Belle Terrace
Inspection history, citations, penalties and survey trends for this long-term care facility in Quakertown, Pennsylvania.
- Location
- 1320 Mill Road, Quakertown, Pennsylvania 18951
- CMS Provider Number
- 395574
- Inspections on file
- 21
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Belle Terrace during CMS and state inspections, most recent first.
A resident with complex medical conditions did not receive a chest X-ray or a stool specimen collection as ordered by the physician. Documentation confirming completion of these diagnostic tests was missing, and the DON verified that the orders were not carried out.
Three residents at risk for pressure ulcers did not receive prescribed interventions, including heel boots and heel elevation, as ordered by physicians and outlined in their care plans. Observations confirmed that two residents were in bed without the required protective devices, and a third had heels resting directly on the bed instead of being floated. The DON confirmed these interventions were not provided as ordered.
The facility failed to conduct necessary background checks, verify licenses, and ensure abuse prevention training for six newly hired staff, including RNs and NAs, as per its policy. This oversight was confirmed by the administrator and identified through employee file reviews.
A resident with dysphagia and dementia was observed during lunch with most of her meal uneaten and food on her sweater. She was biting and licking the food on her sweater instead of using utensils, and staff did not redirect her, failing to promote dignified dining.
The facility did not report an abuse incident involving two residents to the Administrator and the State Survey Agency as required. A resident with cognitive decline and Alzheimer's disease threatened and physically assaulted another resident. The staff delayed notifying the Administrator and failed to report the incident to the State Survey Agency, as confirmed by the DON.
A facility failed to follow a physician's order to float a resident's heels, who was at risk for pressure ulcers due to limited mobility and heart failure. Despite the order given in March 2024, observations in January 2025 showed the resident's heels were directly on the bed, and the resident confirmed the staff's non-compliance.
A facility failed to provide and document ostomy care for a resident with an ileostomy, as required by the care plan. The resident, diagnosed with dementia, did not have their ostomy supplies changed from admission until six days later, when physician orders were finally put in place. The Director of Nursing confirmed the lack of documentation, and a family member reported that the supplies had not been changed since admission.
A resident with anxiety and Alzheimer's was prescribed melatonin and trazodone at bedtime. A pharmacist recommended reviewing the necessity of both medications and possibly discontinuing melatonin. The physician did not address this recommendation for two months, contrary to the facility's policy of addressing such recommendations within five to seven days.
The facility did not conduct QAA meetings with all required members for two quarters in 2024, as the Medical Director was absent. This was confirmed by reviewing QAPI sign-in sheets and an interview with the Administrator.
The facility did not follow its infection control policies for two residents. A physician failed to wear a protective gown while examining a resident with a Stage 3 pressure sore, and an LPN did not wear a gown while flushing a feeding tube for a resident with a history of stroke. These actions were against the facility's Enhanced Barrier Precautions policy.
The facility failed to provide timely written notification to residents and their representatives regarding hospital transfers, including reasons for the transfers and Ombudsman information. This deficiency was identified for three residents who were transferred due to changes in their conditions. The Administrator confirmed that the required written notices were not provided.
The facility did not meet the required nurse aide (NA) to resident ratios on multiple occasions. During the reviewed period, the day shift was understaffed on several days, failing to provide one NA per ten residents. The evening shift on one day did not meet the required one NA per eleven residents, and the night shift was below the required one NA per fifteen residents on multiple days. These deficiencies were identified through a review of nursing time schedules.
The facility did not meet the required LPN to resident ratios, failing to provide one LPN per 25 residents during the day shift on nine out of fourteen days reviewed. This deficiency was identified through nursing schedule reviews and staff interviews.
The facility failed to implement physician's orders for two residents, resulting in deficiencies in care. One resident did not receive prescribed treatment for a surgical incision, while another did not receive ordered medications and treatments for metabolic encephalopathy and cellulitis. The lack of documentation was confirmed by the Manager on Duty.
The facility was found deficient for not having a qualified Infection Preventionist (IP) as required by its policy. The IP is responsible for overseeing the infection prevention and control program, conducting infection surveillance, and serving as a resource for staff. The Administrator confirmed the absence of a qualified IP, violating specific state codes related to resident care policies and nursing services.
The facility did not follow its infection control policies by failing to post required signs for transmission-based precautions for residents who tested positive for COVID-19. This oversight involved 13 residents across two nursing unit wings, where no signs were posted outside their rooms to inform staff and visitors of necessary precautions, as confirmed by the Administrator.
The facility failed to provide a clean, homelike, and comfortable environment on A-wing and B-wing. Observations included holes in partition walls in several rooms, detached molding exposing a large hole in the hallway, and holes in the sheetrock in a shared bathroom and under a window in a resident's room.
Failure to Implement Physician's Orders for Diagnostic Tests
Penalty
Summary
The facility failed to implement physician's orders for one resident who had multiple diagnoses, including congestive heart failure, atrial fibrillation, muscle weakness, angiodysplasia of the stomach and duodenum, and pulmonary hypertension. The clinical record showed that there were physician's orders to schedule a chest X-ray for pleural effusion hypoxia and to obtain a stool specimen to rule out clostridium difficile. However, there was no documented evidence that either the chest X-ray or the stool specimen was completed as ordered. This was confirmed by the Director of Nursing during an interview.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement physician-ordered interventions to prevent pressure ulcers for three residents who were identified as being at risk. For one resident with diagnoses including congestive heart failure, atrial fibrillation, muscle weakness, and pulmonary hypertension, staff did not apply heel boots as ordered while the resident was in bed, despite the care plan identifying a risk for skin breakdown due to immobility. Another resident with vascular dementia, diabetes, heart disease, and muscle weakness, who was nonresponsive and at risk for pressure ulcers, was observed in bed without the ordered Prevalon boots. The care plan for this resident also noted a risk for skin breakdown related to immobility and medical condition. A third resident, with diabetes and muscle weakness and identified as at risk for pressure ulcers, had a physician's order to float heels while in bed. However, observation revealed that the resident's heels were directly on the bed, contrary to the order. The Director of Nursing confirmed that the protective devices and interventions were not in place for these residents as required by their care plans and physician orders.
Failure to Conduct Employee Screening and Training
Penalty
Summary
The facility failed to adhere to its own policies and procedures regarding the screening and training of newly hired employees, which led to deficiencies in preventing abuse, neglect, and theft. Specifically, the facility did not conduct criminal background checks, verify professional licenses or registrations, or ensure that required abuse prevention training was completed in a timely manner for six newly hired employees, including registered nurses, nurse aides, and a dietary aide. These lapses were identified through a review of employee files and confirmed by the facility's administrator. The facility's policy, last reviewed in October 2024, mandates screening potential employees for a history of abuse, neglect, or mistreatment before employment, including obtaining information from previous employers and checking with licensing boards and registries. Additionally, the policy requires educating staff upon hire and annually on preventing abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. However, the facility failed to comply with these requirements for the six employees, as evidenced by missing background checks, unverified licenses, and incomplete training records.
Plan Of Correction
Employees RN1, RN2, RN3, NA1, NA2, and DA1 files were immediately reviewed and missing documents were obtained. These employees also received abuse training per policy. Current employee files were audited. Any missing documentation or education will be completed. NHA/designee will educate HR on the components of this regulation with emphasis to obtain required documents & employees receiving required education upon hire. NHA or designee will audit new hire files to ensure appropriate documentation & abuse training is present. Audit will be conducted 2x a week x 4 weeks, then 1x a week x 4 weeks, then 2x a month x 2 months, then 1x a month x 2 months. The findings of these quality monitoring's will be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
Failure to Assist Resident with Dignified Dining
Penalty
Summary
The facility failed to provide assistance with dining in a manner that promoted dignity for a resident with dysphagia, dementia, and a need for assistance with personal care. The resident, who had neurological deficiencies and a history of weight loss, was observed during lunch with more than 75% of the meal uneaten. The resident was sitting at a table with food on her sweater and was seen biting at and licking the food on her sweater instead of using utensils or eating from her tray. The resident continued to chew and suck on her sweater for the entire observation period without being redirected by staff.
Plan Of Correction
Resident 5 was offered assistance with the remaining portion of her meal but declined. Her sweater was properly cleaned. An audit of current residents was conducted to ensure residents were provided with proper assistance during meals. DON or designee will educate nursing staff on the components of this regulation, with emphasis on ensuring residents are assist/redirected as needed during meals. DON or designee will conduct audits at meal times to ensure residents are offered assistance/redirected as needed during meals. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the Administrator and the State Survey Agency as required by their policy. Resident 41, who has diagnoses including anxiety, cognitive decline, and Alzheimer's disease, was observed by staff to have placed a brief over Resident 16's head, punched Resident 16, and threatened to harm her with a heavy object. Resident 41 also expressed a desire to kill Resident 16 multiple times during the shift. Despite these serious allegations, there was no evidence that the staff notified the Administrator until the evening shift, and the incident was not reported to the State Survey Agency. The Director of Nursing confirmed these lapses in protocol during interviews conducted on January 16, 2025.
Plan Of Correction
NHA was notified of allegation of abuse related to Resident 41. Report to DOH will be submitted. A review of current residents was completed over the last 30 days to ensure any allegations of abuse were reported. DON and/or designee will educate staff on the components of this regulation with emphasis on timely reporting of abuse to the NHA. DON or designee will audit abuse allegations for timely reporting to NHA. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
Failure to Implement Physician's Orders for Heel Elevation
Penalty
Summary
The facility failed to implement physician's orders for a resident with diagnoses including heart failure and reduced mobility. The resident was assessed to be at risk for pressure ulcers and had limited mobility in her lower legs. On March 12, 2024, a physician ordered that the resident's heels be floated while in bed to prevent pressure ulcers. However, observations on January 14 and 15, 2025, revealed that the resident's heels were directly on the bed, contrary to the physician's orders. The resident confirmed that staff had not been floating her heels as required.
Plan Of Correction
Resident 40 heels were elevated to float heels. Current residents with orders to float heels were audited to ensure heels were elevated. DON/designee will educate nursing staff on the components of this regulation with emphasis on elevating residents' heels. DON or designee will perform an audit of 5 residents with float heels orders to ensure heels are floated. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
Failure to Provide Ostomy Care for Resident
Penalty
Summary
The facility failed to provide appropriate ostomy care for a resident with an ileostomy, as outlined in the resident's care plan. The care plan required staff to keep the skin around the stoma clean and dry, monitor for skin irritation, and observe the stoma for unusual changes. However, there was no evidence in the clinical record that ostomy care was provided or that supplies were changed from the time of the resident's admission until six days later. This lack of documentation was confirmed by the Director of Nursing. The resident, who had a diagnosis of dementia, was admitted to the facility without any physician orders for ostomy care until six days after admission. The orders, once in place, specified that the ileostomy wafer should be changed every three days and the ileostomy bag once daily or as needed. A family member reported that the resident's ostomy supplies had not been changed since admission, highlighting the facility's failure to adhere to the care plan and document the necessary care.
Plan Of Correction
Resident 158 received ostomy care immediately. Physician orders for Resident R158 were updated to include ostomy care orders. Current residents with an ostomy were audited to ensure ostomy care physician orders were in place. DON and/or designee is providing staff with education related to timely implementation of ostomy physician orders. DON/designee will perform audit of new admissions to ensure ostomy orders are present. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
Delayed Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely review of pharmacy recommendations by a physician for one of the sampled residents. Resident 41, who had diagnoses of anxiety and Alzheimer's disease, was prescribed melatonin and trazodone at bedtime. On August 1, 2024, a pharmacist recommended that the physician review the necessity of both medications and consider discontinuing melatonin to reduce the resident's medication load. However, there was no evidence that the physician addressed this recommendation until October 1, 2024, and the melatonin was not discontinued until October 2, 2024. During an interview on January 16, 2025, the Director of Nursing confirmed that pharmacy recommendations should be addressed by the physician within five to seven days, but acknowledged that this did not occur in the case of Resident 41.
Plan Of Correction
Unabe to retroactively correct for Resident 41. An audit of current resident's pharmacy recommendations over the last 30 days were reviewed to ensure they were presented to the provider for review. DON will be educated on the components of this regulation, with emphasis on ensuring pharmacy recommendations are addressed timely. DON/designee will perform audit of 5 pharmacy recommendations. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
QAA Meetings Lacked Required Attendance
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for two of the four quarterly meetings in 2024. Specifically, the Medical Director did not attend the QAA meetings in the first and fourth quarters of 2024. This was confirmed through a review of the facility's Quality Assurance and Performance Improvement (QAPI) sign-in sheets and attendance records, as well as an interview with the Administrator on January 16, 2025, who acknowledged the Medical Director's absence from these meetings.
Plan Of Correction
Unable to retroactively correct this alleged deficient practice. No residents were identified to have been affected by this alleged deficient practice. NHA educated on the components of this regulation with emphasis on the need for the Medical Director to attend the QAPI Meetings. RDCS will audit QAPI sign in sheets to ensure Medical Director is present at least quarterly for QAPI meetings. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
Infection Control Policy Breach
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, specifically the Enhanced Barrier Precautions, for two residents. Resident 27, who had a Stage 3 pressure sore on his lower back, was examined by a physician who did not wear a protective gown as required by the facility's policy during high-risk activities. Similarly, Resident 35, who had a history of stroke and received nutrition through a feeding tube, was attended to by an LPN who flushed the feeding tube without wearing a gown, contrary to the facility's guidelines. These actions were observed during specific encounters and were not in compliance with the established infection control procedures.
Plan Of Correction
Unable to retroactively correct this alleged deficient practice. Resident 27 & 35 had no negative outcome related to alleged deficient practice. MD1 & LPN1 were provided education on EBP. An audit of current residents will be completed to ensure EBP is being followed by staff. DON/designee will educate direct care staff on the components of this regulation with emphasis on Enhance Barrier Precautions. DON/designee will conduct random audits of staff performing care in EBP rooms to ensure proper PPE is worn. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
Failure to Notify Residents of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding transfers to the hospital, including the reasons for the transfers and information about the Ombudsman. This deficiency was identified for three residents who were transferred to the hospital due to changes in their conditions. Resident 11 was transferred on October 12, 2024, after a change in condition, Resident 13 was transferred on December 11, 2024, following a fall and change in condition, and Resident 56 was transferred on November 4, 2024, after a change in condition. In each case, there was no documentation to support that the residents or their representatives received the required written information. The Administrator confirmed in an interview that the written notices were not provided.
Plan Of Correction
Resident 11 and 56 no longer reside in the facility. Unable to retroactively correct for resident 13. All residents have the potential to be affected by this alleged deficient practice, however the facility cannot retroactively correct. DON & NHA will be educated on the components of this regulation with emphasis on the need to provide written notification of transfers. NHA or designee will audit 3 hospital transfers to ensure written notification was completed. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios as mandated by the regulation effective July 1, 2024. A review of nursing schedules for the period from December 27, 2024, to January 2, 2025, and January 9, 2025, to January 15, 2025, revealed that the facility did not maintain the minimum staffing levels on several occasions. Specifically, the day shift (7:00 a.m. to 3:00 p.m.) was understaffed on January 9, 11, 12, 13, 14, and 15, 2025, failing to provide one NA per ten residents. The evening shift (3:00 p.m. to 11:00 p.m.) on January 9, 2025, did not meet the required one NA per eleven residents. Additionally, the night shift (11:00 p.m. to 7:00 a.m.) was below the required one NA per fifteen residents on December 31, 2024, and January 9, 10, 11, 12, 13, and 15, 2025. These deficiencies were identified based on a review of the nursing time schedules, indicating a failure to comply with the staffing regulations over eight of the fourteen days reviewed.
Plan Of Correction
1) Facility cannot retroactively correct. 2) NHA/designee will review CNA staffing ratios for the last 4 weeks to ensure compliance and adherence to regulation. 3) NHA/Designee will re-educate staff scheduler and DON on regulation of CNA staffing ratios to ensure ongoing compliance. Facility will conduct daily staffing meeting to review CNA ratios to ensure ongoing compliance and systematic change. 4) NHA/Designee will conduct audit of projected CNA ratios. Audit will be conducted 2x a week x 4 weeks, then 1x a week x 4 weeks, then 2x a month x 2 months, then 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
Failure to Meet LPN to Resident Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios as mandated by regulations effective July 1, 2023. Specifically, the facility did not maintain the minimum ratio of one LPN per 25 residents during the day shift from 7:00 a.m. to 3:00 p.m. on nine out of the fourteen days reviewed. The days in question were December 27, 28, 29, and 30, 2024, and January 1, 2, 13, 14, and 15, 2025. This deficiency was identified through a review of nursing schedules and staff interviews, indicating a consistent shortfall in staffing levels during the specified period.
Plan Of Correction
1) Facility cannot retroactively correct. 2) NHA/designee will review LPN staffing ratios for the last 4 weeks to ensure compliance and adherence to regulation. 3) NHA/Designee will re-educate staff scheduler and DON on regulation of LPN staffing ratios to ensure ongoing compliance. Facility will conduct daily staffing meeting to review LPN ratios to ensure ongoing compliance and systematic change. 4) NHA/Designee will conduct audit of projected LPN ratios. Audit will be conducted 2x a week x 4 weeks, then 1x a week x 4 weeks, then 2x a month x 2 months, then 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.
Failure to Implement Physician's Orders for Two Residents
Penalty
Summary
The facility failed to implement physician's orders for two residents, leading to deficiencies in care. Resident 1, diagnosed with intervertebral disc displacement and morbid obesity, had a physician's order to cleanse and dress a surgical incision on the lower back. The treatment was not documented as completed on several days in July 2024, indicating a lapse in following the prescribed care plan. Resident 2, with diagnoses including metabolic encephalopathy and cellulitis of the lower extremities, also did not receive treatments as ordered. The application of ammonium lactate lotion, administration of doxycycline monohydrate, and Suboxone were not documented on specific days in August 2024. Additionally, a treatment involving moisturizing lotion and an ACE bandage was not documented over several days. The Manager on Duty confirmed the lack of documentation for these treatments and medications, highlighting a failure in executing physician's orders.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility was found to be deficient in its infection prevention and control program due to the absence of a qualified Infection Preventionist (IP). The facility's policy, last reviewed on March 28, 2024, mandates that the IP should oversee the infection prevention and control program, conduct surveillance of infections, and serve as a resource for staff. However, during an interview on August 1, 2024, the Administrator admitted that the facility did not have a qualified IP who had completed specialized training in infection prevention and control. This deficiency is in violation of 28 Pa. Code 211.10(d) regarding resident care policies and 28 Pa. Code 211.12(d)(1)(5) concerning nursing services.
Failure to Implement Transmission-Based Precautions
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, specifically regarding the implementation of transmission-based precautions (TBPs) for residents diagnosed with communicable diseases. The facility's policy, last reviewed on March 28, 2024, mandates that TBPs, including contact, droplet, airborne, and enhanced barrier precautions, be initiated for residents with communicable diseases. Additionally, a sign should be posted on the door of affected residents' rooms to inform staff and visitors to consult the nurse for further instructions on necessary precautions and personal protective equipment (PPE). However, during a clinical record review and observation on August 1, 2024, it was found that no such signs were posted outside the rooms of 13 residents who tested positive for COVID-19, thereby failing to alert staff and visitors of the required precautions. The deficiency was confirmed during an interview with the Administrator on August 1, 2024, who acknowledged that signs should have been posted on the doors of resident rooms when TBPs were necessary. This oversight occurred on both nursing unit wings, A Wing and B Wing, and involved rooms 20, 21, 22, 27, 34, 36, and 41, where the COVID-19 positive residents were located. The failure to post signs as per the facility's policy potentially compromised the infection control measures intended to prevent the spread of COVID-19 within the facility.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, homelike, and comfortable environment on two of its nursing units, A-wing and B-wing. During a tour of these units, several deficiencies were observed. In rooms 27, 32, 36, and 47, there were holes in the partition wall between the residents' sleeping area and the bathroom. Additionally, on the right side of the B-wing hallway, there was detached molding where the floor met the wall, exposing a large hole. In the shared bathroom located between certain rooms, two round holes in the sheetrock were observed. Furthermore, in room [ROOM NUMBER]-2, there was a hole in the wall under the window. These observations indicate a failure to maintain a safe, clean, and comfortable environment for the residents.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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