Bonham Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Stillwater, Pennsylvania.
- Location
- 477 Bonnieville Road, Stillwater, Pennsylvania 17878
- CMS Provider Number
- 395654
- Inspections on file
- 17
- Latest survey
- August 13, 2024
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Bonham Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident who experienced a change in condition and was transferred to the hospital did not have official documentation of the event in their clinical record, as required by facility policy and federal regulations. The Assistant DON confirmed the absence of this documentation, noting it may have been sent with the ambulance during transfer.
The facility failed to maintain its automatic sprinkler system components, affecting the entire facility. An inspection report identified that sprinklers in the 'old part' of the building, dated 1974, were due for UL-Testing, and the FDC needed hydrotesting. A revisit confirmed that the sprinkler issue remained unresolved.
The facility failed to maintain its automatic sprinkler system components, affecting the entire facility. A document review revealed that the sprinklers in the 'old part' of the building were dated 1974 and required UL-Testing, and the FDC needed to be hydrotested. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to document the monthly conductance testing of its generator's maintenance-free batteries, as required by NFPA standards. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director, highlighting a lapse in maintaining essential emergency power system protocols.
The facility failed to maintain unobstructed means of egress on the first floor. The music room's emergency exit door was inoperable due to a screw in its panic bar, and even after removal, it failed to open. Additionally, the stair tower D emergency exit door required excessive force to open. These issues were confirmed by the Administrator and Maintenance Director.
The facility did not maintain smoke barrier doors according to NFPA 101 standards. An observation revealed that the smoke doors near a resident room had a broken magnetically held fire door device, affecting one of the two levels. This was confirmed in an exit interview with the Administrator and Maintenance Director.
A smoke detector in the kitchen wash room on the first floor was found obstructed with a plastic cover and tape, failing to meet NFPA 101 standards. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain the fire resistance rating of linen chutes, affecting two levels. Observations revealed that linen chute doors on the third and second floors of the South Wing did not close and latch properly. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility was found to be in violation of building construction requirements, as it was classified as a four-story, Type II (000), unprotected non-combustible construction, which is fully sprinklered. This classification exceeds the maximum allowable height for unprotected non-combustible construction by two stories. The deficiency was confirmed in an exit interview with the Administrator and Maintenance Director.
Cheltenham Nursing and Rehabilitation Center failed to protect a resident from abuse, resulting in physical harm. A resident with a history of verbal aggression physically assaulted another resident, causing a closed head injury and a fractured finger. Despite previous altercations, the facility did not prevent the escalation to violence.
The facility failed to provide suitable and nourishing snacks to several residents who wanted to eat at non-traditional times, outside of scheduled meal service. Despite the facility's policy requiring bedtime snacks to be accessible and assistance provided as needed, residents reported not being routinely offered these snacks. Observations and records indicated a lack of consistent documentation and assurance that staff were completing this task, with concerns also noted in food committee meeting minutes.
The facility failed to follow professional standards for food service safety, particularly in the dishwashing process. Dietary staff did not conduct a test load or use sanitizer testing strips to verify the concentration of the final rinse water. Additionally, incorrect test strips were used, leading to inaccurate measurements of chlorine concentration. The Food Service Director confirmed these lapses in proper sanitation practices.
The facility failed to develop comprehensive care plans for two residents. One resident, diagnosed with physical aggression, paranoia, and insomnia, was involved in altercations without a care plan addressing these issues. Another resident, requiring oxygen therapy for shortness of breath, also lacked a care plan. These deficiencies highlight a significant oversight in meeting residents' medical and psychosocial needs.
A facility failed to conduct routine testing for therapeutic levels of Depakote for a resident with epilepsy, leading to an incorrect dosage change. Additionally, the facility did not inform the physician of a recommended increase in Risperdal for the resident, resulting in a lapse in communication and adherence to professional standards.
The facility failed to provide necessary treatment and services for two residents with limited range of motion. One resident with paraplegia and multiple sclerosis was not receiving prescribed passive range of motion exercises and splinting. Another resident with a history of stroke and hemiplegia was not receiving the recommended splint and brace program. Observations and interviews confirmed the lack of implementation of these restorative nursing programs.
A resident with a history of opioid dependence and suicidal ideation was found holding razors, which were accidentally left accessible by a nursing assistant. The resident's care plan included measures to prevent self-harm, but the oversight led to a breach in maintaining a safe environment.
The facility failed to ensure medications were administered with adequate indications and monitoring for two residents. One resident was prescribed medications for insomnia without a diagnosis, while another was given Lorazepam without documented rationale for extended use and Depakote without adequate indication. Additionally, a blood level test for Depakote was below normal, with no evidence of physician review.
A facility failed to obtain necessary lab tests for a resident with obesity and high risk for pressure sores. The physician ordered blood tests to assess albumin and thyroid function, but there was no documentation of completion. This was confirmed by an LPN.
A facility failed to maintain enhanced barrier precautions for a resident requiring enteral nutrition. Despite clear instructions and signage, a nurse aide provided incontinence care without wearing a gown, violating infection control protocols. The resident had multiple diagnoses, including Parkinson's disease and dysphasia, necessitating strict adherence to infection prevention measures.
The facility failed to implement timely and effective safety interventions for residents with known fall risks, resulting in serious injuries and a fatality. A resident with a history of falls and assessed as high risk was not adequately supervised, leading to multiple falls and a fatal subdural hematoma. Another resident with Parkinson's Disease experienced repeated falls despite increased supervision, resulting in a hematoma. The facility's inaction and insufficient response to known fall risks led to significant harm.
The facility failed to develop comprehensive care plans for two residents, neglecting to address specific medical needs such as pacemaker monitoring for a resident with a cardiac condition and denture care for a resident with Alzheimer's. These deficiencies were confirmed through clinical record reviews and staff interviews.
Two residents in an LTC facility did not receive timely physician action on pharmacy recommendations regarding their medication regimens. One resident, with major depressive disorder, continued on Trazodone 300 mg daily without physician review for several months despite pharmacy advice. Another resident, with Alzheimer's, was on Divalproex Sodium 375 mg three times daily, with no physician response to pharmacy recommendations for months. The facility policy requires physician action or documented rationale, which was not followed.
A resident with a history of falls and Parkinson's Disease experienced multiple falls in an LTC facility due to ineffective implementation of a QAPI program. Despite being identified as a high fall risk, the facility failed to investigate and analyze the root cause of the falls, particularly in the dining room during the evening shift. The lack of systematic approach and documentation of corrective actions contributed to the deficiency.
A facility failed to provide person-centered care for a resident with a pacemaker, lacking documented physician orders for necessary care, monitoring, and battery checks. This deficiency was confirmed through clinical record reviews and an interview with the DON, resulting in a citation under F656.
A resident developed an avoidable pressure sore due to the facility's failure to monitor a therapeutic device effectively. Despite physician orders for two-hourly skin checks, the facility did not document these checks, leading to a suspected deep tissue injury on the resident's ankle. The resident's care plan lacked necessary interventions for the immobilizer, contributing to the deficiency.
A facility failed to attempt non-pharmacological interventions before administering as-needed pain medication to a resident with multiple fractures and diabetes. The resident received Acetaminophen and Oxycodone HCL without documented non-pharmacological attempts, and the care plan lacked individualized non-pharmacological interventions. The DON confirmed the absence of such documentation.
A facility failed to implement a hospice plan of care for a resident with end-stage chronic kidney disease and stroke. Despite hospice services being triggered in the resident's MDS, the facility's care plan lacked specific goals and interventions for hospice care, as confirmed by the DON.
A facility failed to provide written notice of its bed-hold policy to a resident and their representative upon hospital transfer. A review of records showed no documentation of notification, and during an interview, the NHA and DON could not provide evidence of compliance, violating resident rights.
Incomplete Documentation of Change in Condition
Penalty
Summary
The facility failed to ensure complete and accurate documentation for one resident, as required by federal regulations and the facility's own policy. Specifically, a review of the clinical record for one resident who experienced a change in condition and was transferred to the hospital did not contain official documentation of the change in condition. The facility's policy requires that all change in condition documentation include the date, time, assessment findings, actions taken, notifications, and resident response, and that this documentation be timely, accurate, and complete. During an interview, the Assistant Director of Nursing confirmed that the resident experienced a change in condition and was transferred to the hospital, but the required documentation was not present in the clinical record. It was suggested that the documentation may have been sent with the ambulance during the transfer, but it was not retained in the facility's records as required.
Failure to Maintain Sprinkler System Components
Penalty
Summary
The facility failed to maintain its automatic sprinkler system components, which affected the entire facility. During a document review on December 23, 2024, it was found that the sprinkler inspection report from November 8, 2024, identified deficiencies. Specifically, the sprinklers in the 'old part' of the building, dated 1974, were due for UL-Testing, and the Fire Department Connection (FDC) required hydrotesting. An exit interview with the Administrator and Maintenance Director confirmed these deficiencies. A subsequent onsite revisit on February 11, 2025, revealed that the issue with the sprinklers in the 'old part' of the building remained unresolved, as confirmed by the Administrator during the exit interview.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by this provider of the facts alleged, or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and/or state law. The plan of correction constitutes our credible allegation of compliance. 1. On 1/6/2025 the Maintenance Director contacted The Tustin Group to schedule UL testing for the sprinklers in the "old part" of the building. 2. On 1/31/2025 the Tustin Group gathered the make and model for heads on the "old part" of the building to order replacement parts for the upcoming UL testing. 3. On 2/11/2024 the Maintenance Director checked the most recent sprinkler inspection report for cited deficiencies. There were no other deficiencies. 4. On 2/11/2025 the NHA re-educated the maintenance team on correcting deficiencies cited following a sprinkler inspection. 5. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify that the deficiencies cited following an inspection are corrected timely. Results of the audits will be reviewed at the QAPI meeting held monthly.
Failure to Maintain Sprinkler System Components
Penalty
Summary
The facility failed to maintain its automatic sprinkler system components, which affected the entire facility. During a document review on December 23, 2024, it was found that the sprinkler inspection report from November 8, 2024, identified specific deficiencies. The sprinklers in the 'old part' of the building were dated 1974 and required UL-Testing. Additionally, the Fire Department Connection (FDC) needed to be hydrotested. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director on the same day.
Plan Of Correction
1. On 1/6/2025 the Maintenance Director contacted The Tustin Group to schedule UL testing for the sprinklers in the "old part" of the building. 2. On 1/6/2025 the Maintenance Director contacted The Tustin Group to have the FDC hydrotested. Testing is scheduled for 2/2/2025. 3. On 12/24/2024 the Maintenance Director checked all sprinkler inspection reports for cited deficiencies. There were no other deficiencies. 4. On 12/30/2024 the NHA educated the maintenance team on correcting deficiencies cited following a sprinkler inspection. 5. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify that the deficiencies cited following an inspection are corrected timely. Results of the audits will be reviewed at the QAPI meeting held monthly.
Failure to Document Monthly Generator Battery Testing
Penalty
Summary
The facility failed to maintain the required testing of emergency generator components, specifically the monthly conductance testing of the generator's maintenance-free batteries. This deficiency was identified during a document review conducted on December 23, 2024, at 9:30 a.m., which revealed the absence of verifying documentation for the monthly testing. The lack of documentation indicates that the facility did not adhere to the necessary maintenance protocols for the emergency generator, which is crucial for ensuring the generator's reliability in providing essential power during emergencies. During the exit interview with the Administrator and Maintenance Director on the same day at 12:15 p.m., it was confirmed that the documentation for the monthly conductance testing was missing. This oversight affects the facility's ability to demonstrate compliance with the National Fire Protection Association (NFPA) standards, specifically NFPA 101, NFPA 110, and NFPA 111, which outline the requirements for maintaining and testing emergency power systems in healthcare facilities.
Plan Of Correction
1. On 1/3/2025 the Maintenance Supervisor completed conductance testing of the generator's maintenance free batteries. 2. On (Insert Date) the Maintenance Director revised the generator testing documentation to include monthly conductance testing. 3. On 12/30/2024 the NHA educated the maintenance team on maintaining the required testing of emergency generator components in accordance with NFPA 101 requirements. 4. The Maintenance Director/designee will conduct audits monthly for 3 months to verify proper documentation for generator testing is present. Results of the audits will be reviewed at the QAPI meeting held monthly.
Obstructed Means of Egress on First Floor
Penalty
Summary
The facility failed to maintain the means of egress free of obstructions, affecting one of two levels. On December 23, 2024, at 10:45 a.m., an observation revealed that the emergency exit door in the music room on the first floor was inoperable due to a screw inserted into its panic bar. Even after the screw was removed, the door still failed to open. Additionally, at 10:55 a.m., it was observed that the emergency exit door in stair tower D on the first floor required excessive force to open. These findings were confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 12:15 p.m.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by this provider of the facts alleged, or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and/or state law. The plan of correction constitutes our credible allegation of compliance. 1. On 12/23/2024 the Maintenance immediately removed the screw from the panic bar on the emergency exit door in the music room. The door was tested and opened without restriction. 2. On 12/26/2024 the maintenance team adjusted the stair tower D emergency exit door. The door opens without the use of excessive force. 3. On 12/26/2024 the maintenance team inspected all emergency exit doors to verify that there were no obstructions to egress. 4. On 12/30/2024 the NHA educated the maintenance team on maintaining that the means of egress are free of obstructions. 5. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify the proper functionality of all emergency exit doors in accordance with NFPA 101 requirements. Results of the audits will be reviewed at the QAPI meeting held monthly.
Failure to Maintain Smoke Barrier Doors
Penalty
Summary
The facility failed to maintain smoke barrier doors as required by NFPA 101 standards. During an observation on December 23, 2024, it was noted that the smoke doors near resident room B-1 had a magnetically held fire door device with a broken housing. This deficiency affected one of the two levels in the facility. The issue was confirmed during an exit interview with the Administrator and Maintenance Director on the same day.
Plan Of Correction
1. On 12/26/2024 the Maintenance Director repaired the magnetic housing device. 2. On 12/23/2024 the Maintenance Director inspected all smoke doors to verify that the magnetic housing devices were secure. 3. On 12/30/2024 the NHA educated the maintenance team on maintaining smoke barrier doors in accordance with NFPA 101 requirements. 4. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify that smoke barrier doors are in accordance with NFPA 101 requirements. Results of the audits will be reviewed at the QAPI meeting held monthly.
Smoke Detector Obstruction in Kitchen Wash Room
Penalty
Summary
The facility failed to maintain smoke detectors as required by NFPA 101 standards. During an observation on December 23, 2024, at 11:20 a.m., it was found that a smoke detector in the kitchen wash room on the first floor was obstructed with a plastic cover and tape. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 12:15 p.m.
Plan Of Correction
1. On 12/23/2024 the Maintenance Director removed the plastic cover and tape from the obstructed smoke detector in the kitchen washroom. 2. On 12/23/2024 the maintenance team inspected all smoke detectors in the building to verify there were no obstructions. 3. On 12/30/2024 the NHA educated the Maintenance team on properly maintaining the smoke detection system in accordance with NFPA 101 requirements. 4. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify that smoke detectors are not obstructed. Results of the audits will be reviewed at the QAPI meeting held monthly.
Failure to Maintain Fire Resistance of Linen Chutes
Penalty
Summary
The facility failed to maintain the fire resistance rating of linen chutes and discharge rooms, affecting two of four levels. During an observation on December 23, 2024, between 11:45 a.m. and 12:05 p.m., it was noted that the linen chute doors on the third and second floors of the South Wing did not close and latch properly when tested. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 12:15 p.m.
Plan Of Correction
1. On 1/3/2025 the Maintenance team replaced the existing hardware on the 2nd and 3rd floor South Wing linen chutes. 2. On 12/23/24 the Maintenance Director inspected the linen chutes on the other units and verified the proper functionality. 3. On 12/30/2024 the NHA educated the maintenance team on maintaining the fire resistance rating of the linen chutes in accordance with NFPA 101 requirements. 4. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify positive latching and the proper functionality of the linen chute doors. Results of the audits will be reviewed at the QAPI meeting held monthly.
Building Construction Type Violation
Penalty
Summary
The facility was found to be in violation of building construction requirements as it was classified as a four-story, Type II (000), unprotected non-combustible construction, which is fully sprinklered. This classification exceeds the maximum allowable height for unprotected non-combustible construction by two stories. The deficiency was identified during a document review and confirmed in an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
The facility will be engaging a certified external auditor to conduct a comprehensive Fire Safety Evaluation System (FSES) audit. This audit will evaluate the facility's fire safety measures across all designated zones, ensuring that each area meets or exceeds the rigorous standards set forth by the FSES. A passing score for each zone is a critical requirement, as it will demonstrate the facility's commitment to maintaining a safe environment for all residents, staff, and visitors. Upon successfully achieving a passing score in all zones, the facility will become eligible for the Centers for Medicare & Medicaid Services (CMS) approved time-limited waiver. This waiver will grant the facility an extension to comply with any remaining fire safety requirements that may need additional time or adjustments, while ensuring that essential safety measures are already in place to safeguard occupants in the interim. The FSES audit will cover a range of critical fire safety aspects, including but not limited to: fire detection and alarm systems, emergency evacuation plans, fire suppression systems, staff training and preparedness, and overall compliance with both local fire codes and CMS regulations. Each zone will be meticulously assessed to identify potential vulnerabilities and areas for improvement, and the results will be used to implement necessary corrective actions. Achieving a passing score not only ensures eligibility for the CMS time-limited waiver but also reflects the facility's proactive approach to maintaining a high standard of fire safety, protecting both the health and safety of all those within the facility and mitigating the risk of fire-related incidents.
Failure to Protect Resident from Abuse
Penalty
Summary
Cheltenham Nursing and Rehabilitation Center was found to be non-compliant with federal and state regulations due to a failure to protect a resident from abuse. Resident R46, who had a history of verbal aggression, physically assaulted Resident R112, resulting in actual harm. The incident involved Resident R46 becoming physically violent, leading to Resident R112 sustaining a closed head injury and a fractured right finger. Resident R46 was assessed as alert, oriented, and independent in activities of daily living, with a history of verbal aggression towards Resident R112. Despite this, the facility did not take adequate measures to prevent further altercations. Resident R112, who had severe cognitive impairment and required supervision for daily activities, was left vulnerable to the aggression of Resident R46. The facility's documentation revealed multiple instances of verbal altercations between the two residents, including a significant incident where Resident R46 threatened Resident R112. The situation escalated to physical violence, witnessed by another resident, resulting in injuries to Resident R112. The facility's failure to address the ongoing aggression and protect Resident R112 from harm was substantiated as abuse.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by this provider of the facts alleged, or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and/or state law. The plan of correction constitutes our credible allegation of compliance. 1. Resident R112 was immediately moved to another unit on October 12, 2024, following the resident-to-resident altercation. Resident R112 and R46 remain on separate units. 2. On 12/26/2024 the nurse management team reviewed the Electronic Health Record (EHR) of residents with a history of verbal or physical aggression towards other residents to identify those that were at high risk. 3. On 12/26/2024 The Social Services Director and Nurse Managers reviewed those residents identified at high risk for verbal and physical aggression. Those identified were referred to psych. The care plans were updated, and medications were reviewed. 4. On 12/26/24 the NHA/designee started education for all staff on the facility's abuse policy and supervision of residents. The education was completed by 12/31/2024. 5. The DON and/or designee will conduct audits of residents at high risk for verbal or physical aggression. Audits will be completed weekly for 4 weeks and monthly for 3 months. Results of the audits will be reviewed at the Quality Assurance Performance Improvement meeting held monthly.
Failure to Provide Nourishing Snacks at Non-Traditional Times
Penalty
Summary
The facility failed to provide suitable and nourishing snacks to eight out of nine residents who expressed a desire to eat at non-traditional times, outside of the scheduled meal service. This deficiency was identified through clinical record reviews, interviews with residents and staff, and reviews of policies and procedures. The facility's policy required that bedtime snacks be placed within reach of each resident and that nursing staff assist residents with eating these snacks as necessary. However, during a group meeting, residents reported that they were not routinely offered nourishing snacks at bedtime, despite being able to express their nutritional preferences and needs. Observations revealed that bulk snacks were provided by the dietary department at 6:00 a.m. for use during the 7-3 shift, but there was no consistent documentation or assurance that the 3-11 shift staff offered bedtime snacks to all residents. Clinical records for the involved residents, who were mostly cognitively intact, showed a lack of consistent documentation indicating that staff were completing the task of offering and assisting with bedtime snacks. Additionally, food committee meeting minutes noted a resident's concern about not being frequently offered between meals and bedtime snacks as care planned.
Plan Of Correction
1. On 12/19/2024 the DON assessed Residents R111, R23, R476, R95, R145, R133, R162 and R167 and there were no negative outcomes. On 12/19/2024 the Dietary department delivered HS snacks to all units. 2. On 12/19/2024 the dietician reviewed the electronic records of residents identified as "at risk" for weight loss to verify that nourishment orders were in place if necessary. 3. The dietary department will deliver nourishments 3 times per day for residents with orders and re-stock the units with nourishments for all other residents daily. A nourishment log will be utilized to verify the nourishment delivery. 4. On 12/19/2025 the NHA and Dietary Manager educated the dietary staff, providing nourishments between meals. 5. The NHA/designee will conduct audits of nourishment delivery 3x per week for 4 weeks and monthly for 3 months.
Improper Dishwashing Practices and Testing in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the operation and monitoring of their dishwashing process. During an inspection, it was observed that dietary staff members, Employees E13 and E14, did not conduct a test load of dishes nor use sanitizer testing strips to verify the concentration of the final rinse water when operating the dish machine. This machine operates as a low-temperature unit, relying on chemical sanitation, which necessitates precise monitoring to ensure effective sanitation. Further investigation revealed that the Dietary Assistant, Employee E12, used incorrect test strips, specifically 'QAC QR' test strips, which are intended for measuring Quaternary Ammonium Compounds, rather than the required chlorine test strips. This error resulted in the test strips not changing color, indicating a failure to measure the chlorine concentration accurately. The Food Service Director confirmed that the correct procedure was not followed, highlighting a lapse in proper sanitation practices within the facility.
Plan Of Correction
1. There were no negative outcomes to residents of Cheltenham Nursing and Rehab as a result of not utilizing correct sanitation test strips for the dish machine. 2. On 12/19/2024, the Dietary Manager obtained the proper sanitation levels of the dish machine using the correct test strip. 3. On 12/19/2024, the Dietary Manager educated the dietary staff on the proper method of testing the dish machine sanitation levels, utilizing the proper test strips and accurately completing the sanitation log. 4. The Dietary Manager will label the test strips to make certain that the proper strips are being utilized. 5. The NHA/designee will conduct audits of sanitation logs 3x per week for 4 weeks and monthly for 3 months.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident R46, who was diagnosed with physical aggression, paranoia, insomnia, and was taking antipsychotic medication for psychosis. Despite being alert and oriented, Resident R46 was involved in multiple altercations, including a verbal altercation on May 2, 2024, and a physical altercation on October 12, 2024, which resulted in injuries to another resident. The facility's documentation did not include a care plan addressing these behaviors or the resident's insomnia and medication needs. Additionally, the facility did not create a care plan for Resident R170, who required oxygen therapy. Resident R170 was admitted with diagnoses of anemia and acute myeloblastic leukemia and had a physician's order for oxygen use as needed for shortness of breath. However, there was no care plan developed to address the resident's respiratory needs or the use of oxygen, as confirmed by the Assistant Director of Nursing. These deficiencies indicate a failure to adhere to the facility's policy of developing comprehensive, person-centered care plans that address the medical, nursing, and psychosocial needs of residents. The lack of care plans for both residents R46 and R170 highlights a significant oversight in ensuring the well-being and safety of residents, as required by regulatory standards.
Plan Of Correction
1. On 12/18/2024 the nurse management team developed a care plan for Resident R46 addressing physical aggression, paranoia, suspicious behaviors and insomnia. Resident R170 is no longer in the facility. 2. On 12/26/2024 the nurse management team reviewed the Electronic Health Record of residents with a history of physical or verbal aggression, paranoia and suspicious behaviors. Care plans for those residents were reviewed and revised as needed. 3. During the morning clinical meeting the Interdisciplinary Team will review all admissions and notes from the most recent psych visit to develop a comprehensive care plan that includes resident specific behaviors including physical aggression, paranoia, suspicious behaviors and insomnia. 4. Education on the development of comprehensive care plans to address resident specific behaviors including physical aggression, paranoia, suspicious behaviors and insomnia will be presented by the DON/designee to nursing staff and the Interdisciplinary Team members by 01/16/2025. 5. Audits of comprehensive care plans that include resident specific behaviors for residents physical or verbal aggression, paranoia and suspicious behaviors will be completed weekly for 1 month and then monthly for 1 quarter. Audits will be forwarded to the monthly Quality Assurance Performance Improvement Meeting and evaluated by the Quality Assurance Committee.
Failure to Monitor Medication Levels and Communicate Dosage Changes
Penalty
Summary
The facility failed to provide treatment and services in accordance with professional standards of practice by not conducting routine testing to verify therapeutic levels of a seizure medication for a resident diagnosed with epilepsy. The resident, who was alert, oriented, and capable of making independent decisions, was initially prescribed Depakote at a daily total of 750 mg. However, due to a miscommunication, the dose was incorrectly decreased to 500 mg daily instead of being increased as intended. This error persisted for two weeks before the dose was corrected. Additionally, the facility did not perform routine Depakote level testing after the initial admission test, which was contrary to the care plan that required monitoring of therapeutic levels. Furthermore, the facility failed to inform the physician of a recommended increase in the dose of Risperdal, an antipsychotic medication, for the same resident who was experiencing increased paranoia and aggression. The psychiatrist confirmed that the Depakote dose should not have been changed and that therapeutic levels should be checked every six months. The psychiatrist also confirmed that the recommended increase in Risperdal was not completed, indicating a lapse in communication and adherence to professional standards of practice.
Plan Of Correction
1. On 1/10/2025 the Nurse manager obtained Depakote levels for Resident R46. Medications were at a therapeutic level. Additional Labs will be obtained every 6 months to monitor therapeutic levels. 2. A review of the medical record for Resident R46 identified that there was no physician order to increase Risperdal based on the Psychiatrist's recommendation. Resident R46 remains on the current dose of Risperdal and there is no order to increase. This was verified by the DON on 1/10/2025. 3. On 12/26/2025 the nurse management team completed an audit of all residents receiving Depakote. The nurse management team verified that residents receiving Depakote have laboratory orders in place to monitor therapeutic levels. 4. During morning clinical meeting, the IDT team will review any resident that has an order for Depakote for residents with medications that require routine testing and verify that orders for routine monitoring are present. 5. Education on conducting routine testing to verify therapeutic levels of seizures medication will be presented by the DON/designee to all licensed nursing staff by 1/16/2025. 6. The DON/designee will conduct audits of residents with medications requiring routine monitoring weekly for 4 weeks and monthly for 3 months.
Failure to Provide Restorative Nursing Programs for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to provide necessary treatment and services to maintain or improve the range of motion and mobility for two residents with limited range of motion. Resident R7, who was admitted with conditions including paraplegia, multiple sclerosis, and muscle contractures, was observed with his left arm in a fixed position on his chest. Despite having a restorative nursing program in place, which included passive range of motion exercises and splinting, there was no documented evidence that these interventions were provided to Resident R7. This was confirmed by an interview with the Assistant Director of Nursing. Similarly, Resident R37, who was admitted with a history of cerebrovascular accident and hemiplegia, was not receiving the recommended restorative nursing program. The occupational therapy discharge summary recommended a splint and brace program, but there was no documentation that this was implemented. Observations revealed that Resident R37's left upper and lower extremities were limp, and interviews confirmed that the resident was not receiving the necessary splinting as prescribed. The lack of documentation and implementation of the restorative nursing programs for both residents indicates a failure by the facility to ensure that residents with limited range of motion receive appropriate treatment and services. This deficiency was identified through observations, clinical record reviews, and staff and resident interviews, highlighting a significant oversight in the care provided to these residents.
Plan Of Correction
1. On 12/26/2024 the nurse management team reviewed all residents that have nurse maintenance programs for splinting and implemented sign off sheets for the nurse maintenance programs for Resident R7 and Resident R37. 2. On 12/26/2024 the nursing management team reviewed the electronic health record of residents on a nurse maintenance program for splinting program and verified that proper documentation was present. 3. The IDT team will review new residents on a maintenance program for splinting during clinical meetings to verify documentation is present for maintenance programs. 4. Education on maintaining complete documentation for nursing maintenance programs will be presented by the DON/designee to all CNA staff by 1/16/2025. 5. The DON/designee will conduct audits on nursing maintenance nursing program for splinting documentation for 4 weeks and monthly for 3 months. Results of the audits will be reviewed at the QAPI meeting held monthly.
Resident Access to Hazardous Materials Due to Staff Oversight
Penalty
Summary
The facility failed to ensure that the resident environment was free of accident hazards, specifically by allowing a resident access to hazardous materials. Resident R575, who was admitted with a history of opioid dependence, homicidal ideations, and a previous suicide attempt, was observed holding two razors in the doorway of their room. The resident's care plan included interventions to prevent self-harm, such as removing harmful items from the room and maintaining hourly checks. The incident occurred when Employee E4, a nursing assistant, accidentally left the razors in the bathroom, making them accessible to the resident. Interviews with the Director of Nursing and other staff confirmed that the resident should not have had access to razors, given their history of behaviors and the existing care interventions. This oversight highlights a lapse in maintaining a safe environment for the resident, as required by the facility's policies.
Plan Of Correction
1. On 12/18/2024 the razors were immediately discarded by the CNA. There were no negative outcomes or injuries noted for Resident R575. 2. On 12/18/2024 the nursing staff checked resident rooms to verify that there were no razors left in the room and/or bathrooms. None were identified. 3. On 12/26/2024 the NHA educated the nursing staff on maintaining safety measures for residents regarding razors. 4. The DON/designee will conduct audits 2 times a week for 4 weeks and monthly for 3 months verifying that residents' rooms are free of razors. Results of the audits will be reviewed at the QAPI meeting held monthly.
Inadequate Medication Indication and Monitoring
Penalty
Summary
The facility failed to ensure that medications were administered with adequate indications for use and monitoring for two residents. For Resident R46, the clinical record showed that the resident was prescribed Melatonin and Trazodone for insomnia, despite not having a diagnosis of insomnia. This indicates a lack of adequate indication for the use of these medications. For Resident R83, the facility did not document the rationale for the continued use of Lorazepam beyond 14 days, as required for psychotropic medications. Additionally, the resident was prescribed Depakote without adequate indication for its use, as the medication is typically used for bipolar disorder, epilepsy, or migraines, none of which were documented as diagnoses for the resident. Furthermore, a blood level test for Depakote showed a below-normal range, but there was no documentation that this was reviewed with the physician to ensure proper monitoring.
Plan Of Correction
1. On 12/19/24 the DON assessed Resident R46 and Resident R83 and there were no negative outcomes. 2. On 12/20/2024 the DON obtained an order and added the insomnia diagnosis for Resident R46. On 1/5/2025 he attending physician discontinued the order for Lorazepam for Resident R83. 3. On 12/26/24 the nurse managers reviewed the electronic health records for residents with a PRN order for a psychotropic medication to verify that documentation indicating continued use past 14 days is present. 4. During the morning clinical meeting the IDT team will review new and existing PRN orders for psychotropic medications to verify diagnosis and supporting documentation by the physician for continued use. 5. Education on administering medications with the proper diagnosis and physician documentation for continued psychotropic medications will be presented by the DON/designee to licensed nurses by 1/16/2025. 6. The DON/designee will conduct audits on administering medications with proper diagnosis and documentation for continued use and monitoring weekly for 4 weeks and monthly for 3 months.
Failure to Obtain Ordered Laboratory Services
Penalty
Summary
The facility failed to obtain necessary laboratory studies as ordered by a physician for Resident R158, who was identified as being at high risk for pressure sore development and had moisture-associated skin damage. Resident R158, diagnosed with obesity, was 68 inches tall and weighed 231 pounds, which is 25% above the ideal body weight. The physician had ordered blood tests to assess the metabolism of albumin and thyroid function on November 13 and 15, 2024. However, there was no documentation in the clinical records to indicate that these tests were completed as ordered. This deficiency was confirmed during an interview with a licensed nurse, Employee E17, on December 19, 2024.
Plan Of Correction
1. On 12/19/2024 the DON assessed Resident R158 and there were no negative outcomes for failure to obtain laboratory studies of blood. 2. On 1/5/2025 and 1/16/2025 the Nurse Manager obtained laboratory studies per physician's order. The results are pending review by attending physician. 3. On 12/26/2024 the nurse management team reviewed lab orders for the last 3 months to verify the completion of lab orders per physician orders. 4. The IDT team will review lab binders during morning clinical meetings to verify the completion of labs request from the previous day. 5. Education on obtaining laboratory studies as ordered by the physician will be presented to the licensed nurses by 1/16/2025. 6. The DON/designee will conduct audits of lab binders weekly for 4 weeks and monthly for 3 months. Results of the audits will be reviewed at the QAPI meeting held monthly.
Failure to Maintain Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain enhanced barrier precautions for Resident R15, as required by infection prevention and control regulations. Resident R15, who was admitted with multiple diagnoses including Parkinson's disease, dyskinesia, anxiety, bipolar disorder, muscle wasting, and dysphasia, required enteral nutrition through a gastrostomy tube. The care plan for Resident R15 included goals to keep the tube insertion site free of infection and interventions to monitor and report any signs of aspiration or fever. Despite these precautions, an observation on December 18, 2024, revealed that a nurse aide, Employee E6, was providing incontinence care to Resident R15 while only wearing gloves and not a gown, as mandated by the enhanced barrier precautions. The enhanced barrier precautions, as outlined by the CDC, require the use of gowns and gloves during high-contact resident care activities to prevent the spread of multi-drug resistant organisms. A sign posted outside Resident R15's room clearly indicated the need for such precautions during activities like dressing, bathing, transferring, and providing hygiene. However, during the observation, Employee E6 confirmed awareness of the enhanced barrier precautions but failed to adhere to the proper procedure by not wearing a gown. This lapse in following the infection control protocol contributed to the facility's failure to meet the infection prevention and control requirements.
Plan Of Correction
1. On 12/18/24 the Nurse Manager assessed resident R15 and there were no negative outcomes. The CNA, Employee E6 was immediately educated by the DON on 12/18/24. 2. On 12/18/24 the managers assessed all residents with Enhanced Barrier Precautions to verify that proper PPE was available. 3. The NHA started education for all staff on 12/26/2024 on infection control and prevention. The DON/designee will educate the remainder of the staff by 1/16/2025. 4. The DON/designee will conduct audits on Enhanced Barrier Precautions 3x a week for 4 weeks and monthly for 3 months.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to implement timely and effective safety interventions for residents with known fall risks, resulting in serious injuries and a fatality. Resident 195, who had a history of frequent falls and was assessed as high risk, was admitted to the facility with recommendations for 100% supervision. Despite this, the facility did not adequately address the resident's fall risk in the initial care plan, leading to multiple falls, including one that resulted in a fatal subdural hematoma. The facility's failure to provide necessary supervision and timely interventions contributed to the resident's death. Resident 9, also identified as high risk for falls due to Parkinson's Disease and other conditions, experienced multiple falls within the facility. Despite being on increased supervision with 15-minute safety checks, the resident continued to fall, including an incident that resulted in a hematoma requiring hospital evaluation. The facility did not adequately revise the resident's fall prevention measures or supervision frequency, leading to repeated falls and injury. The Director of Nursing confirmed the facility's responsibility to ensure adequate supervision and fall prevention measures, acknowledging the failure to prevent falls for both residents. The facility's inaction and insufficient response to known fall risks and unsafe behaviors resulted in significant harm, highlighting deficiencies in their fall prevention program and supervision protocols.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents, leading to deficiencies in addressing their specific medical needs. Resident 17, who was admitted with sick sinus syndrome and a pacemaker, did not have a care plan that included monitoring or evaluating the pacemaker's function. This oversight was confirmed by the Director of Nursing during an interview, indicating a lack of proper documentation and planning for the resident's cardiac condition. Similarly, Resident 3, who had chronic obstructive pulmonary disease and Alzheimer's disease, did not have a care plan that addressed her need for denture care. Despite being dependent on staff for personal hygiene, including denture care, there was no documentation or evidence that such care was consistently provided. Interviews with nursing aides revealed that denture care was not included in the resident's Kardex, and the Director of Nursing confirmed the absence of a care plan for the resident's oral hygiene needs.
Physician Inaction on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the physician timely acted upon irregularities identified by pharmacy services during drug regimen reviews for two residents. Resident 30, diagnosed with major depressive disorder, was prescribed Trazodone 300 mg daily since July 2023. A pharmacy recommendation in January 2024 suggested evaluating the medication for side effects, dose changes, or continued use. However, no action was taken by the physician until April 15, 2024, when the Trazodone dosage was adjusted to 275 mg. Similarly, Resident 38, diagnosed with Alzheimer's disease, was prescribed Divalproex Sodium 375 mg three times a day since June 2023. A pharmacy recommendation in December 2023 advised evaluating the medication for side effects, dose changes, or continued use. The physician did not respond until April 16, 2024, when the dosage was reduced to 125 mg twice a day. The facility's policy requires the physician to either accept and act upon pharmacy recommendations or document the rationale for rejection, which was not demonstrated in these cases.
Failure to Implement Effective QAPI Program for Fall Prevention
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by multiple falls experienced by a resident identified as Resident 9. The resident, who was admitted with a history of falls and diagnosed with Parkinson's Disease, muscle weakness, and tremors, experienced seven falls between December 2023 and August 2024. Despite being identified as a high fall risk, the facility did not demonstrate the use of systems for investigating and analyzing the root cause of these adverse events. Resident 9's care plan included various interventions to mitigate fall risks, such as the use of a walker, wheelchair, and scoot-n-go chair, as well as safety checks and alarms. However, the facility's documentation and incident reports revealed that the interventions were not effectively preventing falls, particularly in the dining room during the evening shift. The facility's failure to identify patterns in the falls and adjust staff supervision accordingly contributed to the ongoing issue. The Director of Nursing confirmed the lack of additional documentation regarding efforts to investigate and analyze the falls to determine their root cause. The facility did not provide evidence of a systematic approach to addressing the resident's unsafe behaviors, such as self-transfers and unassisted walking, which resulted in multiple falls and an injury. This lack of effective QAPI program implementation and documentation of corrective actions led to the deficiency cited in the report.
Failure to Provide Person-Centered Care for Pacemaker Management
Penalty
Summary
The facility failed to provide person-centered care for a resident with a pacemaker, as revealed through a review of clinical records and staff interviews. The resident, who was admitted with a diagnosis of sick sinus syndrome and had a pacemaker implanted, did not have documented evidence of current physician orders for the care, monitoring, and battery checks necessary for the pacemaker's proper functioning. An interview with the Director of Nursing on August 1, 2024, confirmed the absence of documented person-centered care and physician orders related to the pacemaker, leading to a deficiency citation under F656 and relevant Pennsylvania codes.
Failure to Monitor Therapeutic Device Leads to Pressure Sore
Penalty
Summary
The facility failed to effectively monitor a resident's use of a therapeutic device, leading to the development of an avoidable pressure sore. Resident 2, who was admitted with multiple diagnoses including diabetes and fractures, was noted to have an immobilizer on the left lower extremity. The physician's orders required skin checks every two hours to prevent pressure sores, but the facility did not document these checks. The resident's baseline care plan did not include the necessary interventions for the immobilizer, such as the required skin checks. A Braden Scale assessment indicated the resident was at moderate risk for pressure ulcer development. Despite this, the facility did not implement consistent skin integrity checks, resulting in the development of a suspected deep tissue injury (DTI) on the resident's left lateral ankle. The facility's failure to conduct timely and consistent skin checks was confirmed by the Director of Nursing. The lack of documentation and adherence to the care plan and physician's orders contributed to the development of the pressure ulcer, which was later observed as a reddened area on the resident's ankle.
Failure to Attempt Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident by not attempting non-pharmacological interventions before administering as-needed pain medication. The clinical record review and staff interviews revealed that Resident 2, who was admitted with multiple diagnoses including diabetes and fractures, received Acetaminophen and Oxycodone HCL without any documented evidence of non-pharmacological interventions being attempted first. The resident's Medication Administration Record showed that Acetaminophen was administered 14 times for pain levels between 2 to 6, and Oxycodone HCL was administered 26 times for pain levels between 7 to 10, all without prior non-pharmacological attempts. The resident's care plan, which was reviewed, included goals and interventions related to pain management but failed to identify individualized non-pharmacological interventions to be attempted before administering medication. The Director of Nursing confirmed the lack of documentation for non-pharmacological interventions prior to the administration of pain medication. This deficiency was noted under the Pennsylvania Code regulations for medical records and nursing services.
Failure to Implement Hospice Plan of Care
Penalty
Summary
The facility failed to fully implement a hospice plan of care for a resident under hospice care. The clinical record review and staff interview revealed that the resident, who was admitted with diagnoses including cerebral infarction, right-sided hemiplegia, chronic kidney disease, and gastro-esophageal reflux disease, was receiving hospice services for end-stage chronic kidney disease and stroke. Despite the hospice care being triggered in the resident's Significant Change MDS, the facility's plan of care did not include specific goals and interventions for hospice care. This deficiency was confirmed during an interview with the Director of Nursing.
Failure to Notify Resident of Bed-Hold Policy
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to a resident and the resident's representative upon the resident's transfer to the hospital. This deficiency was identified during a review of clinical records and staff interviews, which revealed that Resident 30 was transferred to the hospital on March 11, 2024, and subsequently readmitted to the facility. However, there was no documentation indicating that the resident or their representative was informed of the facility's bed-hold and reserve bed payment policy at the time of transfer. During an interview on August 1, 2024, the Nursing Home Administrator and Director of Nursing were unable to provide evidence that such notification had been given, resulting in a violation of resident rights as per 28 Pa Code 201.18 (e)(1) Management and 28 Pa Code 201.29 (b) Resident rights.
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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