chewed. A third nurse administered an incorrect dose of aspirin (81 mg instead of the ordered 325 mg) to a resident with heart disease and a right artificial hip joint, who was prescribed aspirin for blood clot prevention. Interviews with the involved nurses confirmed their actions and lack of awareness regarding proper medication administration procedures. The Nursing Home Administrator also confirmed that the medications were not administered as ordered or according to manufacturer instructions. These actions directly led to the facility exceeding the acceptable medication error rate and not adhering to established medication administration protocols.
QAPI Committee Failed to Address Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct previously identified quality deficiencies and did not ensure that plans to improve care and services effectively addressed recurring issues. Despite developing plans of correction after a prior survey, the facility continued to have repeated deficiencies in areas such as safety and accident hazards, proper catheter care, and accountability of controlled substances. The QAPI committee was responsible for reviewing audit results and maintaining compliance, but the same deficiencies were identified again during the most recent survey. Specifically, the facility had previously committed to conducting audits and reporting findings to the QAPI committee for review in response to deficiencies related to safety hazards, catheter care, and controlled substances. However, the current survey found that these measures were not effectively implemented, as the same issues were cited again under F689, F690, and F755. The report does not mention any specific residents or staff involved, nor does it provide details about individual medical histories or conditions at the time of the deficiencies.
Deficiencies in Food Storage and Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies in food storage and preparation. Observations in the main kitchen revealed that Danishes and dinner rolls were not dated with the date they were opened or a use-by date, contrary to the facility's policy. Additionally, a five-pound roll of ground hamburger in the walk-in cooler was not properly labeled with the date it was removed from the freezer or the date by which it should be cooked, as required by the facility's thawing policy. Interviews with the [NAME] Manager and the Regional Dietary Manager confirmed these lapses in following the facility's food storage and thawing policies. Further deficiencies were noted in the Bayside Nourishment Center, where a microwave used to reheat resident food was found to be unclean, with food splatters on the inside surfaces. Additionally, the ice machine in the same area lacked an air gap between its drain pipe and the floor drain, posing a risk of back-flow contamination. Interviews with the Staff Development/Registered Nurse and the Director of Maintenance confirmed the need for cleaning the microwave and the absence of an air gap in the ice machine, respectively. These findings indicate a failure to maintain sanitary conditions in food preparation and storage areas.
Non-Compliance with Physician Orders in Nutritional, Hypoglycemic, and Bowel Protocols
Penalty
Summary
The facility failed to provide nutritional supplements as ordered by the physician for a resident who was cognitively impaired and had a potential for decreased nutritional intake. Despite physician's orders for the resident to receive a four-ounce Mighty Shake with each meal, observations revealed that the supplement was missing from the resident's meal trays on multiple occasions. This was confirmed by both a nurse aide and the Nursing Home Administrator, indicating a lapse in following the prescribed nutritional care plan. Additionally, the facility did not adhere to hypoglycemic protocols for two residents with diabetes. Physician's orders required the administration of 15 grams of glucose if blood glucose levels fell below 70 mg/dl, followed by a recheck in 15 minutes. However, records showed that on several occasions, these interventions were not documented or carried out, as confirmed by the Director of Nursing. This oversight in managing hypoglycemic events posed a significant risk to the residents' health. The facility also failed to follow physician's orders for medication administration and bowel protocols for several residents. One resident was given full doses of insulin despite eating only half or less of their meals, contrary to the physician's instructions. Furthermore, two residents did not receive bowel medications as ordered, despite documented periods of no bowel movements. These failures were confirmed through interviews with the nursing staff and administration, highlighting a pattern of non-compliance with physician's orders across multiple areas of care.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain a complete and accurate accounting of controlled medications for two residents. For one resident, who was cognitively impaired and received routine pain medication, the controlled drug records indicated that doses of Oxycodone were signed out for administration on specific dates and times. However, there was no documented evidence in the resident's clinical record or Medication Administration Record (MAR) that these doses were actually administered. Similarly, another resident, who was cognitively intact and had a diagnosis of anxiety, had controlled drug records showing that doses of Lorazepam were signed out for administration on several occasions. Yet, the clinical record and MAR lacked documentation confirming the administration of these doses. An interview with the Assistant Director of Nursing confirmed the absence of documentation for the administration of the signed-out doses of both Oxycodone and Lorazepam for these residents.
Failure to Attempt Non-Pharmacological Interventions Before Administering Anti-Anxiety Medication
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted prior to administering anti-anxiety medication to a resident. The resident, who was cognitively intact and diagnosed with anxiety, had a care plan in place since November 2021, which included strategies for managing anxiety without medication. These strategies involved identifying and eliminating the source of anxiety, allowing the resident to express feelings, and offering emotional support and empathetic listening. Additionally, the care plan suggested de-escalation techniques such as music, books, TV, and social interaction, as well as checking for basic needs like pain, hunger, thirst, and toileting. Despite these non-medication interventions being outlined in the care plan, the facility's records showed that Lorazepam, an anti-anxiety medication, was administered to the resident multiple times in April and May 2024 without documented evidence of attempting these interventions first. An interview with the Assistant Director of Nursing confirmed the lack of documentation for non-pharmacological interventions prior to the administration of Lorazepam on the specified dates. This oversight was identified as a deficiency in the facility's compliance with the required nursing services.
Medication and Supply Management Deficiencies
Penalty
Summary
The facility failed to adhere to its medication storage and disposal policy, resulting in deficiencies in two of the three medication rooms reviewed. In the Landing medication room, a 30 ml bottle of Ativan was found opened and undated, which was confirmed by an LPN. Similarly, in the Bayside medication room, an opened and undated multi-dose vial of insulin Glargine was observed, along with expired blood collection tubes. A registered nurse confirmed that the insulin vial should have been dated and the expired tubes discarded. The Nursing Home Administrator acknowledged these deficiencies, confirming that the opened vials should have been dated and the expired supplies removed.
Repeated Deficiencies in Compliance and Care Standards
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations, as evidenced by repeated deficiencies identified in the current survey. These deficiencies included issues with professional standards, quality of care, accident hazards in the resident environment, urinary catheter care, oxygen therapy, accountability of controlled medications, food storage, and infection control practices. The facility had previously developed plans of correction for these issues, which included conducting audits and reporting the results to the QAPI committee. However, the current survey revealed that these plans were not effectively implemented, leading to ongoing non-compliance. Specifically, the facility failed to clarify physician's orders, provide proper incontinent and catheter care, and ensure the provision of oxygen therapy as ordered by the physician. Additionally, the facility did not maintain a safe environment free of accident hazards, properly account for controlled medications, ensure appropriate food storage, or adhere to infection control practices. These repeated deficiencies indicate that the QAPI committee was ineffective in addressing and correcting the cited issues, despite having plans of correction in place from the previous survey.
Failure to Maintain Resident Dignity with Foley Catheter
Penalty
Summary
The facility failed to maintain the dignity of a resident with an indwelling urinary catheter. The resident, who was cognitively impaired and required assistance with personal hygiene due to a stroke, had a care plan that included keeping her Foley catheter drainage bag covered to promote dignity. However, during an observation, the resident was found lying in bed with her catheter drainage bag visibly attached to the side of her bed and not covered by a privacy bag, as required. This was confirmed by both a registered nurse and the Director of Nursing, who acknowledged that the drainage bag should have been covered.
Failure to Clarify Physician's Order for Resident's Pressure Ulcer Treatment
Penalty
Summary
The facility failed to clarify a questionable physician's order for a resident, leading to a deficiency in the care provided. The resident, who had moderate cognitive impairment and a history of stroke, was at risk for developing pressure ulcers. A wound note indicated a pressure-induced deep tissue injury on the resident's right heel, with a recommendation to apply skin prep twice a day. However, the physician's order was incorrectly documented in the Treatment Administration Record, leading to the application of skin prep on the left heel instead of the right. The discrepancy in the treatment order was not clarified with the physician, resulting in a failure to provide the appropriate care for the resident's condition. The Director of Nursing confirmed that the treatment order should have been clarified, indicating a lapse in following professional standards of quality care as outlined in the Pennsylvania Code. This oversight highlights the importance of accurate documentation and communication in ensuring proper treatment and care for residents.
Failure to Follow Wound Care Recommendations
Penalty
Summary
The facility failed to adhere to wound care recommendations for a resident with a Stage III pressure ulcer. The resident, who had moderate cognitive impairment and a history of stroke, was identified as being at risk for developing pressure ulcers. A wound consultation on May 24, 2024, recommended applying Santyl to the resident's right gluteus twice daily. However, the Treatment Administration Record for May 2024 showed no documented evidence that Santyl was applied as recommended. This deficiency was confirmed during an interview with the Director of Nursing on June 5, 2024.
Failure to Adhere to Care Plans and Physician Orders
Penalty
Summary
The facility failed to provide an environment free from accident hazards by not adhering to physician's orders and care-planned interventions for several residents. One resident, who was cognitively impaired and had a history of falls, was supposed to wear shoes when out of bed as per her care plan. However, during a fall incident, she was found wearing yellow grip socks instead of shoes, which was confirmed by the Assistant Director of Nursing. Another resident, who had a diagnosis of cerebral vascular accident with hemiplegia and dysphagia, was supposed to receive a regular, mechanical soft/chopped diet. However, during a meal, the resident was served a whole chicken nugget, which she struggled to swallow, leading to a choking incident. This was confirmed by the Director of Nursing, who acknowledged that the resident was not served her meal as ordered. Additionally, a resident with frail skin was ordered to wear bilateral Geri sleeves to prevent skin tears. Observations revealed that the resident was not wearing the sleeves, and staff confirmed that they were not on her arms as required. Furthermore, another resident, who was at risk for falls, was observed being transported in a wheelchair with his feet dangling between the footrests, which was not safe. The Nursing Home Administrator confirmed that the resident's feet should have been resting on the footrests during transport.
Failure to Prevent Urinary Tract Infections Due to Improper Catheter Care
Penalty
Summary
The facility failed to ensure proper interventions were in place to prevent urinary tract infections for a resident with an indwelling urinary catheter. The facility's policy, dated January 16, 2024, required that catheter tubing and drainage bags be kept off the floor. However, during an observation on June 5, 2024, it was noted that the catheter tubing of Resident 5 was positioned under a fall mat and in contact with the floor. This resident, who had moderate cognitive impairment and a diagnosis of neurogenic bladder, had an indwelling urinary catheter as per physician's orders dated April 29, 2024. Interviews with Nurse Aide 5 and the Director of Nursing confirmed that the catheter tubing should not have been on the floor, indicating a failure to adhere to the facility's catheter care policy.
Oxygen Tubing and Nasal Cannula Found on Floor
Penalty
Summary
The facility failed to ensure that oxygen tubing and a nasal cannula remained off the floor for a resident. The facility's policy on oxygen therapy required that oxygen be administered safely and in accordance with physician's orders. A quarterly Minimum Data Set (MDS) assessment indicated that the resident was cognitively impaired and had chronic respiratory failure with hypoxia, requiring continuous oxygen while sleeping. Physician's orders specified a flow rate of 2 liters per minute via nasal cannula during sleep. However, observations revealed that the resident's oxygen tubing and nasal cannula were found on the floor beside the oxygen concentrator, in contact with the floor. Interviews with a nurse aide and the Director of Nursing confirmed that the oxygen tubing and nasal cannula should not have been in contact with the floor.
Failure to Obtain Physician's Order for Catheterization
Penalty
Summary
The facility failed to obtain a physician's order for an invasive procedure to collect a urine specimen for a laboratory test for one resident. The facility's policy on intermittent catheterization required staff to verify a physician's order before performing the procedure. However, for Resident 58, there was no evidence of a physician's order for catheterization to obtain urine specimens on the specified dates. The resident's care plan indicated a potential for discomfort due to urinary retention, and staff were instructed to perform intermittent catheterization as ordered by the physician. On December 19, 2023, a physician's order was given to obtain a Urine Flex test for Resident 58 due to nausea, vomiting, and elevated temperature. Nursing notes revealed attempts to obtain urine via catheterization on December 19, 2023, and April 8, 2024, but there was no documented physician's order for these procedures. The Assistant Director of Nursing confirmed the absence of such orders during an interview on June 5, 2024.
Failure to Provide Correct Food Consistency
Penalty
Summary
The facility failed to provide the correct food consistency as ordered by the physician for a resident who had a history of Cerebral Vascular Accident (CVA) with hemiplegia and dysphagia. The resident was supposed to receive a regular, mechanical soft/chopped diet to accommodate her swallowing difficulties. However, during a lunch meal, the resident was served a full/intact chicken nugget, which was not in accordance with her prescribed diet. This incident led to the resident experiencing difficulty with something in her throat, which required staff assistance to clear. The resident was able to cough up the intact chicken nugget after being provided with fluids. The incident was confirmed by the Director of Nursing, who acknowledged that the resident was not served her meal as ordered. The deficiency was identified during a review of clinical records and staff interviews, highlighting the facility's failure to adhere to the dietary orders specified for the resident's condition.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices during wound care for two residents. The facility's policy on hand hygiene, dated January 16, 2024, requires hand sanitization or washing before and after glove use. However, during an observation on June 4, 2024, an LPN was seen removing dressings from a resident's feet, changing gloves without performing hand hygiene, and proceeding with wound care. This was observed for Resident 59, who was moderately cognitively impaired and had peripheral vascular disease, with specific physician's orders for wound care on the left foot. Similarly, the LPN was observed performing wound care on Resident 45, who was severely cognitively impaired and also had peripheral vascular disease. The LPN cleansed a wound on the resident's foot, applied treatment, and changed gloves without performing hand hygiene. Interviews with the LPN and the Director of Nursing confirmed the failure to adhere to the facility's hand hygiene policy during these procedures.
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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