Brookview Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chambersburg, Pennsylvania.
- Location
- 1000 Northfield Drive, Chambersburg, Pennsylvania 17201
- CMS Provider Number
- 395012
- Inspections on file
- 19
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Brookview Health Care Center during CMS and state inspections, most recent first.
The facility did not follow its abuse-prevention policy requiring background and credential checks for potential employees when it hired an RN without documented verification of her professional license status. Review of the RN’s personnel file showed no evidence that her license had been checked to confirm it was current and free of disciplinary action, and the Nursing Home Administrator acknowledged that no such documentation could be found, resulting in noncompliance with state regulatory requirements.
The facility failed to follow physician's orders for three residents, leading to improper wound care for one resident, incorrect administration of a Fentanyl patch for another, and failure to monitor blood pressure for a third resident receiving Midodrine. These deficiencies were confirmed by the DON.
The facility failed to maintain sanitary conditions for an ice machine in the [NAME] House, as observed over two days. The ice machine's drain pipe extended to the floor without an air gap for back-flow prevention, confirmed by a maintenance worker.
A facility failed to update a resident's care plan following a quarterly MDS assessment. The resident, who has Alzheimer's and dementia, was observed feeding himself without the non-adherent material under his plate as specified in his care plan. The DON confirmed the care plan should have been revised to discontinue this requirement.
A facility failed to provide trauma-informed care for a resident with PTSD, as required by their policy. The resident, with a history of depression, PTSD, and anxiety, experienced crying episodes and nightmares but did not have completed assessments or identified triggers documented. An interview confirmed the lack of efforts to address these issues, resulting in a deficiency.
A facility failed to accurately document the administration of Morphine Sulfate for a resident with dementia receiving hospice care. Although doses were signed out, the MAR lacked evidence of administration, as confirmed by the DON.
The facility failed to provide written notices to the responsible parties of two residents regarding their transfers to the hospital. One resident experienced vomiting, nausea, and low blood sugar, while another complained of not feeling well and was shivering. Both were transferred to the emergency room with physician orders, but no written notices were documented for their responsible parties.
The facility failed to provide a separately-locked, permanently-affixed compartment in the refrigerator for the storage of controlled drugs. Observations revealed two multi-dose bottles of Ativan stored without a locked compartment. The RN was unaware of the requirement, and the DON confirmed the deficiency.
A facility failed to ensure timely reporting of physical abuse, allowing a nurse aide to return and mentally abuse a resident with Parkinson's disease, anxiety, and depression. The LPN who witnessed the incident did not immediately report it or protect the resident, resulting in Immediate Jeopardy to the safety of all residents.
A resident with Parkinson's disease, anxiety, and depression was subjected to physical and verbal abuse by a nurse aide during a transfer using a Hoyer lift. The nurse aide slapped the resident's hand and verbally abused her after the resident expressed discomfort. The incident was witnessed by staff and confirmed by the resident, leading to Immediate Jeopardy to the resident's health and safety.
A facility failed to address a resident's behavior of removing her feet from wheelchair footrests, leading to Immediate Jeopardy when a nurse aide repeatedly grabbed the resident's ankles, causing distress and resulting in physical and verbal altercations.
The NHA and DON failed to ensure a safe environment free from abuse, timely reporting of abuse, and proper behavior management of residents, as required by their job descriptions and regulatory requirements.
A facility failed to include instructions regarding behaviors and the use of psychotropic medications in a baseline care plan for a newly admitted resident with dementia, anxiety, and major depression. The resident exhibited significant behavioral issues, including aggression and refusal to take medications, which were not addressed in the care plan.
The facility failed to develop comprehensive care plans for a resident with Parkinson's disease, anxiety, and depression, who exhibited combative behaviors and resistance to care. Despite documented incidents of aggression, a care plan addressing these behaviors was not created until several months later.
Failure to Complete Required Licensure Check Prior to RN Hire
Penalty
Summary
The facility failed to ensure that a licensure check was completed prior to hire for one of five employee files reviewed, specifically for a registered nurse. The facility’s abuse policy dated February 27, 2026, required that potential employees be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, and that background, reference, and credential checks be conducted on potential employees, contracted temporary staff, students, volunteers, and consultants. Review of the personnel file for the registered nurse, who was hired on December 29, 2025, showed no documented evidence that her professional license had been checked to verify it was current and free of disciplinary action. In an interview, the Nursing Home Administrator confirmed they could not locate any documentation that a licensure check had been obtained prior to the nurse’s hire, resulting in noncompliance with 28 Pa. Code 201.14(a) and 201.18(e)(1).
Failure to Follow Physician's Orders for Resident Care
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice by not following physician's orders for three residents. For Resident 17, who was cognitively intact and required assistance for daily care needs, the facility did not document evidence of wound care treatment on specific dates in October 2024, as ordered by the physician. Additionally, the treatment was administered more frequently than required in February 2025, despite the resident's visit to the wound clinic. Resident 32, who was cognitively impaired and receiving hospice services, did not receive a Fentanyl patch every 72 hours as ordered by the physician. The patch was administered on December 24 and December 28, 2024, which did not comply with the prescribed schedule. This discrepancy was confirmed by the Director of Nursing during an interview. For Resident 56, who was admitted to the facility with orders to receive Midodrine for low blood pressure, the facility failed to monitor the resident's blood pressure and adjust the medication administration accordingly. The parameters for holding the medication were not added to the order, resulting in the resident receiving Midodrine when the blood pressure readings indicated it should have been withheld. This oversight was confirmed by the Director of Nursing.
Ice Machine Sanitation Deficiency
Penalty
Summary
The facility failed to ensure that ice was made and stored in sanitary conditions in one of its ice machines located in the [NAME] House. Observations on two consecutive days revealed that the drain pipe from the ice machine extended down to the floor and ran horizontally to the floor drain, lacking an air gap necessary for back-flow prevention. This deficiency was confirmed through an interview with a maintenance worker, who acknowledged the absence of an air gap between the ice machine's drain pipe and the floor drain.
Failure to Revise Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to review and revise the care plan for one of the residents, identified as Resident 11, following a quarterly Minimum Data Set (MDS) assessment. The facility's policy mandates that the comprehensive care plan should be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. However, the care plan for Resident 11, which was last updated in May 2023, was not revised to reflect changes in the resident's care needs as of the quarterly MDS assessment conducted in January 2025. During an observation on February 25, 2025, it was noted that Resident 11, who has Alzheimer's disease and dementia, was feeding himself without the non-adherent material under his plate, as specified in his care plan. An interview with the Director of Nursing confirmed that the care plan should have been updated to discontinue the use of non-adherent material under the resident's plates and bowls at all meals. This oversight indicates a failure to adhere to the facility's policy on care plan revisions, potentially impacting the resident's care.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident diagnosed with Post Traumatic Stress Disorder (PTSD) received trauma-informed care to mitigate triggers. The facility's policy on Trauma Informed Care, dated April 11, 2024, mandates that care should be culturally competent and address the needs of trauma survivors by minimizing triggers. However, the facility did not adhere to this policy for one resident, as evidenced by incomplete Trauma Informed Care Assessments and a lack of documented attempts to identify specific triggers that could re-traumatize the resident. The resident in question, who has a history of depression, PTSD, crying episodes, anxiety, and nightmares, was heard screaming upon awakening since September 2023. Despite these symptoms, the facility did not complete the necessary questionnaires or consult others to identify potential triggers. An interview with the Infection Preventionist confirmed the absence of documented efforts to identify and address these triggers, leading to the deficiency noted in the report.
Failure to Document Administration of Controlled Medication
Penalty
Summary
The facility failed to maintain a complete and accurate accounting of controlled medications for a resident, identified as Resident 32. The resident, who was cognitively impaired, required assistance for daily care needs, had a diagnosis of dementia, and was receiving hospice services, was prescribed Morphine Sulfate Oral Solution for breakthrough pain. Physician's orders indicated the administration of 0.25 ml of Morphine Sulfate as needed. However, the medication accountability sheet showed that doses were signed out on specific dates, but the Medication Administration Record (MAR) lacked documented evidence of administration on those dates. An interview with the Director of Nursing confirmed the absence of documentation for the administration of the signed-out doses.
Failure to Provide Written Notice for Hospital Transfers
Penalty
Summary
The facility failed to provide a written notice to the responsible parties of two residents regarding their transfers to the hospital. Resident 2, who was cognitively intact and required assistance for daily care, experienced vomiting, nausea, and low blood sugar on January 17, 2025. The physician was notified, and an order was given to transfer the resident to the emergency room, with the resident's son present and agreeing to the transfer. However, there was no documented evidence that a written notice was provided to the resident's responsible party explaining the reason for the transfer. Similarly, Resident 13, who was also cognitively intact, complained of not feeling well and was observed shivering in bed on February 16, 2025. The physician was notified, and an order was received to transfer the resident to the emergency room, with the resident agreeing to the transfer. Again, there was no documented evidence that a written notice was provided to the resident's responsible party regarding the reason for the transfer. The Nursing Home Administrator confirmed the lack of documentation for both residents' transfers.
Failure to Secure Controlled Drugs in Locked Compartment
Penalty
Summary
The facility failed to provide a separately-locked, permanently-affixed compartment in the refrigerator for the storage of controlled drugs in the medication room at [NAME] House. Observations on March 13, 2024, revealed two multi-dose bottles of Ativan, a controlled medication used to treat anxiety, stored on the top shelf of the refrigerator without a locked compartment. Registered Nurse 1 was unaware of the requirement for a locked compartment, and the Director of Nursing confirmed the deficiency during an interview. This failure is a violation of 28 Pa. Code 211.9(a)(1) Pharmacy Services.
Failure to Report and Prevent Abuse
Penalty
Summary
The facility failed to ensure that staff reported physical abuse in a timely manner, which allowed the staff member to return to the resident and mentally abuse her. The incident involved a resident with Parkinson's disease, anxiety, and depression, who was being assisted by a nurse aide and a licensed practical nurse (LPN). The nurse aide attempted to place the resident's feet on the footrests of her wheelchair, despite the resident's resistance and vocal objections. When the resident hit the nurse aide in response, the nurse aide retaliated by slapping the resident and verbally abusing her. The LPN witnessed the incident but did not immediately report it or take steps to protect the resident from further abuse, allowing the nurse aide to return to the room and continue the abuse by making a hurtful comment while combing the resident's hair. The facility's abuse policy mandates immediate reporting and protective actions in cases of abuse, but these procedures were not followed. The LPN did not send the nurse aide off the unit or report the incident to the Director of Nursing (DON) or Nursing Home Administrator (NHA) immediately. This failure to act allowed the nurse aide to re-enter the resident's room and continue the abuse. The NHA later reviewed the incident with the LPN and confirmed that the nurse aide should have been removed from the unit and not allowed to return to the resident's room. The deficiency was identified during a review of policies, clinical records, and staff interviews. The facility's failure to ensure timely reporting and protection of the resident resulted in Immediate Jeopardy to the physical and mental safety of all residents. The incident highlighted a significant lapse in the facility's adherence to its abuse prevention policies, putting residents at risk of further harm.
Removal Plan
- Nurse Aide 2 was suspended of her duties, and her employment with the facility was terminated.
- An audit of residents was performed.
- Licensed Practical Nurse 1 was re-educated regarding abuse.
- Re-education regarding abuse to staff was started.
- Daily random audits of residents were being completed.
- The nurse aide was suspended and is no longer employed at the facility.
- An in-house audit was performed on residents, and assessments were completed along with interviews to confirm no other residents were identified.
- In-house re-education was provided to staff on abuse and reporting of abuse. The facility will not allow an employee to work unless education has been completed prior to returning to work.
- Daily random audits of care and interviews continue to ensure that no residents have been affected. The audits are going to be reviewed at Quality Assurance Performance Improvement (QAPI) meetings.
Failure to Protect Resident from Physical and Mental Abuse
Penalty
Summary
The facility failed to ensure that residents were free from physical and mental abuse, as evidenced by an incident involving a resident with Parkinson's disease, anxiety, and depression. During a transfer using a Hoyer lift, the resident expressed discomfort by removing her feet from the wheelchair footrests. Despite this, a nurse aide repeatedly attempted to place the resident's feet on the footrests, leading to the resident hitting the nurse aide. In response, the nurse aide slapped the resident's hand and verbally abused her by calling her an 'ass' and later stating, 'I hope that did hurt.' This incident was witnessed by a Licensed Practical Nurse and overheard by a student nurse, who reported the nurse aide's raised voice and abusive comments. The resident confirmed the abuse during an interview with a social worker, stating that the caregiver had chosen clothes she did not want, cussed at her, and hit her on the wrist. The Director of Nursing was informed of the incident shortly after it occurred, and the Licensed Practical Nurse corroborated the resident's account, noting that the resident appeared shaken and that the nurse aide had been insistent on placing the resident's feet on the footrests despite her resistance. The nurse aide's actions and comments were consistent with the reports from other staff members. The facility's abuse policy, dated April 13, 2023, mandates the protection of residents from abuse, neglect, exploitation, and misappropriation of property. However, the actions of the nurse aide on January 29, 2024, directly violated this policy, resulting in Immediate Jeopardy to the resident's physical and mental health and safety. The deficiency was cited as past non-compliance, and the facility was required to take corrective actions to address the issue and prevent future occurrences.
Failure to Address Resident's Behavioral Needs
Penalty
Summary
The facility failed to properly address a resident's behavior of repeatedly taking her feet off the wheelchair footrests and placing them on the ground. This resulted in Immediate Jeopardy when a nurse aide continued to grab hold of the resident's ankles, causing her to yell out and place her feet back on the ground. The resident then hit the nurse aide, who responded by slapping the resident's hand and calling her an offensive name. The resident involved had diagnoses including Parkinson's disease, anxiety, and depression. Despite the resident's clear distress and refusal to keep her feet on the footrests, the nurse aide persisted in trying to place the resident's feet back on the footrests. This escalated the situation, leading to physical and verbal altercations between the resident and the nurse aide. There was no documented evidence in the resident's clinical record indicating that the nurse aide attempted different approaches or interventions to prevent the behavior from escalating. The facility's policy on behaviors, which includes various non-pharmacological interventions, was not followed in this instance, leading to the deficiency.
Failure to Ensure Resident Safety and Proper Behavior Management
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to ensure that the residents' environment remained free from abuse, as required by their job descriptions. The deficiencies cited under the Code of Federal Regulatory Groups for Long-Term Care, 483.12 Freedom from Abuse, Neglect, and Exploitation (F600), revealed that the NHA and DON did not fulfill their essential job duties. This included failing to ensure that staff reported abuse and protected residents from further abuse, as well as failing to properly address a resident's behavior. The job descriptions for both the NHA and DON outlined their responsibilities for overseeing compliance with regulatory requirements and maintaining the highest practicable well-being of each resident, which they did not meet. Additionally, the deficiencies cited under 483.12(b)(1) and 483.12(b)(5)(iii) revealed that the NHA and DON did not ensure that staff timely reported abuse and allowed staff to return to the resident. Furthermore, under 483.40(b)(2), it was found that the NHA and DON failed to ensure that staff properly addressed a resident's behavior, particularly in cases where the resident's assessment did not reveal a diagnosis of a mental or psychosocial adjustment difficulty. These failures were in direct violation of the responsibilities outlined in their job descriptions and the regulatory requirements for long-term care facilities.
Failure to Include Behavioral and Psychotropic Medication Instructions in Baseline Care Plan
Penalty
Summary
The facility failed to ensure that a baseline care plan included instructions regarding behaviors and the use of psychotropic medications for a resident admitted after February 9, 2024. The resident, who had a history of dementia with behaviors, anxiety, and major depression, was prescribed multiple psychotropic medications including Seroquel, lorazepam, and escitalopram. Upon admission, the resident exhibited significant behavioral issues such as agitation, anxiety, and refusal to take medications or undergo assessments. Despite these behaviors and the use of psychotropic medications, the baseline care plan did not include necessary instructions to manage these issues. The resident's daughter informed the facility of the resident's aggressive behaviors, including hitting, spitting, kicking, and throwing objects when upset. Staff documented multiple instances of the resident being combative and uncooperative, including refusing to remove her coat, throwing a cup of gingerale, and hitting and spitting at staff. Despite these documented behaviors and the use of psychotropic medications, the baseline care plan failed to address these critical aspects of the resident's care. The Nursing Home Administrator confirmed that the baseline care plan should have included this information.
Failure to Develop Comprehensive Care Plans for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of Resident 2. The resident, who had diagnoses of Parkinson's disease, anxiety, and depression, exhibited combative behaviors and resistance to care, such as refusing baths and hitting, pinching, and cursing at staff. Despite these behaviors being documented in nursing notes, there was no evidence of a comprehensive care plan addressing these behaviors until February 15, 2024. On January 29, 2024, an incident occurred where Resident 2 hit a nurse aide while being assisted into a wheelchair. The resident repeatedly removed her feet from the wheelchair footrests and became physically aggressive when the nurse aide attempted to place her feet back on the footrests. The Nursing Home Administrator later revealed that they did not believe the resident had any behaviors that warranted a care plan until February 15, 2024, indicating a delay in addressing the resident's specific needs and behaviors.
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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