Burgh Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 909 West Street, Pittsburgh, Pennsylvania 15221
- CMS Provider Number
- 395883
- Inspections on file
- 41
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Burgh Care Center during CMS and state inspections, most recent first.
The facility did not maintain comfortable air temperatures on one nursing unit, despite a policy requiring temperatures in common resident areas to be kept between 71°F and 81°F. During a tour with the NHA, multiple rooms on the 2nd floor were measured between 64°F and 68°F. Several residents reported that it had been cold for about a week, described the environment as cold or "kind of cold," and complained of being cold in their rooms. The NHA acknowledged that the facility failed to ensure comfortable temperature levels on the 2nd floor.
Two residents with orders for regular hemodialysis did not have complete dialysis communication forms for multiple visits, as required by facility policy. The DON confirmed that documentation was incomplete, resulting in inconsistent communication with the dialysis provider.
The facility did not ensure timely and accurate behavioral services from outside vendors for two residents, as psychological service notes were documented for individuals who were either not present or had already passed away, according to staff confirmations and clinical records.
The facility did not inform the State agency when a new Medical Director replaced the previous one, as confirmed by the Nursing Home Administrator during an interview.
Multiple rooms on one unit were found to be missing bed frames, mattresses, and functional furniture, with some rooms also being used for storage instead of resident accommodation. The NHA confirmed these rooms were not available for resident use and lacked required furnishings as mandated by regulations.
A resident with multiple medical conditions developed a new abscess on the back. Despite existing physician orders for skin assessments and antibiotics, an LPN, without a physician's order, attempted to squeeze and manipulate the abscess using lidocaine cream, gauze, and tweezers. The procedure caused significant pain and bleeding, and the resident was subsequently transferred to the hospital for further care. Facility staff confirmed that the LPN acted outside the scope of practice and against facility policy.
Two residents with tracheostomies did not receive care consistent with professional standards, as the facility failed to maintain current physician orders, implement individualized care plans, and ensure staff competency in tracheostomy care. Emergency supplies were missing or improperly stored, staff lacked training in emergency and routine trach procedures, and care plans were incomplete or outdated. These failures resulted in one resident experiencing a complete tracheostomy obstruction and both residents suffering respiratory and emotional distress.
A resident with multiple medical conditions who required assistance with bed mobility fell from bed and sustained a head injury after side rails ordered by a physician were not installed or included in the care plan. Staff interviews and documentation revealed delays and confusion regarding the installation of side rails, and the resident had previously requested them and reported prior falls. The DON confirmed the facility failed to provide necessary goods and services to prevent the fall, resulting in actual harm.
The facility did not have its four week cycle menu and nutritional substitutes reviewed and approved by a Registered Dietitian before implementation for a period of ten months, as required by policy. This lapse was confirmed by the NHA and was not in compliance with dietary service regulations.
Staff failed to prevent cross contamination during a dressing change and medication passes, including improper use of PPE and hand hygiene. Surfaces used during care were not cleaned, and medications were handled with bare hands. The facility also did not implement or document an infection control surveillance plan, and staff and residents were not tested for infectious diseases according to national standards.
The facility did not implement an antibiotic stewardship program for ten months, as required by its own policies. Infection control surveillance records lacked documentation of antibiotic monitoring, and the infection preventionist and leadership confirmed that no such monitoring or stewardship activities were conducted during this time.
The facility did not have a qualified individual onsite to oversee the infection prevention and control program for a period of several months. The assigned IP was not certified until late in the period and was still learning the role, which was confirmed by the Administrator and DON.
The facility did not provide required Quality Assurance and Performance Improvement (QAPI) training to five nurse aides, as confirmed by a review of education records and staff interview. This failure was cited under regulations for licensee responsibility, management, and staff development.
The facility did not monitor or log dish machine temperatures per shift in the main kitchen for a ten-month period, as required by policy. This was confirmed during kitchen tours and interviews with the NHA, Dietary Manager, and Corporate Director of Dining Services.
The facility did not provide an activities program that met the needs of its residents, as several residents reported insufficient variety and limited access to activities, especially for those wishing to go outdoors or participate in creative and challenging options. Activity calendars showed early end times, overlapping schedules, and lacked details on locations, while clinical records had inadequate documentation of resident participation. The NHA confirmed these deficiencies during an interview.
The facility did not employ a qualified activities director for an extended period, as required by federal regulations. Review of the employee file and staff interviews confirmed that the individual in the role lacked the necessary credentials, certification, or experience to direct the activities program.
The facility failed to provide safe and appropriate dialysis care for multiple residents with end stage renal disease, including missing or delayed physician orders, incomplete documentation of pre- and post-dialysis assessments, and lack of proper care coordination with dialysis providers. Staff confirmed lapses in documentation, order entry, and infection prevention practices, resulting in missed treatments and inadequate monitoring.
Two residents did not receive necessary care due to insufficient nursing staff, resulting in missed dialysis appointments for one and a missed follow-up appointment for another. Staffing shortages led to delays in entering physician orders, lack of appointment scheduling, and required the RN Supervisor to perform both supervisory and direct care duties. The DON and NHA confirmed ongoing staffing issues, with no agency nurses used to fill gaps.
The facility did not ensure that nursing staff, including LPNs and an RN Supervisor, had documented education or competency in tracheostomy care, despite being assigned to care for two residents with tracheostomies. Facility assessment also failed to include tracheostomy care, and interviews confirmed the lack of appropriate staff training and competency validation.
The facility did not complete required annual performance evaluations for three nurse aides, as confirmed by a review of personnel records and staff interviews. This failure was acknowledged by Human Resources and was not in compliance with facility policy and state regulations.
Surveyors found that two insulin pens were incorrectly labeled with misspelled last names, and two residents did not receive their prescribed medications as ordered. These issues were confirmed by nursing staff and the DON, indicating failures in medication labeling and the implementation of pharmaceutical services.
A resident's room was repeatedly observed to be unclean and disorganized, with spilled fluids, soiled linens, scattered clothing, and an odor of urine present. Staff acknowledged the need for housekeeping intervention, but the environment remained unsanitary and not homelike, in violation of facility policy and state regulations.
A resident with a tracheostomy, history of falls, and hip fracture reported prolonged waits for incontinence care and developed sores due to infrequent changes. Despite facility policies requiring prompt reporting and thorough investigation of neglect, the facility's investigation was incomplete, lacking identification of a perpetrator and missing nursing staff witness statements. The resident continued to experience delays in care and expressed fear of retaliation, while leadership confirmed policies were not properly implemented.
A resident with multiple chronic conditions reported to the NHA that a nurse aide was mean and refused to provide care, and also alleged rough treatment during care. Despite these allegations, the facility did not report the incident to the required state authorities as mandated by policy.
A resident with multiple chronic conditions was admitted without a comprehensive review or documentation of admission rights, including information on financial liability, resident rights, consent, and appeal processes. The facility's records lacked required admission documentation, and staff confirmed the deficiency during interviews.
A resident was readmitted with multiple diagnoses and had a PEG tube placed for enteral feeding, representing a significant change in condition. Despite updated care plans and physician orders reflecting the new feeding requirements, staff did not complete a significant change MDS assessment as required. The RNAC confirmed the assessment was not done after team discussion.
A resident with multiple medical conditions was identified as a smoker needing supervision and a smoke apron during smoke breaks, but this was not included in the care plan. The resident was later observed smoking without a smoke apron, and staff confirmed the care plan did not address his smoking needs.
Two residents did not receive care in accordance with physician orders and discharge instructions. One resident did not receive a prescribed pureed diet for three days after admission, and another received a discontinued pain medication multiple times after transfer from the hospital. The DON and Nursing Home Administrator confirmed these failures.
A resident with a history of tracheostomy, repeated falls, and GERD was not provided with hearing aids or a care plan addressing her hearing impairment. Staff confirmed the resident's hearing aids were with her family, and communication required staff to speak loudly in front of her. The facility did not implement interventions or care planning for the resident's hearing needs, resulting in noncompliance with regulatory requirements.
A resident with a history of cerebral infarction, hemiplegia, and incontinence did not receive timely implementation of recommended wound care after a sacral wound resolved. Despite a provider's recommendation for ongoing use of a barrier cream, there was no active physician order, and staff confirmed the treatment was not provided as directed. The resident experienced excoriation and discomfort, and the DON acknowledged the lapse in ensuring necessary wound care services.
A resident with an indwelling Foley catheter did not have physician orders specifying the catheter size or balloon inflation amount, despite having orders for catheter care and use. The DON confirmed the omission after a review of the clinical record and physician orders.
The facility failed to document and monitor fluid intake for a resident on a fluid restriction, resulting in untracked consumption beyond physician orders, and did not reweigh or consult the dietician for another resident who experienced significant unplanned weight loss. Facility leadership confirmed these lapses in care and documentation, which did not meet established policies or physician directives.
A resident with a PEG tube did not receive appropriate care due to unclear and outdated physician orders, lack of documentation of the current tube feeding rate, and failure to specify downtime for oral intake. Observations showed the tube feeding pump was left unattended and uncapped, causing formula to drip onto the floor, and staff confirmed the lack of clarity in orders and care planning.
A resident with a PICC line and orders for weekly sterile dressing changes did not have a care plan in place for IV therapy. The absence of a care plan was confirmed by the DON and observed in the clinical record, despite the resident's ongoing need for IV access due to conditions such as cellulitis and sepsis.
Three residents with PTSD did not have care plans that identified or addressed their trauma triggers, despite the facility's trauma-informed care policy and staff training. Staff and DON confirmed that care plans lacked documentation of PTSD-related triggers, leaving these residents without individualized interventions to prevent re-traumatization.
Facility staff did not act in a timely manner on pharmacy recommendations for a resident with PTSD, chronic kidney disease, and repeated falls. The pharmacist requested clarification on the frequency of an as-needed Melatonin order, but despite physician acknowledgment, the order was not updated to include the required frequency, resulting in noncompliance with medication review policy.
Two residents did not receive their prescribed medications as ordered, including missed doses of Tamiflu due to unavailability and incorrect dosing of cyclosporine following a hospital discharge. Facility leadership and nursing staff confirmed these significant medication errors.
Surveyors found that medical supplies and biologicals were not properly stored in a medication cart and medication room, including expired items, opened wound vac kits, and insulin pens not stored in bags. Both an LPN and the DON confirmed these storage issues, which were not in accordance with facility policy.
A resident who was supposed to receive a double portion of protein at lunch was served only a single portion, despite their dietary ticket indicating otherwise. The resident confirmed the missing portion, and this failure was observed during meal service and staff interviews.
The facility did not serve breakfast at the scheduled time, as required by policy, with tray carts arriving significantly late and a resident reporting that food often sits for an hour before being distributed, resulting in cold meals.
Two residents with complex medical needs did not have timely outside appointments scheduled or documented as required. One resident's follow-up tracheostomy evaluation was not tracked by the facility, and another resident did not have a transplant surgery follow-up appointment scheduled after hospital discharge. Staff confirmed these lapses in scheduling and documentation.
The QAPI committee did not correct previously cited deficiencies, resulting in repeated and new deficiencies, including F600 and F695, as confirmed by the Nursing Home Administrator.
A facility failed to identify and supervise a resident at risk for elopement, resulting in the resident leaving the premises without authorization. Despite exhibiting exit-seeking behaviors and being assessed as an elopement risk, the resident's care plan was not updated, and staff failed to recognize the risk. The resident left during a smoke break, highlighting deficiencies in the facility's elopement protocol and staff training.
The NHA and DON failed to manage the facility effectively, resulting in a resident's elopement and creating an immediate jeopardy situation. Their job descriptions required adherence to federal, state, and local standards to ensure quality care, but this was not achieved, leading to a serious breach in resident safety.
The facility did not designate a specific physician as the medical director, as required. A contract dated December 2023 indicated a medical group would provide oversight, but information submitted in March 2025 listed a different individual as the medical director since January 2020. Interviews revealed that the current medical director took over in August 2024, and the medical group was considered the director. The DON confirmed the failure to designate a physician.
A resident with a history of substance abuse and cerebral infarction left Burgh Care Center without authorization. The facility's investigation was incomplete, lacking witness statements from key staff and residents. The Director of Nursing confirmed the failure to fully investigate the incident to rule out neglect.
A resident with a history of substance abuse and cerebral infarction left the facility without authorization, and the facility failed to provide adequate discharge planning. The resident was cognitively intact, but there was no physician's discharge order, and the facility lacked information on the resident's whereabouts after the incident. Staff interviews confirmed the failure to complete a timely and safe discharge.
A facility failed to ensure a physician conducted the initial visit for a resident admitted with anemia, bacteremia, and heart failure. Instead, a CRNP performed the visit, violating federal regulations. The Medical Doctor and DON confirmed the oversight, with the doctor misunderstanding the regulation requirements.
A resident with a history of substance abuse and cerebral infarction eloped from the facility without authorization. The facility did not notify the State Survey Agency within the required two-hour timeframe, as confirmed by the Regional Clinical Specialist. Despite efforts to locate the resident, including area searches and phone calls, the resident was not found.
The facility did not provide two residents with a written notice of their rights, services, and rules upon admission. The admission packet included necessary documents, but one resident had no signed admission agreement or authorization to treat until months later, and another resident's record lacked these documents entirely. The Nursing Home Administrator confirmed this oversight.
Failure to Maintain Comfortable Temperature Levels on One Nursing Unit
Penalty
Summary
The facility failed to maintain comfortable and safe air temperature levels on one of two nursing units, specifically the 2nd floor. The facility’s “Safe and Homelike Environment” policy, dated 7/24/25, states that the facility will provide a safe, clean, comfortable, and homelike environment and will maintain comfortable and safe temperature levels, striving to keep temperatures in common resident areas between 71°F and 81°F. During a tour and interview with the Nursing Home Administrator on 1/29/26 at 10:45 a.m., multiple rooms on the 2nd floor were found to have temperatures below this range, with readings of 64°F, 66°F, 67°F, and several rooms at 68°F. Resident interviews conducted later that day further confirmed concerns about low temperatures. One resident reported that the facility had been cold for about a week, though not at the time of the interview. Another resident stated it was “kind of cold” in the facility that day, while additional residents reported that it had been cold, that it was cold in their room, or directly complained of being cold. At 3:30 p.m. on the same day, the Nursing Home Administrator confirmed that the facility failed to ensure comfortable air temperature levels on the 2nd floor nursing unit, in violation of 28 Pa. Code 201.18(b)(3) regarding management responsibilities.
Failure to Maintain Consistent Dialysis Communication and Documentation
Penalty
Summary
The facility failed to maintain consistent and complete communication regarding dialysis care for two residents who required regular hemodialysis treatments. According to facility policy, ongoing communication and collaboration with the dialysis provider is required, including the use of telephone or written communication such as dialysis communication forms. For both residents, who had diagnoses including end stage renal disease, diabetes, seizures, high blood pressure, and anemia, physician orders and care plans specified dialysis three times weekly. However, a review of dialysis record of visit forms over a specified period revealed that all forms for both residents were incomplete. Interviews with the Director of Nursing confirmed that the required documentation was not fully completed for these residents, resulting in a lack of consistent communication with the dialysis facility. This deficiency was identified through review of clinical records, facility policy, and staff interviews, and was cited under relevant state codes for clinical records and nursing services.
Failure to Provide Timely and Accurate Behavioral Services from Outside Vendors
Penalty
Summary
The facility failed to provide behavioral services from outside vendors in a timely and accurate manner for two residents. According to facility policy, the facility is responsible for obtaining and ensuring the timeliness and professional standards of outside services. For one resident, clinical records showed a psychological services progress note was documented on a date when the resident was not present in the facility, as confirmed by the Nursing Home Administrator. For another resident, a psychological services progress note was also documented after the resident had already passed away, as confirmed by the Director of Nursing. These findings were based on a review of clinical records, facility documents, and staff interviews. The records indicated discrepancies in the provision and documentation of behavioral services, with services being recorded for residents who were either not present or deceased at the time. The facility acknowledged these failures during staff interviews.
Failure to Notify State Agency of Medical Director Change
Penalty
Summary
The facility failed to notify the State agency of a change in its Medical Director at the time the change occurred. Review of facility data showed that Doctor Employee E1 was the Medical Director as of 1/1/20, but during an interview, the Nursing Home Administrator stated that Doctor Employee E1 was no longer employed and that Doctor Employee E2 became the new Medical Director effective 7/24/25. The Nursing Home Administrator confirmed during the interview that the State agency had not been informed of this change in Medical Director as required by regulations.
Missing Beds, Mattresses, and Furniture in Resident Rooms
Penalty
Summary
Surveyors observed that multiple resident rooms on the third floor were missing essential furnishings, including bed frames, mattresses, and functional furniture. Both single and dual occupancy rooms were affected, with some rooms lacking one or two bed frames and mattresses, as well as necessary furniture. Additionally, one double occupancy room was found to have a key lock on the doorknob and was being used for storage rather than for resident accommodation. These findings were based on direct observation during the survey. During an interview, the Nursing Home Administrator confirmed that the rooms in question were not readily available for resident use as required. The absence of proper beds, mattresses, and furniture was acknowledged, and it was stated that these items were on order. The deficiency was cited under federal and state regulations requiring that each resident be provided with a separate bed of proper size and height, a clean and comfortable mattress, appropriate bedding, and functional furniture suitable to the resident's needs.
LPN Performed Unauthorized Procedure on Resident Abscess
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) performed a procedure outside of accepted standards of practice on a resident who had a history of spinal stenosis, anxiety disorder, hypertension, and hypothyroidism. The resident was identified as having a potential for skin impairment and had a new abscess on her back, which was documented by nursing staff. Physician orders were in place for skin assessments and antibiotics, but there were no orders for any invasive procedures such as excision, debridement, or lancing of the abscess. Despite these orders and facility policy, the LPN proceeded to manipulate the abscess after the resident requested assistance. The LPN used lidocaine cream, gauze, and tweezers, and attempted to squeeze the abscess, resulting in pain and bleeding. The LPN did not have a physician's order to perform this procedure and did not use sanitized instruments, as reported by the resident. The Assistant Director of Nursing (ADON) and other nursing staff confirmed that LPNs are not permitted to lance or excise abscesses and that the LPN had been instructed not to intervene in this manner. Following the unauthorized intervention, the resident experienced significant pain and required transfer to the hospital, where further medical intervention was necessary. Interviews with staff and review of facility documentation confirmed that the LPN's actions were not in accordance with professional standards, facility policy, or the scope of practice for LPNs. This failure resulted in actual harm to the resident and was reported to facility leadership.
Failure to Provide Safe and Appropriate Tracheostomy Care
Penalty
Summary
The facility failed to provide tracheostomy care consistent with professional standards of practice for two residents, resulting in an Immediate Jeopardy situation. Both residents had tracheostomies and required specialized respiratory care, including suctioning, oxygen therapy, and regular monitoring. The facility did not maintain current physician orders for tracheostomy care, failed to implement individualized care plans, and did not ensure that staff were competent or properly trained in tracheostomy care. For one resident, the care plan was not updated within 48 hours of admission, and there were no orders for suctioning, tracheostomy care, or enhanced barrier precautions. The other resident's care plan and orders were discontinued and not reinstated upon readmission, leaving the resident without necessary tracheostomy care instructions. Observations revealed that essential emergency supplies, such as an Ambu bag, obturator, and appropriately sized inner cannulas, were not available at the bedside. Suction equipment was improperly stored, and expired supplies were found in residents' rooms. Staff interviews confirmed a lack of training and competency in tracheostomy care, including emergency procedures, suctioning, and obtaining tracheostomy cultures. One LPN admitted to not receiving any training on tracheostomy care and was unaware of emergency protocols or how to obtain a tracheostomy culture. Additionally, staff failed to follow physician orders for oxygen therapy and did not notify the physician when changes in oxygen demand occurred. Residents reported that staff did not know how to care for tracheostomies, and one resident experienced a complete tracheostomy obstruction, requiring hospital transfer and intervention. Documentation and monitoring were inconsistent, with care plans lacking details on the frequency of tracheostomy care and the size of inner cannulas. The facility assessment did not include tracheostomy care, and staff files lacked evidence of education or competency in this area. These failures led to significant respiratory and emotional distress for the residents involved.
Failure to Provide Ordered Side Rails Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate goods and services to prevent falls, resulting in neglect of a resident who required partial to moderate assistance with bed mobility. The resident had significant medical diagnoses, including respiratory failure, heart failure, and diabetes, and was assessed as needing help to roll in bed. Despite a physician's order for bilateral side rails, the resident's care plan did not include the use of side rails, and they were not present on the bed at the time of the incident. During care, a nurse aide was repositioning the resident in bed without the use of side rails, and the bed was in a high position. The resident rolled out of bed and sustained a head injury, including a minimally depressed right orbital floor fracture, requiring transfer to the hospital. Interviews and documentation confirmed that the resident had previously requested side rails and reported prior falls from bed, but no new interventions were implemented. Staff interviews revealed confusion about the process and timeliness for installing side rails after an order was placed, with delays attributed to maintenance procedures. Observations after the incident showed the resident with visible injuries and without side rails on the bed. Multiple staff members, including nurse aides, LPNs, and the occupational therapist, acknowledged that side rails should have been installed promptly following the physician's order. The Director of Nursing confirmed that the facility failed to provide necessary goods and services to prevent the fall, resulting in actual harm to the resident.
Menus Not Reviewed by Registered Dietitian Prior to Implementation
Penalty
Summary
The facility failed to ensure that its four week cycle menu and nutritional substitutes were reviewed and approved by a Registered Dietitian prior to implementation for a period spanning ten months, from June 2024 to March 2025. Review of facility policies indicated that each resident should be provided with a nourishing, well-balanced diet that meets daily nutritional and special dietary needs. However, documentation showed that the menus and nutritional substitutes did not include a signed review by the Registered Dietitian for the specified period. This was confirmed by the Nursing Home Administrator during an interview, acknowledging that the required review and approval process by the Registered Dietitian was not completed as mandated by facility policy and regulatory requirements.
Failure to Prevent Cross Contamination and Implement Infection Control Surveillance
Penalty
Summary
The facility failed to prevent cross contamination during clinical care and medication administration, as well as to implement an effective infection control surveillance plan. During a dressing change for one resident, an LPN placed a garbage bag on the overbed tray table and a disposable gown on the dresser, using the gown as a clean field for dressing supplies. The LPN did not clean the surfaces before or after the procedure, used PPE inconsistently, and failed to maintain proper hand hygiene throughout the dressing change. The LPN confirmed these lapses during an interview. During medication passes, two LPNs were observed using improper hand hygiene techniques, such as wiping hands with a washcloth soaked in hand sanitizer and returning it to the medication cart, and handling medications with bare hands. One LPN picked up a medication bottle lid from the floor and replaced it without performing hand hygiene, then continued preparing medications. These actions were confirmed by the staff involved during interviews. The facility also failed to implement and document an infection control surveillance plan in accordance with national standards. There was no line listing for COVID-19 or Influenza cases, and staff and residents were not tested according to established protocols. The infection preventionist was unfamiliar with outbreak management procedures, and symptomatic staff were not promptly tested for COVID-19. The Director of Clinical Operations and the Director of Nursing confirmed these failures in monitoring, tracking, and testing for infectious diseases.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for a period of ten months, from June 2024 through February 2025. Review of the facility's infection control policies indicated that the purpose of the antimicrobial stewardship program was to monitor antibiotic use among residents, including documentation of indications for use. However, infection control surveillance records for October 2024 through February 2025 did not include evidence that antibiotic monitoring was completed, and the infection preventionist was unable to provide documentation for June 2024 through September 2024. During interviews, the infection preventionist, who began the role in January 2025, and facility leadership confirmed that antibiotic monitoring and stewardship activities were not carried out during this period.
Failure to Designate Qualified Onsite Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified individual onsite to be responsible for implementing the infection prevention and control program from January 2025 to March 2025. According to staff interviews, the person assigned as the infection preventionist (IP) began the role in January 2025 but did not become certified until March 27, 2025, and was still learning the responsibilities associated with the position. The Nursing Home Administrator and DON confirmed that during this period, the facility did not have a qualified individual onsite fulfilling the required duties for infection prevention and control, as mandated by federal and state regulations.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) program to five staff members. A review of facility education documents for 2024 showed that none of the five nurse aides had received QAPI training. This was confirmed during an interview with a Human Resources employee, who acknowledged that the required QAPI training had not been provided to these staff members. The deficiency was cited under state regulations related to the responsibility of the licensee, management, and staff development. No information was provided regarding any residents' medical history or condition in relation to this deficiency.
Failure to Monitor and Log Dish Machine Temperatures
Penalty
Summary
The facility failed to properly monitor and log dish machine temperatures per shift in the main kitchen over a ten-month period. According to the facility's dish machine temperature policy, a test run should be completed before use, and temperatures should be recorded on a monitoring log if the required temperature is reached. During two separate tours of the kitchen, surveyors did not find any per shift temperature logs for the dish machine. Interviews with the Nursing Home Administrator, Dietary Manager, and Corporate Director of Dining Services confirmed that the facility did not monitor or log dish machine temperatures as required from June 2024 to March 2025.
Failure to Provide Comprehensive Activities Program
Penalty
Summary
The facility failed to implement an activities program that met the needs of its residents, as evidenced by interviews, documentation review, and direct observation. Four out of six interviewed residents expressed dissatisfaction with the variety and scheduling of activities, stating they desired more diverse, creative, and challenging options, as well as increased access to outdoor activities for both smokers and non-smokers. The activity calendars for January through March showed that most activities ended by 2pm or 3pm, with limited variety and overlap between popular activities such as bingo and scheduled smoking times, preventing some residents from participating. Additionally, the calendars did not specify the locations or nursing units where activities were held, further limiting accessibility. Review of clinical records revealed inadequate documentation of resident participation in activities, with some records lacking any notes of involvement and others containing only sporadic entries over several months. During an interview, the Nursing Home Administrator confirmed the absence of sufficient documentation and acknowledged that the current activities program did not meet resident needs. These findings demonstrate a failure to provide a comprehensive activities program as required by state regulations.
Unqualified Activities Director Employed
Penalty
Summary
The facility failed to employ a qualified activities director from October 2024 to April 2025. Review of the personnel file for the individual serving as Activity Director (Employee E25) revealed that there was no documentation or evidence of meeting any of the federal requirements for the position, such as appropriate certification, licensure, experience, or completion of a state-approved training course. During interviews, both the Activity Director and the Nursing Home Administrator confirmed that the individual did not possess the necessary qualifications as outlined in federal regulations.
Failure to Provide Safe and Coordinated Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for residents requiring such treatment, as evidenced by incomplete records of pre- and post-dialysis assessments, untimely entry of physician orders, and lack of proper coordination with dialysis providers. For three residents with end stage renal disease and dependence on dialysis, the facility did not maintain required documentation, including dialysis communication forms and assessment records. In one case, a resident missed scheduled dialysis sessions due to the facility's failure to timely enter physician orders, resulting in the resident being sent to the hospital for emergent dialysis. Another resident's records showed no updated dialysis communication forms for several months, despite ongoing orders to obtain vital signs before and after dialysis. The Director of Nursing confirmed the absence of complete records for this resident. Additionally, a third resident was observed with a central venous catheter for dialysis that was left uncovered and without a dressing, contrary to standard infection prevention practices. The facility also delayed entering dialysis orders for this resident and failed to provide necessary vaccination status information to the dialysis center. Interviews with facility staff, including the DON, RN Supervisor, and Nursing Home Administrator, confirmed these failures in documentation, order entry, and care coordination. The facility did not ensure that residents received dialysis services as ordered, nor did it maintain ongoing communication and assessment of residents' conditions before and after dialysis treatments, as required by professional standards and facility policy.
Insufficient Nursing Staff Leads to Missed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in missed essential medical care and unaddressed physician orders for two residents. One resident, with diagnoses including end stage renal disease and heart failure, missed scheduled dialysis appointments on two occasions due to the facility's failure to timely enter physician orders and ensure transportation to dialysis. This led to the resident being sent to the hospital for emergent dialysis after presenting with a critical venous oxyhaemoglobin level. Facility records did not show documentation of the resident's leave of absence for dialysis as ordered. Another resident, admitted with respiratory failure, immunodeficiency, and kidney transplant rejection, did not have a required follow-up appointment with a transplant surgery office scheduled, as ordered in the hospital discharge summary. The RN Supervisor, responsible for scheduling such appointments, confirmed the delay was due to staffing issues. Additionally, new nursing staff reported not being assigned a preceptor or mentor, and the RN Supervisor was observed performing multiple roles, including medication administration and supervisory duties, due to lack of available staff. Interviews with staff and review of staffing sheets revealed that the facility often had only one nurse assigned to a floor, with the RN Supervisor covering both supervisory and direct care roles. The DON and NHA confirmed that the facility did not have enough nursing staff scheduled, and that nurses frequently called off, with no agency nurses used to fill gaps. These staffing shortages directly contributed to the failure to provide necessary care and services to residents as required by regulation.
Lack of Competency and Training for Tracheostomy Care Among Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skills to provide tracheostomy care for residents requiring this service. Review of four staff personnel files, including LPNs and an RN Supervisor, showed no evidence of education or competency in tracheostomy care. One LPN, on their first day, reported not receiving any training or education on tracheostomy care from the facility, despite being assigned to a resident with a tracheostomy. Although the LPN had prior experience in pediatric tracheostomy care, there was no documentation of facility-specific training or competency validation. Additionally, the facility assessment did not include tracheostomy care, even though two residents required this service. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that the facility did not ensure sufficient nursing staff with the necessary competencies and skill sets for tracheostomy care. This deficiency was identified through review of facility policy, staff records, training documentation, and staff interviews.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for three out of five nurse aides, as required by facility policy and state regulations. Specifically, there were no documented performance evaluations for three nurse aides with hire dates of 8/21/07, 11/1/19, and 7/19/22. This deficiency was confirmed during an interview with the Human Resources employee, who acknowledged that the required annual evaluations had not been completed for these staff members. The deficiency was identified through a review of facility policy, personnel records, and staff interviews, which revealed the absence of the necessary performance evaluations for the specified nurse aides.
Medication Labeling and Pharmaceutical Service Deficiencies
Penalty
Summary
The facility failed to correctly label medications and ensure the accurate provision of pharmaceutical services for multiple residents. During an observation of the medication room, two insulin pens belonging to two residents were found in the medication refrigerator with incorrect labeling; the last names were misspelled and labeled using the second letter of the residents' last names. This was confirmed by an LPN and the Director of Nursing. Additionally, the facility's policies require thorough medication regimen reviews and emergency drug services, but these were not properly implemented. Further review of clinical records revealed that two other residents did not receive their prescribed medications as ordered. One resident, with diagnoses including atrial fibrillation, breast neoplasm, and osteoarthritis, had orders for Lidocaine Viscous and Kool 'N Fit Spray that were either awaiting delivery or not being filled by the pharmacy. Another resident, diagnosed with acute respiratory failure with hypoxia and kidney transplant rejection, had orders for Repatha and Biotin Forte that were not administered as prescribed. These failures were confirmed by nursing staff and the Director of Nursing.
Failure to Maintain a Safe and Clean Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for one resident, as required by its own policy and state regulations. Observations conducted on two separate days revealed that the resident's room contained chocolate milk and a clear fluid spilled on the floor, cups, clothes, and a jacket scattered on the floor. On a subsequent observation, the room was found with a white sheet and pink blanket on the floor, patches of a brown substance on the floor, an odor of urine, and a white cup lid on the floor. During these observations, a nurse aide acknowledged the need for housekeeping to address the cleanliness issues. These findings were communicated to the Nursing Home Administrator, confirming the facility's failure to provide a sanitary and orderly environment for the resident.
Failure to Implement Abuse and Neglect Prevention Policies
Penalty
Summary
The facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for one resident. Facility policy required that all incidents, regardless of severity, be reported promptly, investigated, and documented with witness statements. However, for a resident with a tracheostomy, repeated falls, and a hip fracture, there were multiple reports of neglect, including long waits to be changed and the development of sores. The resident, who was cognitively intact, reported waiting five to six hours to be changed and expressed concerns about staff turning off the call light and not returning for hours. The investigation into the resident's allegations was incomplete, as it failed to identify an alleged perpetrator and did not include witness statements from nursing staff. The only statements obtained were from the DON and Medical Director, both signed by the Nursing Home Administrator. Documentation showed the resident's brief was changed only two to three times a day. The resident continued to report delays in care and expressed fear of retaliation. Facility leadership confirmed that written policies and procedures to prevent abuse, neglect, and exploitation were not properly implemented for this resident.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect involving one resident. According to the facility's Protection from Abuse policy, all allegations of abuse or neglect must be reported to the appropriate state agencies, including the Department of Health and Department of Aging. A review of the resident's grievance document showed that the resident reported to the Nursing Home Administrator that a nurse aide was mean to her and refused to provide care on a specific morning. Additionally, the Assistant Director of Nursing/Infection Preventionist documented hearing the resident allege that the nurse aide was rough with her during care. Despite these allegations, there was no evidence that the facility reported the incident to the required state authorities. The resident involved had a medical history including COPD, history of alcohol abuse, diabetes, and hypertension. The deficiency was identified through review of facility policy, resident records, investigation documents, and staff interviews, which confirmed that the required reporting procedures were not followed for this allegation of neglect.
Failure to Provide and Document Comprehensive Admission Rights
Penalty
Summary
The facility failed to provide a comprehensive review of admission rights and maintain complete admission documentation for one resident. Specifically, the facility's policy requires informing residents of their rights and responsibilities upon admission. However, for one resident with diagnoses including diabetes, dementia, and hypertension, the admission record lacked documentation of an admissions packet or discussion covering key topics such as patient portion liability, daily rate cost structure, resident rights, appeal rights, consent to treatment, Medicare and Medicaid processes, choice of ancillary services, bed hold policy, and consequences for non-payment. The resident's surrogate decision maker was identified, but there was no evidence that this information was communicated or documented as required. During interviews, medical records staff could only provide a single sheet from the resident's admission record, and the DON confirmed that the facility did not provide or maintain the required comprehensive admission documentation. This deficiency was identified through review of facility policy, resident records, admissions documentation, and staff interviews, and it was found to be out of compliance with state regulations regarding management, admission policy, and resident rights.
Failure to Complete Significant Change MDS Assessment After PEG Tube Placement
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for a resident who experienced a major change in condition. The resident was readmitted with diagnoses of hypertension, malnutrition, and depression, and had a percutaneous endoscopic gastrostomy (PEG) tube placed during a recent hospital stay. Documentation in the clinical record, including physician orders and care plans, indicated the initiation of enteral feeding and water flushes via the PEG tube, reflecting a substantial change in the resident's nutritional status and care needs. Despite these changes, a review of the resident's MDS assessments revealed that a significant change MDS was not completed to capture the new PEG tube and related care requirements. During staff interview, the Registered Nurse Assessment Coordinator (RNAC) confirmed that the significant change MDS was not completed, stating that the team discussed the situation and decided it was unnecessary. This omission was identified during the survey and was found to be out of compliance with regulatory requirements for timely and appropriate assessment following a significant change in a resident's condition.
Failure to Address Smoking Needs in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing all of a resident's needs, specifically regarding smoking. Upon admission, a resident with diagnoses including hypertension, hyperlipidemia, and a history of alcohol abuse was identified as a smoker who required supervision and the use of a smoke apron during smoke breaks, as documented in his smoke evaluation. However, the resident's care plan did not include any information about his smoking status or required precautions. During an observed smoke break, the resident was seen smoking outside with other residents and was not wearing a smoke apron as required. Facility staff confirmed that the care plan did not address the resident's smoking needs, resulting in noncompliance with regulatory requirements for comprehensive care planning.
Failure to Provide Appropriate Treatment and Care per Physician Orders
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents as required by physician orders and resident needs. For one resident with diagnoses including atrial fibrillation, breast neoplasm, and osteoarthritis, the hospital discharge record included a physician order for a pureed diet. However, the facility did not include this dietary order in the resident's clinical record until three days after admission, resulting in a delay in providing the prescribed diet. The Director of Nursing confirmed that the pureed diet order was not implemented in a timely manner. For another resident admitted with respiratory failure, immunodeficiency, and kidney transplant rejection, the hospital discharge summary indicated that a pain medication (Hydrocodone-Acetaminophen) was discontinued. Despite this, the facility obtained a new physician order for the same medication and administered it 19 times during the month. The Registered Nurse Supervisor confirmed that the medication should not have been ordered or administered, as it had been discontinued at the hospital. These findings were acknowledged by both the Director of Nursing and the Nursing Home Administrator.
Failure to Provide Hearing Assistive Devices and Care Planning for Hearing-Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident with hearing impairment had access to proper assistive devices to maintain adequate hearing. Review of facility policy indicated that staff are responsible for assisting hearing-impaired residents with communication, locating resources, scheduling appointments, arranging transportation, and maintaining or replacing hearing devices. However, for one resident with a history of tracheostomy, repeated falls, and GERD, the clinical record did not include a care plan or interventions addressing the resident's hearing impairment. During interviews, the resident was observed to be hard of hearing and reported not having her hearing aids. Staff confirmed that the resident's hearing aids were not present in the facility and were with the family. Communication with the resident required staff to stand in front of her and speak loudly. Both the RN Supervisor and the Director of Nursing confirmed that the resident was not care planned for hearing impairment and did not have access to necessary assistive devices, resulting in a failure to meet regulatory requirements.
Failure to Timely Implement Wound Care Recommendations
Penalty
Summary
The facility failed to ensure that a resident received timely and appropriate wound care services as recommended by the wound care provider. The resident, who had a history of cerebral infarction, hemiplegia, and incontinence, was identified as being at risk for pressure injuries. After a partial thickness sacral wound was resolved, the wound care provider recommended the continued use of Triad paste twice daily for skin protection. However, a review of the clinical record revealed that there was no active physician order for the barrier cream as recommended, and staff interviews confirmed that the order had not been implemented. Further, staff noted that the resident's buttock was excoriated and the resident reported discomfort, indicating ongoing skin issues. The wound care nurse practitioner stated that wound care recommendations should be implemented the next day if supplies are available, or the provider should be notified if not. The Director of Nursing confirmed that the facility did not ensure timely implementation of wound care recommendations for the resident, resulting in a failure to provide necessary services as required by facility policy and state regulations.
Lack of Physician Order Specifications for Indwelling Catheter
Penalty
Summary
The facility failed to obtain and document physician order specifications for the size and balloon inflation amount of an indwelling Foley catheter for one resident. The resident in question had diagnoses including obstructive uropathy, hypertension, and heart failure, and was noted to use an indwelling Foley catheter as per the Minimum Data Set assessment. While physician orders were present for catheter care, securing the catheter, and applying a drainage bag, there were no documented orders specifying the catheter size or the amount of balloon inflation required. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the clinical record lacked the necessary specifications for the indwelling catheter. The absence of these details was found during a review of the resident's clinical record and physician orders, which did not include the required information for one of three residents reviewed for catheter care.
Failure to Monitor and Document Fluid Intake and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident with end stage renal disease and heart failure received sufficient fluid intake in accordance with physician orders and care plan requirements. The resident was on a 1500 ml fluid restriction, with specific allocations for dietary and nursing shifts, and was to be weighed at the same time daily. However, the clinical record did not include documentation of the total amount of fluids consumed each shift, and there was no physician order to weigh the resident daily as required by the care plan. Observations revealed the resident had access to fluids beyond the prescribed restriction, and meal tickets indicated the provision of fluids not consistent with the restriction. The DON confirmed the lack of documentation and monitoring of fluid intake for this resident. Another resident, who had a history of high blood pressure, dementia, and end stage renal disease, experienced a significant unplanned weight loss of 14.46% in less than one month. The care plan required regular weighing at the same time each day and dietician evaluation for tube feed and flush recommendations. Despite this, the clinical record did not show evidence that the resident was reweighed to confirm the weight loss or that the dietician addressed the significant change. Interviews with facility staff, including the DON and registered dietician, confirmed that the expected protocol for reweighing and dietician consultation was not followed, and the dietician was unaware of the resident's weight loss. These deficiencies were confirmed by facility leadership, who acknowledged the failure to provide care and services necessary to maintain acceptable parameters of nutritional status for both residents. The facility did not ensure proper documentation, monitoring, and response to significant changes in residents' hydration and nutritional status, as required by facility policy and physician orders.
Failure to Provide Appropriate Care for Resident with PEG Tube
Penalty
Summary
The facility failed to ensure that a resident with a percutaneous endoscopic gastrostomy (PEG) tube received appropriate treatment and services to prevent potential complications. The resident was admitted with a PEG tube for nutritional support due to weight loss and failure to thrive, with physician orders specifying a gradual increase in tube feeding rate. However, the orders were not updated to reflect the current running rate, and there was no clear documentation of the actual rate being administered. The care plan directed staff to refer to physician orders for current feeding instructions, but these orders were unclear and did not specify parameters for tube feeding downtime to allow for oral intake, despite the resident also being on a regular, pureed diet. Observations revealed that the tube feeding pump was left unattended and alarming, with the delivery tubing disconnected and uncapped, resulting in formula dripping onto the floor. Staff interviews confirmed that the tubing was left uncapped and that the feeding rate was not clearly documented or communicated. The registered dietician and DON both acknowledged the lack of clarity in the orders and care plan, and the inability to determine the current feeding rate or appropriate downtime for oral intake. These actions and omissions resulted in the resident not receiving care consistent with physician orders, facility policy, or current standards of practice.
Failure to Implement Care Plan for IV Therapy
Penalty
Summary
The facility failed to implement a care plan for intravenous (IV) therapy for one of two residents reviewed. Specifically, a resident with diagnoses of high blood pressure, cellulitis of the left lower limb, and sepsis was admitted and had a physician's order for weekly sterile dressing changes to a peripherally inserted central catheter (PICC) line. Review of the resident's clinical record revealed that there was no care plan in place addressing the PICC line or IV therapy. This was confirmed during an interview with the Director of Nursing, and direct observation showed the resident had a PICC line in place without an associated care plan documented in the record.
Failure to Identify and Care Plan PTSD Triggers for Residents
Penalty
Summary
The facility failed to develop care plans that included identified triggers for residents diagnosed with Post-Traumatic Stress Disorder (PTSD), as required by their trauma-informed care policy. Specifically, three residents with PTSD did not have care plans that addressed their individual trauma triggers, which are necessary to prevent re-traumatization. For one resident, the care plan noted a history of traumatic events, including the loss of parents and sexual molestation, but did not identify or address specific triggers related to PTSD. Another resident's care plan referenced a traumatic, life-threatening illness but similarly lacked documentation of PTSD-related triggers. The third resident with a PTSD diagnosis also did not have a care plan that included a focus on or triggers related to PTSD. Staff interviews, including those with the Social Service employee and the Director of Nursing, confirmed that the care plans for these residents did not include the required identification of behavioral triggers associated with PTSD. The facility's policy indicated that all staff receive in-service training on trauma and trauma-informed care, emphasizing the importance of identifying and decreasing exposure to triggers. Despite this, the care plans reviewed did not meet these requirements for the sampled residents, as confirmed by staff during the survey.
Failure to Timely Act on Pharmacy Medication Recommendations
Penalty
Summary
A deficiency was identified when facility staff failed to act on pharmacy medication recommendations in a timely manner for one resident. The facility's policy requires that a licensed pharmacist perform a monthly drug regimen review (MRR) and that staff act upon all recommendations according to established procedures. For the resident in question, who had diagnoses including PTSD, chronic kidney disease, and a history of repeated falls, the pharmacist's MRR on 1/10/25 requested clarification regarding the frequency of administration for an as-needed Melatonin order, as the original order did not specify how often the medication should be given. Although the physician signed the MRR recommendation on 1/15/25, indicating that the frequency should be added, the Melatonin order remained unmodified and still lacked the required frequency of administration as of the review date. This failure to update the medication order as recommended by the pharmacist was confirmed during an interview with facility leadership, demonstrating noncompliance with the facility's own medication regimen review policy.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two cases involving missed or incorrect medication administration. For one resident with diagnoses including Influenza A, hypoxemia, and sleep apnea, a physician order required Tamiflu to be administered on specific days. However, the medication was not available from the pharmacy, and the order was discontinued without the resident receiving the prescribed doses. This was confirmed by the Director of Nursing and the Nursing Home Administrator. In another case, a resident with respiratory failure, immunodeficiency, and kidney transplant rejection was ordered to receive 125 mg of cyclosporine every 12 hours following hospital discharge. Instead, the facility administered 100 mg of cyclosporine twice daily for 14 days, due to an error in order entry upon admission. This discrepancy was confirmed by the RN Supervisor and facility leadership, who acknowledged that the resident did not receive the medication as ordered during the specified period.
Improper Storage of Medications and Biologicals
Penalty
Summary
Surveyors identified that the facility failed to properly store medical supplies and biologicals in both a medication cart and a medication room on the 4th floor. During observations, the 4th floor North medication cart was found to contain a tube of zinc oxide, a box of lidocaine patches, a tube of skin protectant, and a 60 cc flush piston with an expired date. In the 4th floor medication room, there were four opened wound vac kits, a box of opened gloves, an air compressor, a bag of depends, and a bag containing a can of coffee stored under the sink. The medication room refrigerator contained bags of vancomycin labeled with specific 'do not use beyond' dates, a tubersol vial that was opened but not dated, and insulin pens (Novolog and Lantus) that were not stored in bags. Staff interviews confirmed these findings, with both an LPN and the Director of Nursing acknowledging the improper storage of medical supplies and biologicals. Facility policies require that all drugs and biologicals be stored in a safe, secure, and orderly manner, and that multi-dose containers be dated when opened. The observed deficiencies were in direct violation of these policies and relevant state codes regarding nursing and pharmacy services, as well as resident care policies.
Failure to Provide Meal According to Resident Preference
Penalty
Summary
The facility failed to provide menu selections according to a resident's documented preference. During meal tray observations, a resident who was supposed to receive a double portion of protein, as indicated on their lunch ticket, was instead served only a single portion. The resident confirmed that the double portion was missing from their meal. This was identified during a review of the facility's food and nutritional services policy, which states that reasonable efforts will be made to accommodate residents' choices and preferences, as well as through direct observation and interviews with the resident and staff.
Failure to Serve Breakfast at Scheduled Time
Penalty
Summary
The facility failed to serve breakfast at the regularly scheduled time as required by its own policy and posted meal times. According to the facility's food and nutritional services policy, meals are to be provided within 45 minutes of the scheduled meal time, with breakfast scheduled to arrive at 7:30 a.m. On the day of observation, breakfast tray carts were seen on the second floor at 8:54 a.m., and the DON confirmed that the trays had arrived 15 minutes prior, indicating a significant delay. Additionally, a resident reported that food often arrives cold because it sits upstairs for an hour before being distributed. These findings demonstrate that the facility did not ensure timely meal service for breakfast on the observed date.
Failure to Schedule and Document Timely Outside Professional Services
Penalty
Summary
The facility failed to ensure timely scheduling and documentation of outside professional services for two residents. One resident, who had a tracheostomy and a history of repeated falls and GERD, was scheduled for a tracheostomy evaluation. Although the resident attended the initial appointment, the facility did not document awareness of the follow-up appointment that was scheduled by the otolaryngology provider. This lack of documentation indicated a failure to coordinate and track necessary outside services as ordered by the physician. Another resident, admitted with diagnoses including respiratory failure, immunodeficiency, and kidney transplant rejection, was discharged from the hospital with instructions to follow up with the transplant surgery office within three weeks. The facility did not schedule this follow-up appointment, and there was no evidence in the clinical record or physician orders that the appointment was made. Staff interviews confirmed that the required outside appointments were not scheduled in a timely manner for both residents.
Failure to Correct Repeated Quality Deficiencies by QAPI Committee
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct previously identified quality deficiencies and did not ensure that plans to improve care and services effectively addressed these issues. Documentation and survey results showed that deficiencies cited in a prior state survey were not resolved, and some deficiencies were repeated in the current survey, including those related to F600 and F695. The Nursing Home Administrator confirmed that the facility had both previous and current deficiencies, indicating that the QAPI committee did not successfully implement or sustain corrective actions to maintain compliance with nursing home regulations.
Failure to Identify and Supervise Elopement Risk
Penalty
Summary
The facility failed to ensure adequate supervision and identification of a resident at risk for elopement, resulting in an elopement incident. The resident, who had a history of substance abuse and a cerebral infarction, was admitted to the facility and initially assessed as not being at risk for elopement. However, subsequent assessments indicated that the resident exhibited behaviors consistent with elopement risk, such as wandering and expressing a desire to leave the facility. Despite these indicators, the facility did not update the resident's care plan to address the elopement risk. On the day of the incident, the resident was observed displaying exit-seeking behavior, expressing a need to inform family members of their whereabouts, although no family contact information was available in the resident's records. The resident was last seen in the common area before being observed leaving the facility with a dietary aide during a smoke break. The facility's staff, including the medical records employee and the RN supervisor, failed to recognize the resident as a potential elopement risk, and the resident was able to leave the premises without being stopped. The facility's elopement protocol was not effectively implemented, as evidenced by the lack of a comprehensive assessment and care plan for the resident's elopement risk. The facility did not have an alarm system for the doors, and staff were not adequately trained to identify and respond to exit-seeking behaviors. The failure to identify the resident as an elopement risk and provide appropriate supervision led to the resident's unauthorized leave of absence, creating an immediate jeopardy situation.
Plan Of Correction
1. Resident R1 is no longer a resident at the facility but was located post elopement by the housing director of the YMCA where the resident had lived prior to hospitalization. Resident is safe according to his friends in the northside area where he has been a lifelong resident. This was verified by the Administrator on 12 March 2025. 2. All residents will be assessed for elopement risk by the Director of Nursing or designee by the end of the day on 13 March 2025. All care plans for residents identified with elopement risks will be reviewed and updated with interventions to prevent elopement by the end of the day on 13 March 2025 by the Director of Nursing or designee. Residents admitted within the last 30 days and who are currently in-house will be added to the Elopement Binder by the Administrator or designee by 13 March 2025. 3. The elopement assessment tool will be updated by the Director of Nursing or designee by 13 March 2025. Education will be completed by all staff on Elopement Risks, Assessments, Care Plans, and Supervision of Residents by the Director of Nursing or designee by 13 March 2025. Policies and/or procedures will be updated to identify residents who are at risk for eloping by the Administrator or designee by 13 March 2025. Elopement Books with identified resident photos will be placed on all nurses stations in addition to the current one at the receptionist's desk by the Administrator or designee by 13 March 2025. A new process will be implemented by the Administrator or designee to ensure that Residents sign out of the facility when going on an LOA. This process will have the Registered Nurse (RN) Supervisor or designated nurse (RN or LPN) complete an LOA Approval Form which is to be given to the Receptionist before the receptionist can allow the resident to exit the facility by 13 March 2025. The Directed Inservice for F-689, entitled Accident Prevention and Supervision will be conducted by Affinity Health Services on April 4, 2025. 4. Audits will be implemented by the Nursing Home Administrator or designee for LOA Sign Out compliance weekly for 3 weeks and then monthly for 2 months. Audits will be implemented weekly for 3 weeks and then monthly for 2 months to monitor that the elopement assessments have been completed at admission, quarterly, and with changes in conditions. An Ad Hoc Quality Assurance and Process Improvement Meeting will be held by the Administrator or designee by the 13 March 2025. This plan of correction will be monitored at the Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met. 5. How the corrective actions(s) will be monitored to ensure the practice will not recur: - Audits will be implemented by 3/13/25, for LOA sign out compliance weekly for 4 weeks, then monthly for two months. - An Ad Hoc Quality Assurance and Process Improvement Meeting will be held by the NHA or designee by 3/13/25. - This plan of correction will be monitored at the QAPI meeting until such time is consistent substantial compliance has been met. On 3/13/25, at 12:43 p.m. it was confirmed 78/78 Residents were reassessed for an elopement risk. 13/78 Residents were identified as a risk, and 13/13.
Removal Plan
- All residents will be assessed for elopement risk by the Director of Nursing or designee.
- All care plans for residents identified with elopement risks will be reviewed and updated with interventions to prevent elopement by the DON or designee.
- Residents admitted within the last 30 days and who are currently in-house will be added to the Elopement Binder by the NHA or designee.
- The elopement assessment tool will be updated by the Director of Nursing or Designee.
- Education will be completed by all staff on Elopement Risks, Assessments, Care Plans, and Supervision of residents by the DON or designee.
- Policies and/or procedures will be updated to identify residents who are at risk for eloping by the NHA or designee.
- Elopement Books with identified resident photos will be placed on all nurses' stations in addition to the current one at the receptionist's desk by the NHA or designee.
- A new process will be implemented by the NHA or designees to ensure that residents sign out of the facility when going on a leave of absences (LOA).
Failure to Prevent Resident Elopement
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility, resulting in the elopement of a resident, identified as Resident R1. This incident created an immediate jeopardy situation for one of the five residents reviewed. The job descriptions for both the NHA and the DON clearly outline their responsibilities to manage the facility in accordance with federal, state, and local standards, and to ensure the highest degree of quality care is provided to residents at all times. However, their failure to prevent the elopement indicates a lapse in fulfilling these essential duties. During an interview conducted on February 11, 2025, at 1:13 p.m., both the NHA and the DON were informed of their failure to manage the facility effectively, which led to the elopement incident. The report cites specific Pennsylvania Code regulations that were not adhered to, highlighting the responsibility of the licensee and the management to ensure proper nursing services and overall facility management. The deficiency was identified as an immediate jeopardy situation, indicating a serious breach in the facility's duty to protect its residents.
Plan Of Correction
F-835 Administration 1. The elopement assessment was rewritten by the Regional Clinical Director and Director of Nursing on March 13, 2025. The resident elopement books were updated by the Administrator and Director of Nursing on March 13, 2025. The Resident LOA Policy was updated on March 13, 2025, to include a system requiring the orders are reviewed before allowing the residents to leave the facility. 2. A Root Cause Analysis was completed by the Administrator on March 13, 2025, which identified four risk factors for future elopements. 3. An audit will be completed on each new admission by the Administrator or designee to assess each resident against the four risk factors identified in the Root Cause Analysis. These audits will be completed weekly for 3 weeks then monthly for 2 months. An audit will be completed by the Director of Nurses or designee to ensure that the elopement assessments have been completed for new admissions, readmissions, quarterly, and change of condition. The audits will be completed weekly to ensure the LOA policy change is being properly implemented. This will be completed weekly for 3 weeks then monthly for 2 months. 4. A summary of the audits will be reviewed in the monthly QAPI meeting. The Regional Director of Operations and the Regional Clinical Director will meet with the Administrator and Director of Nursing to review the audit results and discuss any new issues that may impact safety in the facility. These meetings will take place weekly for 3 weeks and then monthly for 2 weeks.
Failure to Designate a Physician as Medical Director
Penalty
Summary
The facility failed to designate a physician to serve as the medical director, as required by regulations. The review of the facility's medical director contract, dated December 1, 2023, indicated that a medical group was to provide medical directorship and oversight services, assigning 'physicians' to provide such services. However, information submitted to the Department of Health on March 12, 2025, revealed that Employee E16 was listed as the designated Medical Director since January 1, 2020. Interviews with staff, including the Regional Clinical Specialist and the current Medical Director, Employee E15, indicated that she took over the role in August 2024 and that the medical group was considered the medical director. The Director of Nursing confirmed the facility's failure to designate a specific physician as the medical director.
Plan Of Correction
F-841 Responsibilities of Medical Director 1. A specific Medical Director will be assigned to the facility by the Administrator or designee. 2. There are no other like individuals in this position in this facility to review. 3. The Medical Director will be educated by the Administrator or designee on regulation F-841. 4. The Director of Nursing and/or the Administrator will review facility clinical and operational areas weekly for 3 weeks and monthly for 2 months. A summary of these meetings will be reviewed in the monthly QAPI meetings for 2 months.
Incomplete Investigation of Resident Elopement
Penalty
Summary
Burgh Care Center was found non-compliant with federal and state regulations due to a failure to fully investigate an incident involving a resident's unauthorized leave of absence. The facility's policy required all incidents to be thoroughly investigated and reported, including witness accounts. However, the investigation into the incident involving a resident who left the facility without authorization was incomplete. The resident, who had a history of opioid, alcohol, and psychoactive substance abuse, as well as a cerebral infarction, left the facility dressed in street clothes and was last seen heading towards a bus stop. Despite the facility's efforts to locate the resident, including searching the area and contacting a previous residence, the investigation did not include statements from all relevant witnesses, such as another resident and staff members who observed the incident. The Director of Nursing confirmed that the facility did not fully investigate the incident to rule out neglect. The report highlights that the facility failed to obtain witness statements from key individuals, including a dietary aide and a registered nurse supervisor, who were present during the incident. Additionally, the elopement risk screening tool used by the facility relied solely on nursing judgment, which may have contributed to the oversight. This lack of thorough investigation and documentation was a significant factor in the facility's non-compliance with the requirements for investigating and preventing potential abuse or neglect.
Plan Of Correction
Burgh Care Center acknowledges receipt of the Statement of Deficiencies and proposes this Plan of Correction to the extent that the summary of findings is factually correct and to maintain compliance with applicable rules and provisions of quality of care of residents. The Plan of Correction is submitted as a written allegation of compliance. Burgh Care Center's response to this Statement of Deficiencies does not denote agreement with the Statement of Deficiencies nor does it constitute an admission that any deficiency is accurate. Further, Burgh Care Center reserves the right to refute any of the deficiencies on this Statement of Deficiencies through Informal Dispute Resolution, formal appeal procedure and/or any other administrative or legal proceeding. F- 610 Investigate/Prevent/Correct Alleged Violation 1. Elopement Procedure was implemented by the Director of Nursing to search for the resident on 2/25/25. Event Report submitted to DOH by the Administrator on 2-26-25. Physician, Police, and Area Agency on Aging were notified by the Administrator on 2/25/25. Statements were gathered from the staff and residents by the Administrator on 2/25/25 and 2/26/25. The Elopement Book was updated by the Director of Nurses by 2/25/25. A Root Cause Analysis was completed by the Administrator on 2/26/25. Elopement Drills were conducted on each shift by the Human Resources Director by 2/28/25. The staff was educated on the Elopement Policy and Procedure by the Human Resources Director started on 2/25/25. The elopement assessment was rewritten by the Regional Clinical Director and Director of Nursing on March 13, 2025. The Resident LOA Policy was updated on March 13, 2025, by the Administrator to include a system requiring the orders are reviewed before allowing the residents to leave the facility. An Ad Hoc QAPI Meeting was held by the Administrator on 2/25/25. 2. A revised elopement Assessment was completed on each resident by the Director of Nursing and Assistant Director of Nursing on 3/13/25. 3. The Resident LOA Policy was updated on March 13, 2025, to include a system requiring that the orders are reviewed before allowing the residents to leave the facility. An audit will be completed on each new admission by the Administrator or designee to assess each resident against the four risk factors identified in the Root Cause Analysis. These audits will be completed weekly for 3 weeks then monthly for 2 months. An audit will be completed by the Director of Nurses or designee to ensure that the elopement assessments have been completed for new admissions, readmissions, quarterly, and change of condition. These audits will be completed weekly for 3 weeks then monthly for 2 months. Audits will be completed by the Administrator or designee to ensure the LOA policy change is being properly implemented. This will be completed weekly for 3 weeks then monthly for 2 months. 4. A summary of the audits will be reviewed in the monthly QAPI meeting for 2 months.
Failure in Discharge Planning for a Resident
Penalty
Summary
The facility failed to provide adequate discharge planning for a resident, identified as Resident R1, who was admitted with diagnoses including opioid abuse, alcohol abuse, other psychoactive substance abuse, and cerebral infarction. The resident was cognitively intact as per a Brief Interview for Mental Status assessment. However, on a specific date, Resident R1 left the facility without authorization, and the facility did not have a discharge order from the physician for this resident. The facility's policy on discharging residents requires consultation with the resident about the discharge process, assessment and documentation of the resident's condition, and preparation of necessary equipment and supplies. However, these steps were not followed for Resident R1, as evidenced by the lack of documentation regarding the resident's discharge needs and the absence of a physician's order for discharge. Additionally, the facility did not have information on the resident's whereabouts after the unauthorized leave of absence. Interviews with staff revealed that the discharge Minimum Data Set (MDS) assessment was completed after the resident's elopement, with the assumption that the resident would not return. The Director of Nursing confirmed that the facility failed to complete a timely and safe discharge for Resident R1, indicating a lapse in the discharge planning process as required by regulations.
Plan Of Correction
F-660 Discharge Planning 1. A discharge order was obtained for R1. 2. Resident discharges will be reviewed at the next Clinical Meeting to ensure compliance with the discharge process. 3. The IDT Team will be educated on the discharge policy and procedure to include all items needed for discharge. The Director of Nursing or designee will audit all discharges weekly for 2 weeks and then monthly for 2 months to ensure discharges are completed per policy. 4. A summary of the results of the audits will be reviewed by the Director of Nursing or designee in the Monthly QAPI meeting for 2 months.
Failure to Ensure Physician Conducted Initial Visit
Penalty
Summary
The facility failed to ensure that a physician completed the initial visit for a resident, identified as Resident R2, as required by federal regulations. According to the clinical records, Resident R2 was admitted to the facility with diagnoses of anemia, bacteremia, and heart failure. The initial visit was conducted by a Certified Registered Nurse Practitioner (CRNP), Employee E17, instead of a physician, which is a violation of the regulation that mandates a physician must personally conduct the initial visit. Further review of Resident R2's clinical record showed that a history and physical visit was completed by Medical Doctor, Employee E15, but it was noted that the resident was not seen and was still in the hospital at that time. During interviews, both the Medical Doctor, Employee E15, and the Director of Nursing confirmed the failure to have a physician complete the initial visit. The Medical Doctor also expressed a misunderstanding of the regulation requirements.
Plan Of Correction
F-712 Physician Visits - Frequency/ Timeliness/ Alt NP 1. The cited areas cannot be corrected. 2. An audit of new admissions will be conducted by the Administrator or designee for the past 30 days to determine compliance with the regulation. 3. The Medical Director, attending physician, and nurse practitioners will be educated on regulation F-712 by the Director of Nursing or designee. 4. Audits will be completed by the Administrator or designee for the completion of the Comprehensive Visits by the physician within 10 days on all new admissions weekly for 3 weeks and then monthly for 2 months. A summary of the audits will be reviewed in the monthly QAPI for 2 months by the Administrator or designee.
Failure to Timely Report Resident Elopement
Penalty
Summary
The facility failed to notify the State Survey Agency of an incident of elopement within the required two-hour timeframe. This deficiency was identified through a review of clinical records, incident reports, and staff interviews. The incident involved a resident who left the facility without authorization. The resident, who had a history of opioid abuse, alcohol abuse, psychoactive substance abuse, and cerebral infarction, was observed leaving the facility and heading towards a bus stop. Despite efforts by staff to locate the resident, including searching the area and attempting to contact the resident via a listed phone number, the resident was not found. The facility's policy on investigating and reporting accidents and incidents requires that all incidents involving residents be reported to the administrator. However, the facility did not complete an incident report or notify the State Survey Agency within the required timeframe. This lapse was confirmed by the Regional Clinical Specialist, who acknowledged the failure to report the elopement incident involving the resident.
Plan Of Correction
0008 Notification 1. The required notification time period for this incident cannot be corrected. 2. Department of Health Event Reports for the past 30 days will be audited by the Administrator or designee against the required reporting time periods to determine the level of compliance. 3. The Administrator and Director of Nurses will be educated on regulation H-0008 by the Regional Clinical Specialist or designee. The Department of Health Event Reports will be audited for compliance with the correct time periods daily for 3 weeks and then monthly for 2 months. 4. Audits will be reviewed in the monthly QAPI meetings for 2 months.
Failure to Provide Written Notice of Rights and Services
Penalty
Summary
The facility failed to provide two residents with a written notice of their rights, services, and the rules and regulations governing their conduct and responsibilities during their stay. This deficiency was identified through a review of the facility's admission packet and resident records. The admission packet included various documents such as the application for admission, legal representation, and notice of privacy practices, among others. However, for Resident R2, there was no signed admission agreement or authorization to treat until several months after admission. Similarly, Resident R3's record lacked a signed admission agreement or authorization to treat. The Nursing Home Administrator confirmed this oversight during an interview, acknowledging the facility's failure to comply with the requirement to provide these documents prior to or upon admission.
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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