Carlisle Skilled Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Carlisle, Pennsylvania.
- Location
- 940 Walnut Bottom Road, Carlisle, Pennsylvania 17013
- CMS Provider Number
- 395746
- Inspections on file
- 33
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 27 (2 serious)
Citation history
Health deficiencies cited at Carlisle Skilled Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents experienced deficiencies in care when staff failed to complete ordered weekly skin checks for one resident with complex medical conditions and did not perform timely, comprehensive assessment and monitoring for another resident with dementia and metastatic cancer who had worsening abnormal labs and increasing lethargy. For the first resident, multiple weekly skin checks were marked as not done on the MAR with no supporting progress notes, despite care-plan directives to monitor and report skin changes. For the second resident, abnormal and worsening sodium, chloride, osmolality, potassium, and calcium levels were not adequately addressed, an ordered potassium dose was not documented as given, and when the resident became unresponsive, nursing staff did not document a full assessment, omitted critical lab and treatment information on the SBAR, delayed calling 911 after the physician ordered transfer, and did not remain with the resident, leaving EMS to find the resident alone, in shallow respirations, and without a clear report or code status.
The facility failed to ensure that dental services and dentist recommendations were provided and implemented for three residents. One resident with dementia and progressive multiple sclerosis had a dental consult recommending a special fluoride gel and an oral surgeon referral, but no corresponding physician orders or nursing review were found. Another resident with vascular dementia and muscle weakness lost upper and lower dentures; although Step 1 of denture replacement was documented and a follow-up was scheduled, no further dental notes appeared in the record despite repeated inquiries from the resident’s representative, and the DON confirmed the dentist had not seen the resident again. A third resident with a neurocognitive disorder and heart failure had a periodic oral exam with a prophylaxis visit scheduled, but no subsequent dental documentation existed, indicating that planned routine dental care was not completed or recorded.
A resident with anxiety and depression did not receive scheduled doses of Lorazepam due to a lapse in obtaining a new prescription, resulting in missed medication administration. Documentation was lacking for the missed doses, and the pharmacy did not dispense the refill because the required prescription was not provided in time.
Several residents with dysphagia were served vegetables in a form that did not meet their prescribed diet texture, as kitchen staff provided sliced carrots instead of the required chopped form. This failure to follow physician orders and facility policy was confirmed by dietary and clinical staff, and placed additional residents with similar dietary needs at high risk, resulting in Immediate Jeopardy.
Staff failed to implement suicide precautions for a resident who expressed suicidal ideation, resulting in the resident being left unsupervised and able to self-harm. Additionally, the facility did not conduct thorough fall investigations for another resident with a history of falls, as required by policy.
The facility did not notify the Office of the State LTC Ombudsman about several resident hospital transfers, as required. Multiple residents with complex medical conditions were transferred to the hospital, but documentation and staff interviews confirmed that notifications were not made at the time of transfer.
Surveyors identified that several resident assessments did not accurately reflect the clinical status of four residents, including errors in documenting medication administration, pressure ulcer status, PASRR determinations, and attempts at gradual dose reduction for psychotropic medications. These discrepancies were confirmed through record reviews and staff interviews, with the DON acknowledging the MDS coding errors.
Surveyors identified that several residents did not receive care and services as ordered, including missed laboratory tests, incomplete wound care documentation, administration of medication above recommended dosages, missed insulin doses on dialysis days, delayed response to bleeding in a resident with hemophilia, and undocumented wound treatments. The DON confirmed these deficiencies and was unable to provide explanations for several missed or undocumented interventions.
Two residents with pressure ulcers or at risk for skin breakdown did not receive care consistent with professional standards, as recommended interventions such as pressure off-loading boots were not ordered by a physician, not included in care plans, and not documented as being used, despite wound team recommendations and observations showing the devices were not consistently applied.
The facility did not complete required annual performance reviews for five employees, as confirmed by the Nursing Home Administrator during document review and staff interviews.
Surveyors found that expired Novolog insulin and Afluria influenza vaccine vials were not discarded as required by facility policy and manufacturer guidelines. The DON and Nursing Home Administrator confirmed that medications should be stored and discarded according to policy, but expired medications were observed in both a medication cart and a medication room.
The facility did not ensure its main kitchen dish machine consistently reached the manufacturer-required minimum wash temperature of 160°F, as logs and direct observation showed repeated operation below this standard over several months. Staff were under the mistaken belief that a lower temperature was acceptable, leading to ongoing noncompliance with food service safety standards.
The facility did not consistently review or update care plans to reflect residents' current needs, failed to document care plan meetings, and did not ensure that residents or their representatives were invited to participate. Several residents with complex medical conditions lacked updated care plans or evidence of care plan meetings, and staff interviews confirmed these deficiencies.
A resident admitted with a fracture and scalp laceration did not have a baseline care plan developed within 48 hours that addressed all assessed needs, including urinary incontinence and pain management preferences. Additionally, neither the resident nor their representative received a summary of the baseline care plan as required by facility policy.
A resident with muscle weakness, obesity, and a chronic foot ulcer did not consistently receive scheduled bathing assistance as required by her care plan and facility policy. Documentation showed missed or unrecorded showers, and the resident reported not always receiving showers. Facility leadership confirmed expectations for care and documentation were not met.
A resident with chronic kidney disease and hypothyroidism experienced hearing difficulties and requested medical attention. Although a practitioner ordered an audiology referral for hearing loss, the resident was not placed on the audiology list as required, resulting in a delay in evaluation.
Two residents with limited ROM did not receive or have documentation of restorative nursing care as required by their care plans and therapy recommendations. For one, passive ROM interventions were not documented due to a system error, and for the other, tasks related to palm guards and ROM were not properly entered or documented. The DON confirmed these lapses in both implementation and documentation.
Three residents experienced deficiencies in pain management, including missed doses of prescribed pain medication due to unavailability, lack of timely reordering, and failure to use emergency supplies. One resident's care plan lacked a comprehensive approach and did not include non-pharmacological interventions as ordered. Another resident's pain goals were not specified, and refusals of topical pain patches were not documented or communicated to the physician. Ongoing reports of severe pain were not promptly addressed or followed up by nursing staff.
A resident with anxiety disorder and dysphagia experienced difficulty eating due to ill-fitting new dentures. Despite insurance approval for new dentures, no follow-up dental appointment was scheduled, resulting in a delay in necessary dental care.
Staff failed to follow infection control protocols during medication administration, including handling oral medications with contaminated gloves and not cleansing the rubber seal of an insulin pen before attaching a new needle. The DON confirmed these lapses in infection control procedures.
The facility did not provide enough nursing staff on one unit, leading to multiple residents reporting long wait times for call bell responses. Grievances and Resident Council Meeting minutes confirmed ongoing concerns about delayed assistance, and direct observation showed call bells going unanswered for over 25 minutes.
The facility consistently failed to meet the required nurse aide (NA) staffing ratios across multiple shifts and days. On several occasions, the NA ratios were below the mandated levels for day, evening, and night shifts, with specific deficiencies noted on January 5, 6, 10, and 11, 2025. This indicates a pattern of inadequate staffing to meet the needs of the residents.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident per day for four days due to staff call-offs related to illnesses and weather. The Nursing Home Administrator confirmed the shortfall in care hours.
The facility failed to maintain resident dignity by improperly storing incontinent briefs in public view on nightstands for several residents with cognitive impairments. Observations over multiple days confirmed this practice, and staff interviews revealed a lack of specific policy on brief storage. The residents involved were unable to express preferences, highlighting a violation of their rights to dignity and respect.
The facility failed to notify residents, their representatives, and the Ombudsman of hospital transfers for eight residents with conditions like dementia and heart failure. Documentation was lacking for these notifications, as confirmed by staff interviews.
The facility failed to provide bed hold policy notices to residents or their representatives upon hospital transfer, affecting several residents with conditions like dementia and heart failure. The policy requires staff to deliver and document the notice, but interviews confirmed the absence of such documentation. The facility acknowledged the issue and was working on improving the process.
The facility failed to ensure accurate resident assessments, affecting six residents. Discrepancies were found in the documentation of physical impairments, medication administration, and discharge locations. These inaccuracies highlight a pattern of documentation errors in resident assessments.
The facility failed to update care plans for several residents, including one with a gastrostomy tube and another with a foley catheter, both requiring Enhanced Barrier Precautions (EBP) that were not documented. Another resident with trigeminal neuralgia lacked a pain management plan, and a resident with a PICC line had no related interventions in their care plan. The DON confirmed these care plans were not revised timely.
A resident with limited mobility and a history of joint replacement surgery was not provided with the recommended restorative nursing program. Despite a physical therapy discharge summary advising the use of an assistive device and participation in a restorative program, the resident's care plan lacked documentation of such a program. The DON confirmed the absence of implementation during an interview.
The facility failed to provide proper respiratory care for three residents, including undated oxygen tubing and uncleaned equipment. A resident with respiratory failure had outdated tubing, while another with COPD had no orders for tubing changes and lacked documentation of oxygen use. A third resident's oxygen concentrator filter was not cleaned as required.
The facility failed to act on pharmacy recommendations for several residents, leading to deficiencies in medication management. A pharmacist's recommendation for a diclofenac gel order update was delayed for a resident, while another resident's gradual dose reduction for zolpidem and olanzapine was not documented. Additionally, a resident's ibuprofen order was not discontinued timely, and a pharmacy recommendation for another resident was not addressed. A physician declined a dose reduction for a resident's risperidone without proper rationale.
The facility failed to ensure that two residents' medication regimens were free of unnecessary psychotropic medications. One resident was on multiple psychotropic drugs without evidence of gradual dose reduction or review, while another was prescribed antipsychotics without monitoring target behaviors or including them in the care plan. Interviews confirmed the lack of documentation and monitoring, leading to deficiency findings.
The facility failed to date opened medications in two medication carts, contrary to its policy. Observations revealed that several open stock bottles, including stool softener and aspirin, lacked open dates. Staff interviews indicated a lack of awareness about this requirement, despite the facility's expectation to date opened medications.
The facility failed to store food and utilize equipment according to professional standards, with multiple instances of improperly labeled or unlabeled food items and missing temperature logs for refrigeration equipment. Many food items were past their 'use by' dates or lacked proper sealing, and there were numerous missing entries in temperature logs across different pantry areas.
The facility failed to document education on the benefits and side effects of pneumococcal and influenza vaccinations for several residents. A resident with chronic kidney disease and bladder cancer refused both vaccinations without documented education. Another resident with heart failure and COPD had no updated pneumococcal vaccination record since 2016. A third resident requested a pneumococcal vaccination, but its administration was not documented. Lastly, a resident with Parkinson's disease refused the pneumococcal vaccination without documented education. The DON acknowledged the documentation gaps.
The facility failed to document COVID-19 vaccine education for three residents, leading to a deficiency. A resident with chronic kidney disease and bladder cancer refused the vaccine without documented education. Another resident with heart failure and COPD had no record of being offered a booster or educated on the vaccine after their last booster. A third resident with Parkinson's and thyroid cancer also lacked documentation of being offered a booster or educated after their last dose. The DON confirmed the absence of additional information to address these concerns.
The facility failed to maintain a safe and homelike environment in the East Lounge by improperly storing a large number of empty wheelchairs and specialty chairs, which obstructed residents' access to activities. A resident had to move a wheelchair to access a puzzle table, highlighting the issue. The NHA and DON acknowledged the improper storage during the survey.
A resident reported an allegation of physical abuse, and although the facility initiated an investigation immediately, they failed to report the incident to the appropriate authorities within the required 24-hour period. The delay in reporting was confirmed by the NHA and DON, indicating non-compliance with the facility's policy and state regulations.
A resident with end stage renal disease and acute respiratory failure was admitted without a baseline care plan documenting hemodialysis needs. The facility's failure to include hemodialysis care in the plan was confirmed by the Nursing Home Administrator and DON.
The facility failed to ensure comprehensive care plans accurately reflected the needs of two residents. One resident's care plan did not include the use of prescribed antipsychotic medications, while another resident's plan lacked identified PTSD triggers, despite these being assessed at admission. These deficiencies were confirmed through staff interviews with the DON and the Nursing Home Administrator.
A resident with vascular dementia and other conditions had medications improperly stored at their bedside without necessary orders or approvals, contrary to facility policy. The DON confirmed that these prescribed medications should not have been kept at the bedside.
The facility failed to provide proper treatment orders for two residents. One resident with a PICC line lacked orders for site monitoring and DNR instructions, while another resident undergoing dialysis had no orders for treatment or access site care. The DON confirmed the absence of these necessary orders.
The facility failed to ensure proper catheter care for two residents, leading to potential risks of urinary tract infections. A resident with bladder cancer was observed with a catheter drainage bag on the floor, while another resident's catheter tubing was found touching the floor. The DON confirmed these practices were against facility policy.
A resident with CHF, CKD, and hypertension had a fluid restriction order of 1800 ml per day, but the facility failed to monitor and manage this effectively. Observations showed the resident had access to fluids exceeding the prescribed limits, and staff followed outdated guidelines. The dietary department provided incorrect fluid amounts, and the resident was unsure about the restriction details. The DON was informed, and the resident expressed a desire not to comply with the restriction.
The facility failed to maintain safe and appetizing food temperatures during a meal on the Arcadia unit. Observations revealed that milk, Salisbury steak, mashed potatoes, and vegetables were served at temperatures outside the facility's guidelines. The Dietary Manager acknowledged the issue, and the NHA confirmed the expectation for appropriate food temperatures.
A resident with a history of atrial fibrillation, CHF, and COPD experienced an unwitnessed fall, resulting in a wrist fracture. The facility failed to conduct neurovascular assessments and manage the resident's pain effectively. Despite the resident's requests and visible pain, there was a significant delay in transferring her to the hospital for appropriate treatment.
Failure to Complete Skin Checks and Inadequate Response to Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to complete ordered and care-planned skin assessments for one resident and failure to provide timely, comprehensive assessment and response to a change in condition for another resident. For the first resident, who had multiple sclerosis, diabetes mellitus, dementia, and zoster encephalitis, the care plan included interventions to observe skin for abnormalities and report changes in skin integrity to the Nurse Practitioner, with these interventions initiated in 2019. The January 2026 Medication Administration Record documented that weekly skin checks were not completed on four separate dates, and there were no corresponding progress notes regarding these missed skin checks. A regional clinical support staff member confirmed that the weekly skin check should have been completed for this resident. For the second resident, who had Alzheimer’s disease, thyroid cancer, and metastatic cancer of the liver, colon, and lymph nodes, the facility did not provide timely and comprehensive care and services after a documented change in condition. Laboratory results showed abnormal and worsening values for sodium, chloride, calculated osmolality, potassium, and calcium over several days, consistent with dehydration and electrolyte disturbances. The Nurse Practitioner documented lethargy and non-responsiveness to verbal stimuli and ordered IV D5W for hypernatremia/dehydration and a one-time dose of potassium chloride 40 mEq on two separate dates. The March Medication Administration Record did not show that the ordered potassium dose was administered, and the Director of Nursing’s later assertion that the potassium was placed on hold by the Nurse Practitioner was not supported by any documentation. On the day of acute decline, nursing documentation noted lethargy, refusal of meals with minimal fluid intake, and later an acute visit by the physician who found the resident unresponsive and ordered transfer to the emergency room. An SBAR completed by the RN supervisor documented fever and unresponsiveness as the change in condition, with limited vital signs and no repeat vitals after the change in condition except for blood pressure. The SBAR omitted the abnormal laboratory results, new medications, and IV fluids, and indicated that respiratory and neurological assessments were not clinically applicable, despite the resident’s altered responsiveness. There was no nursing assessment documented of the resident’s condition after the change in status. EMS records indicated a delay in gaining access to the locked unit, absence of staff in the resident’s room on arrival, shallow breathing requiring immediate oxygen via non-rebreather, and difficulty obtaining report, code status, and medical history from staff. EMS documented that care was delayed due to waiting for access, that staff were initially on their phones and not answering the door, and that a nurse present knew only limited information about the resident’s condition and medications. Hospital records showed the resident required intubation and was admitted to the ICU with acute respiratory failure, failure to thrive, cardiac arrest, hypocalcemia, and hypokalemia, and the facility’s failures were cited as not assessing the resident after a change in condition, delaying the 911 call by approximately 54 minutes after the physician’s order to send the resident out, not remaining with the resident to monitor for further decline, not assessing respiratory status despite respiratory distress, and not providing EMS or the ED with timely and thorough report. The cited regulatory violations included 28 Pa. code 201.14(a) Responsibility of licensee, 28 Pa code 201.18(b)(1) Management, and 28 Pa code 211.12(c)(d)(1)(3)(5) Nursing services. These citations were based on the failure to complete routine and weekly skin checks as ordered and care-planned for one resident, and the failure to provide timely, accurate, and comprehensive assessment, monitoring, documentation, and communication in response to another resident’s significant change in condition, including omission of critical clinical information on the SBAR and lack of appropriate respiratory assessment and presence of staff during EMS arrival and transfer.
Failure to Provide and Follow Through on Dental Services and Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that routine and 24-hour emergency dental services were provided and that dental recommendations were implemented for three residents. For one resident with dementia and progressive multiple sclerosis, a care plan meeting note documented that the resident wished to be seen by a dentist for possible dentures. A subsequent dental consultation recommended use of Prevident 5000 Dry Mouth gel and referral to an oral surgeon for extraction of all non-restorable teeth. The consultation lacked any review signature by nursing staff or the resident’s physician, and the physician orders contained no orders for the oral surgeon consultation or the Prevident gel. For a second resident with vascular dementia and generalized muscle weakness, a dental consultation documented that the resident had lost upper and lower dentures and that Step 1 of the denture replacement process had been completed, with a follow-up visit scheduled for Step 2. Facility-provided information from the contracted dental services provider indicated the resident was seen for Step 1 and scheduled for Step 2, but the clinical record contained no additional dental consultations or visit notes over several months. Progress notes showed that the resident’s representative repeatedly inquired about the status of the denture replacement, and was told the resident was in Step 2, while the DON later confirmed the resident had not been seen by the dentist since the initial consultation. For a third resident with a neurocognitive disorder with Lewy bodies and heart failure, a dental consultation documented a periodic oral exam and scheduled a prophylaxis visit for a later date. The clinical record contained no further dental consultations after that exam. The NHA confirmed there was no additional information in the record regarding the scheduled prophylaxis visit and reported contacting the contracted dental services provider to investigate what had happened with that visit. Overall, the records and staff interviews showed that scheduled dental services and dentist recommendations were not carried out or documented for all three residents.
Failure to Provide Timely Pharmaceutical Services for Anxiolytic Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident diagnosed with generalized anxiety disorder and major depressive disorder. The resident had a physician's order for Lorazepam to be administered three times daily for anxiety. Review of the medication administration record showed that on two occasions, the Lorazepam was not administered as indicated by 'NN' (no/see nurse notes), and there were no corresponding nursing progress notes documenting the missed doses. Further investigation revealed that the pharmacy did not dispense the Lorazepam refill because a new prescription was required, and the necessary prescription was not obtained and sent to the pharmacy before the resident ran out of medication.
Failure to Provide Prescribed Altered Texture Diets for Residents with Dysphagia
Penalty
Summary
The facility failed to provide altered texture diets as prescribed by physicians for multiple residents with dysphagia. Specifically, six residents who were ordered a dysphagia advanced texture diet received round slices of carrots that exceeded the recommended size for their diet, rather than the required chopped carrots no larger than ½-inch by ½-inch pieces. This was observed during meal service, and the meal tickets for these residents clearly indicated the need for chopped carrots, but the kitchen staff served sliced carrots instead. Facility policies required that residents with swallowing difficulties receive appropriate diet modifications, and the master menu diet guide sheets specified the correct form and size for vegetables on dysphagia advanced diets. Despite these guidelines, the kitchen staff did not follow the prescribed diet texture, and the dietary manager confirmed that the carrots served did not meet the required specifications. The speech language pathologist also confirmed that no changes had been made to the menu guidance and that the expectation was for kitchen staff to serve food in the appropriate texture as outlined by the International Dysphagia Diet Standardization Initiative. This failure to provide food in the prescribed form placed an additional fourteen residents with similar dietary needs at high risk, resulting in an Immediate Jeopardy situation. The deficiency was identified through observations, record reviews, and staff interviews, which confirmed that the facility did not follow its own policies or physician orders regarding diet texture for residents with dysphagia.
Failure to Implement Suicide Precautions and Conduct Thorough Fall Investigations
Penalty
Summary
The facility failed to conduct thorough fall investigations for one resident and did not implement suicide precautions for another resident who expressed suicidal ideation. In the case of the resident with suicidal ideation, staff were made aware that the resident was expressing thoughts of self-harm, including statements about wanting to kill himself and asking for a lawyer before doing so. Despite this, the LPN on duty did not initiate the facility's suicide precautions protocol, which required immediate assessment, one-to-one supervision, notification of the registered nurse supervisor and physician, and removal of potentially dangerous items from the resident's environment. As a result, the resident was left unsupervised in his room, where he was able to obtain a sharp plastic object and cut himself before staff intervened. The clinical record review showed that no orders for suicide precautions or one-to-one supervision were obtained or entered into the electronic health record in response to the resident's expressed suicidal ideation. Staff witness statements confirmed that the resident was not under constant supervision at the time of the self-injury, and that the required safety interventions were not put in place. The facility's policy on suicide precautions outlined specific steps to be taken when a resident exhibits suicidal behavior or ideation, but these were not followed by the staff involved. Additionally, the facility failed to conduct thorough fall investigations for another resident with a history of repeated falls and a recent fracture. Fall reports for this resident on two separate occasions did not include any staff witness statements, and the DON confirmed that she was unable to locate such statements. The facility's falls management policy required thorough assessment and documentation following a fall, but this was not completed as expected.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to provide required notification to the Office of the State Long-Term Care Ombudsman regarding resident transfers to the hospital for five out of eleven residents reviewed. Clinical record reviews and facility documentation revealed that notifications were not sent for multiple hospitalizations involving residents with diagnoses such as muscle weakness, unsteadiness, hypertension, diabetes, hemophilia, neuromuscular dysfunction of the bladder, dementia, chronic kidney disease, depression, and chronic pain syndrome. Specific instances included residents being transferred to the hospital on several occasions, with no evidence that the Ombudsman was notified as required by regulation. Staff interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that they expected all resident transfers to be reported to the Ombudsman in a timely manner, but documentation and email communications indicated that notifications were not made at the time of the transfers. The deficiency was identified through review of clinical records, facility documentation, and staff interviews, which consistently failed to show timely notification to the Ombudsman for the affected residents' hospitalizations.
Inaccurate Resident Assessments Documented in Clinical Records
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' clinical status for four individuals. For one resident with anxiety disorder, epilepsy, and depression, the Minimum Data Set (MDS) assessments inaccurately documented the administration of antianxiety, anticonvulsant, and opioid medications, with discrepancies between the MDS and the Medication Administration Record (MAR). Another resident with anxiety, post-traumatic stress disorder, and hemophilia was incorrectly coded on the MDS as not having a related condition per the Preadmission Screening and Resident Review (PASRR), despite documentation from the state indicating otherwise. A third resident with chronic pain syndrome and a stage 4 pressure ulcer was not consistently coded on the MDS regarding the presence and admission status of the pressure ulcer, despite clinical records confirming its existence and that it was present upon admission. Additionally, this resident was receiving hospice services. For a fourth resident with schizoaffective disorder, bipolar disorder, and major depressive disorder, the MDS assessments failed to accurately reflect attempts at gradual dose reduction (GDR) for antipsychotic medications, even though clinical documentation and physician orders indicated that GDRs had been attempted and medication dosages had been adjusted. These inaccuracies were confirmed through clinical record reviews, MARs, and staff interviews, with the Director of Nursing acknowledging the errors in MDS coding. The deficiencies were identified during the survey process and were found to be in violation of state regulations regarding medical records and nursing services.
Failure to Follow Physician Orders and Document Care for Multiple Residents
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for several residents, resulting in deficiencies related to medication administration, wound care, and response to acute medical needs. For one resident with cerebrovascular disease and scoliosis, a physician ordered a urine analysis with culture and sensitivity (UA/C&S) after multiple falls, but the test was never completed or documented, and no laboratory results were found. The Director of Nursing (DON) confirmed the order was not fulfilled and could not provide additional information. Another resident with multiple wound care orders for a diabetic toe wound had several days where treatments were not documented as completed on the Treatment Administration Record (TAR). The DON acknowledged that some treatments were performed during wound rounds but were not properly documented, and could not explain other missed entries. Additionally, this resident received more than the recommended daily dose of acetaminophen due to overlapping orders, which were not discontinued as new orders were placed, as confirmed by the DON. A resident with diabetes and end-stage renal disease missed scheduled insulin doses on multiple days when away for hemodialysis, despite the care plan indicating diabetes medication should be administered as ordered. Another resident with hemophilia and a history of hematuria experienced blood in the urine, but staff did not notify the hemophilia treatment center as ordered, and the prescribed medication for bleeding was not administered until nearly 24 hours after the initial observation. The DON confirmed the lack of documentation and delayed response. Finally, a resident with a skin tear did not have wound treatments documented on two occasions, with the DON unable to provide an explanation. These findings demonstrate failures in following physician orders, documenting care, and responding to residents' clinical needs.
Failure to Implement and Document Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to provide care consistent with professional standards to treat and prevent pressure ulcers for two residents. For one resident with osteomyelitis of the left ankle and foot and diabetes, the wound team recommended the use of pressure off-loading boots, but there was no physician order for the boots, no documentation of their use, and the care plan did not include their use. Observation showed the resident in a wheelchair with the boots beside the bed, and the resident reported that staff only occasionally applied the boots at night. The Director of Nursing confirmed that a physician order and care plan revision should have occurred after the wound team’s recommendation, but these steps were not taken. Similarly, another resident with osteomyelitis and a pressure ulcer of the sacral region had a wound team recommendation to float heels in bed, but there was no physician order for off-loading boots, no documentation of their use, and the care plan did not address their use. Observation found the resident in bed with the boots beside the bed, and the DON confirmed that the necessary physician order and care plan revision were not completed after the wound team’s recommendation. In both cases, the facility failed to document or implement recommended interventions for pressure ulcer prevention and care.
Failure to Complete Annual Employee Performance Reviews
Penalty
Summary
The facility failed to complete yearly employee performance reviews for five employees, as required by facility policy and state regulations. On June 25, 2025, the Nursing Home Administrator was unable to provide documentation of performance reviews conducted within the past year for these employees when requested. During a staff interview, the Administrator confirmed that no such reviews had been completed for the identified employees within the required timeframe. This deficiency was identified through facility document review and staff interviews.
Expired Medications Not Discarded per Policy and Manufacturer Guidelines
Penalty
Summary
The facility failed to properly discard expired medications as required by both facility policy and manufacturer guidelines. During an observation of the B Hall medication cart, a Novolog insulin vial was found with an open date of May 24, 2025, which exceeded the 28-day usage period specified in the facility's policy and the manufacturer's instructions. Additionally, in the [NAME] Wing medication room, two open Afluria influenza vaccine vials were found, one opened on December 24, 2024, and the other on May 20, 2025, both of which were also past the 28-day usage period after opening as per manufacturer guidelines. The Director of Nursing confirmed via email that the Afluria multi-dose vials are only good for 28 days once opened and acknowledged that expired vaccines had been removed from the medication refrigerators. During an interview, both the Nursing Home Administrator and the DON confirmed that medications are expected to be stored and discarded according to policy and manufacturer guidelines. These findings indicate that the facility did not consistently follow its own policies or manufacturer recommendations regarding the storage and timely disposal of expired medications.
Failure to Maintain Required Dish Machine Wash Temperatures
Penalty
Summary
The facility failed to operate its main kitchen dish machine in accordance with professional standards for food service safety. Manufacturer guidelines for the CL44e dish machine require a minimum wash temperature of 160°F for proper high-temperature sanitizing. However, direct observation of the dish machine in use showed a wash temperature of only 152°F. Review of the facility's dish machine temperature logs from October 2024 through June 2025 revealed numerous instances across breakfast, lunch, and dinner where recorded wash temperatures were below the required 160°F minimum. This pattern of substandard temperatures was consistent over several months and meal periods. Interviews with the Certified Dietary Manager indicated a misunderstanding of the required minimum wash temperature, as staff believed 150°F was sufficient. The logs and staff statements confirm that the dish machine was routinely operated below the manufacturer's specified temperature, and the staff were not following the correct standard. The deficiency was identified through review of documentation, direct observation, and staff interviews, with no mention of specific residents or patient outcomes related to this deficiency.
Failure to Review, Revise, and Document Care Plans and Resident Participation
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised to reflect residents' current status and did not provide residents or their representatives with the opportunity to participate in the care planning process. Multiple residents with complex medical conditions, such as diabetes, end stage renal disease, dementia, congestive heart failure, hypertension, and mental health disorders, did not have documented evidence of care plan meetings being held or invitations extended to them or their representatives. In several cases, the last documented care plan meetings were many months prior to the survey, and staff could not provide further documentation of more recent meetings or invitations. Additionally, the facility did not update care plans to reflect changes in residents' conditions or physician orders. For example, one resident's care plan continued to list interventions for medications that had been discontinued, and another resident's care plan did not include a newly ordered renal diet. There were also instances where care plans failed to address significant care needs, such as incontinence care for residents who were always incontinent or had discontinued use of a foley catheter but were now frequently incontinent of bowel. Interviews with residents, their representatives, and facility staff confirmed that care plan meetings were not being held as expected, and documentation of these meetings, including invitations and attendance, was lacking. Facility policy required care plans to be reviewed and revised after each assessment and as needed, and for care plan meetings to be documented, but these requirements were not met for several residents during the review period.
Failure to Develop and Communicate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission that included the minimum healthcare information necessary to properly care for a resident. Specifically, for a resident admitted with a right humerus fracture and scalp laceration, the baseline care plan did not address urinary incontinence or incontinence care, despite the resident being assessed with these needs upon admission. Additionally, the care plan included a focus on pain management but did not document what the resident considered an acceptable level of pain. Further, there was no evidence in the clinical record or progress notes that the resident or their representative was provided with a summary of the baseline care plan within 48 hours of admission. This summary should have included initial goals, medications, dietary instructions, and services or treatments to be administered. Staff interviews confirmed these omissions, and facility policy requires that such information be documented and communicated to the resident and their representative.
Failure to Provide and Document Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide necessary care and services related to hygiene and bathing for one resident, as required by both facility policy and the resident's care plan. The policy mandates that ADL care, including bathing, be provided according to the resident's needs and documented every shift. The resident in question had diagnoses of muscle weakness, obesity, and a non-pressure chronic ulcer on the left foot, and her care plan specified modified independence with bathing. The most recent MDS assessment indicated she required supervision and touching assistance for bathing. Despite these requirements, documentation showed that the resident was scheduled for showers or baths on Wednesday and Saturday evenings but only received one documented shower/bath during the review period. Several scheduled shower/bath days were either marked as non-applicable or had no documentation at all. The resident reported not always receiving her showers, and during interviews, facility leadership confirmed they had no additional information and expected staff to provide and document care as per the care plan.
Failure to Ensure Timely Audiology Referral for Hearing Loss
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and services to maintain hearing abilities. Clinical record review showed that the resident had diagnoses including stage 3 chronic kidney disease and hypothyroidism. The resident reported difficulty hearing and stated she had requested to see a doctor because her hearing aids were no longer effective. A medical practitioner documented an acute visit for hearing loss and ordered a referral to audiology for evaluation. Despite the physician's order for an audiology referral, the resident was not placed on the list to be seen by audiology. The Nursing Home Administrator confirmed that the resident was not added to the audiology list after the order was made and acknowledged that this should have occurred. The audiology provider later confirmed that the resident was not scheduled due to missing information, resulting in a delay in the resident receiving the necessary evaluation for her hearing loss.
Failure to Provide and Document Restorative Nursing Care for Range of Motion
Penalty
Summary
The facility failed to provide restorative nursing care for range of motion (ROM) exercises for two residents with limited ROM. For one resident with diagnoses including dysphagia, vascular dementia, and contractures of the hands, neck, and legs, the care plan and Kardex specified restorative passive ROM for both upper and lower extremities during morning and evening care. However, there was no documentation in the clinical record to indicate that these restorative nursing services were being provided. The Director of Nursing (DON) confirmed that a system glitch prevented the task from being added for staff to complete, and no documentation could be provided to show that the care was delivered prior to a certain date. The DON stated that staff were expected to perform the care, but acknowledged it was not documented anywhere. For another resident with dementia, chronic kidney disease, and depression, an occupational therapy note recommended the use of palm guards and both active and passive ROM as part of a restorative nursing program. The nursing tasks included encouraging the use of palm guards and providing hand hygiene, but there was no documentation to confirm these interventions were carried out. The DON explained that the task was entered incorrectly, resulting in a lack of documentation, and stated that restorative nursing programs should be implemented and documented.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for three residents, as evidenced by review of clinical records, interviews, and facility policy. For one resident with cerebrovascular disease and scoliosis, there were multiple instances where prescribed oxycodone was not administered due to the medication being unavailable and awaiting pharmacy delivery. Documentation showed that the medication was not reordered in a timely manner, and the in-house emergency supply was not utilized as expected. The Director of Nursing confirmed that management was not made aware of the need for a refill, and the responsible LPN did not follow procedures to ensure continuity of pain medication. Another resident, who required assistance with personal care and had muscle weakness and unsteadiness, reported ongoing back pain that was not adequately relieved by current medication. Although a nurse practitioner documented a plan to use an ice pack for pain relief, there was no corresponding physician order or care plan entry for this intervention. The resident's care plan also lacked a comprehensive approach to pain management, and the Director of Nursing acknowledged that the expected process for ordering and documenting non-pharmacological interventions was not followed. A third resident, admitted with a right humerus fracture and scalp laceration, reported that her pain was not managed to her comfort level. Her care plan did not specify her desired pain goal, and there were missed doses of acetaminophen without documentation or physician notification. The resident refused topical pain patches on several occasions, but there was no documentation of the reasons for refusal or physician notification. Additionally, non-pharmacological interventions were not documented prior to administration of as-needed pain medication, and ongoing reports of severe pain were not promptly communicated to the physician or nurse practitioner. The resident's pain management regimen was not adjusted despite continued complaints of inadequate pain control.
Failure to Provide Timely Dental Services After Denture Authorization
Penalty
Summary
The facility failed to provide timely dental services to a resident with anxiety disorder and dysphagia. The resident reported having new dentures that did not fit properly, resulting in difficulty eating. Clinical record review showed that the resident was last seen by the facility's dentist several months prior, at which time a preauthorization for new dentures was submitted. Although the insurance claim for the dentures was approved, no follow-up dental appointment was scheduled for the resident after the approval. The Nursing Home Administrator confirmed that the delay in scheduling or addressing dental services was not expected.
Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during the preparation and administration of medications to four residents. Facility policy directed staff to avoid touching medications unless wearing gloves, but observations revealed that a staff member, after cleansing her hands and donning gloves, touched unclean surfaces such as medication cart keys and drawer handles before handling oral medications. She then pushed pills from blister packs into her gloved hands and placed them into medicine cups, subsequently administering these medications to three residents without changing gloves or performing hand hygiene between tasks. The staff member confirmed during interview that she had touched the medications with the same gloves that had contacted unclean items. Additionally, another staff member was observed preparing an insulin injection for a resident using an insulin pen. The staff member applied a new needle to the pen without cleansing the rubber seal, contrary to manufacturer instructions. The facility's policy on subcutaneous insulin did not include guidance to cleanse the rubber seal before needle application, and the staff member confirmed she had not performed this step. The DON acknowledged that both staff members did not follow appropriate infection control practices as required by facility policy and manufacturer guidelines.
Insufficient Nursing Staff Resulting in Delayed Call Bell Responses
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents on one of its nursing units, specifically the West wing. During the survey, ten residents reported concerns regarding delayed call bell response times and inadequate staffing. Review of facility grievances from April, May, and June 2025 identified three complaints related to extended wait times for call bells to be answered. Additionally, Resident Council Meeting minutes from April and May 2025 documented resident complaints about prolonged call bell wait times. Direct observation on June 23, 2025, showed that call lights in specific rooms remained activated for extended periods, with one call bell not answered for 27 minutes and another for 32 minutes. The Nursing Home Administrator did not provide further information during the interview.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios on multiple occasions, as evidenced by a review of staffing documents and staff interviews. On January 5, 2025, during the night shift, the facility had a census of 141 residents but only maintained a NA ratio of 5.84, falling short of the required 9.40. Similarly, on January 6, 2025, the day shift had a census of 141 residents with a NA ratio of 10.28, not meeting the required 14.10. The night shift on the same day also failed to meet the required ratio, with a NA ratio of 5.73 against the required 9.40. Further deficiencies were noted on January 10, 2025, during the evening shift, where the facility had a census of 140 residents and a NA ratio of 11.97, below the required 12.73. On January 11, 2025, the day shift had a census of 141 residents with a NA ratio of 13.16, not meeting the required 14.10. Additionally, the night shift on January 11, 2025, had a census of 142 residents with a NA ratio of 8.31, failing to meet the required 9.47. These findings indicate a consistent failure to maintain the mandated staffing levels across various shifts and days.
Plan Of Correction
1. No residents affected. Residents received care in accordance with their plan of care and attending physician orders. 2. No residents affected. All residents will continue to receive care in accordance with their plan of care and attending physicians orders. 3. The NHA, Clinical Leadership Team, Human Resources, and Scheduler will review the schedule in daily meetings. In the event of call offs, the facility will follow staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to coordinate staffing schedules and replace call offs per policy. The facility will continue to hire for all open positions using a new recruitment platform, job fairs, and utilize agency staff as needed. 4. NHA has re-educated the Director of Nursing and Scheduler on Nursing ratios and PPD requirements and the importance of maintaining the schedule as posted. 5. To monitor and maintain ongoing compliance, the NHA/DON/Designee will audit staffing daily x 4 weeks then weekly for 2 months for review and revision as needed. Results of audits will be reported to the QAPI Committee.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct nursing care per resident per day for four out of seven days reviewed. Specifically, on January 5, 2025, the facility provided only 2.90 hours of direct care per resident, 2.52 hours on January 6, 2025, 3.05 hours on January 10, 2025, and 2.89 hours on January 11, 2025. This deficiency was confirmed during an interview with the Nursing Home Administrator, who attributed the shortfall to staff call-offs related to illnesses and adverse weather conditions.
Plan Of Correction
1. No residents affected. Residents received care in accordance with their plan of care and attending physician orders. 2. No residents affected. Residents will continue to receive care in accordance with their plan of care and attending physician orders. 3. The NHA, Clinical Leadership Team, Human Resources, and Scheduler will review the schedule in daily meetings. In the event of call offs, the facility will follow staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to coordinate staffing schedules and replace call offs per policy. The facility will continue to hire for all open positions using a new recruitment platform, job fairs, and utilize agency staff as needed. 4. NHA has re-educated the Director of Nursing and Scheduler on Nursing ratios and PPD requirements and the importance of maintaining the schedule as posted. 5. To monitor and maintain ongoing compliance, the NHA/DON/Designee will audit staffing daily for 4 weeks, then weekly for 2 months for review and revision as needed. Results of audits will be reported to the QAPI Committee.
Improper Storage of Incontinent Briefs Compromises Resident Dignity
Penalty
Summary
The facility failed to promote care for residents in a manner that enhances their dignity, as evidenced by the improper storage of incontinent briefs for four residents. Observations revealed that stacks of eight to ten incontinent briefs were left in public view on the nightstands of residents diagnosed with conditions such as vascular dementia, cognitive communication deficit, aphasia, dementia, cerebral infarction, paranoid schizophrenia, and mild intellectual disabilities. These observations were made over several days, indicating a consistent practice of storing briefs in a manner that did not respect the residents' dignity. Interviews with facility staff, including the Nursing Home Administrator (NHA), Director of Nursing (DON), and a Nurse Aide, confirmed that the practice of storing briefs on nightstands was standard across the facility. The DON acknowledged the lack of a specific policy on the storage of incontinent briefs and recognized that the residents involved were not capable of expressing their preferences regarding the storage of their personal items. This deficiency was identified as a violation of the residents' rights to dignity and respect, as outlined in the facility's policies and state regulations.
Failure to Notify of Hospital Transfers
Penalty
Summary
The facility failed to provide timely notification of hospital transfers to residents, their representatives, and the Office of the State Long-Term Care Ombudsman for eight out of eleven residents reviewed. This deficiency was identified through clinical record reviews and staff interviews. The residents involved had various medical conditions, including vascular dementia, congestive heart failure, chronic kidney disease, hypertension, and end-stage renal disease, which necessitated their transfers to the hospital. For Resident 5, the facility did not provide documentation that the responsible party or the Pennsylvania State Ombudsman was notified of the transfer to the hospital. Similarly, Resident 7's transfer was not communicated to the Ombudsman, and the facility acknowledged the lack of documentation. Resident 22 was transferred without receiving a notice of transfer, and the facility confirmed the absence of such documentation. Resident 25's responsible party and the Ombudsman were also not notified of the transfer. Resident 27 and Resident 39 were transferred to the hospital without their representatives or the Ombudsman being informed. Resident 54's transfers were not communicated to the Ombudsman, and Resident 103 did not receive a notice of transfer for multiple hospitalizations. The facility confirmed the lack of evidence for these notifications during staff interviews, indicating a systemic issue in their process of notifying relevant parties about resident transfers.
Failure to Provide Bed Hold Policy Notices
Penalty
Summary
The facility failed to provide residents and/or their representatives with the bed hold policy upon transfer to a hospital or during therapeutic leave, as required by their policy. This deficiency was identified for seven out of eleven residents reviewed for hospitalization. The facility's policy, revised on August 5, 2022, mandates that staff complete the Bed Hold Notice Form, deliver it to the resident or their representative, and document the delivery in the electronic health record. However, the facility was unable to provide documentation that this process was followed for the affected residents. The clinical records of several residents, including those with diagnoses such as vascular dementia, congestive heart failure, and end-stage renal disease, were reviewed. These residents were transferred to hospitals on various dates, but there was no evidence that the bed hold policy was communicated to them or their representatives. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed the lack of documentation for these notifications. The NHA acknowledged during interviews that the facility did not have evidence of providing the bed hold notices to the residents or their representatives at the time of hospitalization. The facility was reportedly working on improving the process of providing these notices, but at the time of the survey, the deficiency remained unaddressed. The lack of documentation and communication of the bed hold policy was a consistent issue across multiple cases reviewed.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate resident assessments, affecting six residents. For Resident 7, there was a discrepancy between the physical therapy evaluation and the Minimum Data Set (MDS) regarding lower extremity impairment. The therapy evaluation noted impairment, but the MDS did not reflect this, indicating a lack of accurate documentation of the resident's condition. Resident 25's MDS inaccurately documented medication administration. The MDS did not reflect the administration of a hypnotic, antibiotic, and opioid, which were confirmed by the Medication Administration Record (MAR), and incorrectly noted the administration of an anticoagulant. Similarly, Resident 38's MDS inaccurately indicated the receipt of an anticoagulant, which was not supported by physician orders. For Resident 39, the MDS failed to capture a fall with major injury, specifically a clavicle fracture, following a fall. Resident 123's discharge MDS inaccurately indicated a discharge to the hospital instead of home, and Resident 124's discharge MDS incorrectly noted a discharge to home rather than the hospital. These inaccuracies highlight a pattern of documentation errors in resident assessments.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for four residents, leading to deficiencies in their care. Resident 5, diagnosed with vascular dementia and having a gastrostomy tube, was observed to be on Enhanced Barrier Precautions (EBP) for infection control, but this intervention was not included in their care plan. Similarly, Resident 40, who had an indwelling foley catheter and was ordered to be on EBP, did not have this reflected in their care plan. The Director of Nursing (DON) later confirmed that these care plans should have been updated to include the necessary precautions. Resident 41, suffering from trigeminal neuralgia and morbid obesity, was observed in pain, yet their care plan lacked a focus area or intervention for pain management related to their condition. Additionally, Resident 113, diagnosed with short bowel syndrome and protein-calorie malnutrition, had a PICC line inserted, but their care plan did not address this intervention. The DON acknowledged that the care plans for these residents were not revised in a timely manner, as expected by the facility's standards.
Failure to Implement Restorative Nursing Program for Resident
Penalty
Summary
The facility failed to provide appropriate services and assistance to maintain or improve mobility for a resident with limited range of motion. Resident 115, who had a history of orthopedic aftercare following joint replacement surgery, hereditary and idiopathic neuropathy, and major depressive disorder, was not receiving the recommended restorative nursing program. The resident had previously received therapy services but reported not getting out of bed much since then. A review of the resident's clinical record and care plan did not show any notation of a restorative nursing program, despite recommendations from a physical therapy discharge summary. The discharge summary, signed by a physical therapist, indicated that the resident should use an assistive device for safe functional mobility and participate in a restorative nursing program. However, during an interview, the Director of Nursing confirmed the absence of documentation indicating the implementation of the recommended program.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for three residents. Resident 41, diagnosed with respiratory failure and morbid obesity, was observed receiving supplemental oxygen via nasal cannula without a date on the tubing, and additional tubing was dated nearly three weeks prior. The facility's policy required weekly changes and dating of oxygen tubing, which was not adhered to. Resident 54, with vascular dementia and COPD, was observed using supplemental oxygen with undated tubing and a storage bag dated from the previous month. There were no physician orders for changing the oxygen tubing, and the resident's medication administration record did not document the observed oxygen use. Resident 84, diagnosed with emphysema and chronic respiratory failure, was observed using an oxygen concentrator with a filter covered in gray debris, indicating it had not been cleaned as required by the facility's policy. Despite observations over several days, the filter remained uncleaned until it was addressed after the surveyor's findings. The facility's failure to maintain proper respiratory care equipment and documentation for these residents was confirmed through staff interviews and clinical record reviews.
Failure to Act on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were appropriately acted upon for several residents, leading to deficiencies in medication management. For Resident 7, the pharmacist recommended updating the diclofenac gel order to include a specified amount of grams to apply. However, this recommendation was not addressed in a timely manner, as the order was not updated until after the resident's hospital readmission, and the documentation was not signed by a physician. Resident 25's medication regimen was reviewed by the consultant pharmacist, who recommended a gradual dose reduction for zolpidem and olanzapine. The facility could not locate the original reports that would have been reviewed and signed by the physician, and there was no evidence of a gradual dose reduction for olanzapine. Similarly, Resident 54's ibuprofen order was recommended for discontinuation due to non-use, but the original report was missing, and the order was not discontinued until much later. For Resident 51, the facility failed to provide a copy of the pharmacy recommendation made on June 20, 2024, and it was revealed that the recommendation had not been addressed. Resident 56's case involved a recommendation for a gradual dose reduction of risperidone due to increased risk for stroke and mortality in those with dementia-related psychosis. The physician declined the recommendation without providing an appropriate clinical rationale, and there was no documentation supporting the decision to refuse the dose reduction.
Failure to Monitor and Review Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that the medication regimen for two residents was free of unnecessary psychotropic medications. For Resident 25, the clinical record revealed the use of multiple psychotropic medications, including belsomra, lorazepam, olanzapine, and venlafaxine. Despite recommendations from the consultant pharmacist for gradual dose reductions, there was no evidence that these recommendations were reviewed or implemented. Additionally, there were missing psychiatric visit notes, and the facility could not provide documentation to show that the psychotropic medications had been reviewed for efficacy or necessity. Resident 56 was prescribed antipsychotic medications, including Rexulti and risperidone, for agitation and depression. However, there was no monitoring of target behaviors associated with the use of these medications, and the resident's comprehensive care plan did not include the use of antipsychotic medication. The interdisciplinary progress notes documented instances of hallucinations and combative behavior, but there was no targeted behavior tracking in place prior to July 17, 2024. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the lack of documentation and monitoring for both residents. The facility's failure to adhere to its policy on psychotropic medication use and the absence of necessary documentation and monitoring led to the deficiency findings.
Failure to Date Opened Medications
Penalty
Summary
The facility failed to comply with its policy regarding the labeling of medications, as observed during a survey. Specifically, the facility did not place opened dates on medications in two of the three medication carts observed, located in the 100 Hall and 200 Hall. The facility's policy, last reviewed on April 24, 2024, requires that once any medication or biological package is opened, the date should be recorded on the primary medication container if the medication has a shortened expiration date once opened. However, during the observation on July 17, 2024, it was found that several open stock bottles, including stool softener, chewable aspirin, delayed release aspirin, vitamin D3, and ibuprofen, lacked the required open dates. Interviews with staff members revealed a lack of awareness regarding the requirement to date stock bottles of medication when opened. Employee 8 and Employee 6, who were interviewed during the observations, both expressed uncertainty about the need to date opened stock bottles. Furthermore, during a subsequent interview with the Nursing Home Administrator and the Director of Nursing, it was confirmed that the facility's expectation was indeed for stock medication bottles to be dated when opened. This deficiency was noted under the regulatory codes 28 Pa. Code 201.18(b)(1) Management and 28 Pa. Code 211.9(a)(1) Pharmacy services.
Food Storage and Equipment Utilization Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food storage and equipment utilization in the main kitchen and nourishment areas. Observations revealed multiple instances of improperly labeled or unlabeled food items, including wheat bread, hoagie rolls, white bread, sauerkraut, cinnamon rolls, English muffins, diced carrots, pineapple sauce, ziti, ground pork, pureed vegetables, chili, chicken pot pie, spinach, puffed rice cereal, elbow noodles, bologna, pureed chicken, turkey, snacks, thickened orange juice, fudge round cookies, thickened cranberry juice, and individual juices. Many of these items were past their 'use by' dates or lacked proper sealing, posing a risk of spoilage and contamination. Additionally, the facility failed to maintain accurate temperature logs for refrigeration equipment, with missing entries on several dates across different pantry areas. The west pantry area refrigerator was noted to have been at 70 degrees on one occasion and out of service on another, while the east and arcadia pantry areas also had numerous missing temperature log entries. These lapses in monitoring and documentation further indicate a failure to comply with the facility's policies and professional standards for food safety.
Deficiency in Immunization Documentation and Education
Penalty
Summary
The facility failed to ensure that each resident's medical record included documentation indicating that the resident or their representative was provided education regarding the benefits and potential side effects of pneumococcal and influenza immunizations. This deficiency was identified for four out of five residents reviewed for immunizations. The facility's policies required documentation of informed consent or declination, as well as education and counseling on the benefits of immunization, but these were not consistently followed. Resident 17, who had chronic kidney disease and bladder cancer, refused both vaccinations, yet there was no evidence of education provided. Resident 25, with chronic diastolic heart failure and COPD, had no documentation of additional pneumococcal vaccinations since 2016. Resident 47, with congestive heart failure and atrial fibrillation, requested the pneumococcal vaccination, but there was no documentation of its administration. Resident 107, with Parkinson's disease and thyroid cancer, refused the pneumococcal vaccination, and there was no evidence of education provided. The Director of Nursing acknowledged the lack of documentation and indicated a need to review records for Resident 47.
Deficiency in COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to provide evidence of COVID-19 vaccine education to three residents, leading to a deficiency in their immunization process. The facility's policy, IC604 COVID-19 Vaccination, requires that residents be educated on the risks and benefits of the COVID-19 vaccine and that consent be obtained. However, for Resident 17, who has chronic kidney disease and bladder cancer, there was no documentation of education provided before the resident refused the vaccine. Similarly, Resident 25, with chronic diastolic heart failure and COPD, had no record of being offered a booster or receiving education on the vaccine's benefits and side effects after their last booster in November 2022. Resident 107, diagnosed with Parkinson's disease and thyroid cancer, also lacked documentation of being offered a booster or receiving education on the vaccine after their last dose in October 2021. During an interview, the Director of Nursing confirmed the absence of additional information to address these concerns. This lack of documentation and education for the residents reviewed indicates a failure to comply with the facility's vaccination policy, as required by state regulations.
Improper Storage of Wheelchairs in East Lounge
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in the East Lounge, as observed by surveyors. The facility's policy, OPS200 Accommodation of Needs, emphasizes the importance of maintaining an environment that supports residents' independent functioning and dignity. However, during observations, it was noted that a significant number of empty wheelchairs and specialty chairs were stored in the East Lounge, obstructing the space. On one occasion, a resident using a walker had to move an empty wheelchair that was blocking access to a table with a jigsaw puzzle, indicating that the storage of these chairs impeded residents' access to activities. The observations were shared with the Nursing Home Administrator (NHA) and Director of Nursing (DON), who acknowledged that the storage of chairs should not have blocked residents' access to activities. The facility's failure to appropriately store the chairs in a manner that did not impede residents' access to the lounge activities was a direct violation of their policy and contributed to the deficiency noted by the surveyors.
Delayed Reporting of Alleged Abuse Incident
Penalty
Summary
The facility failed to adhere to the mandated reporting timelines for alleged abuse incidents. According to the facility's policy, any allegations of abuse must be reported immediately, but no later than 24 hours if the incident does not result in serious bodily injury. In this case, a resident with diagnoses including liver failure and muscle weakness reported an allegation of physical abuse by a staff member. The facility initiated an investigation immediately upon receiving the report on January 22, 2024, at 3:15 PM, and concluded the investigation by January 23, 2024, at 3:00 PM. Despite completing the investigation within the required timeframe, the facility did not report the incident to the appropriate authorities within the stipulated 24-hour period. The report to the Pennsylvania Department of Aging was made on January 23, 2024, at 5:11 PM, while the reports to the local police and the local Area Agency on Aging were delayed until January 24, 2024. This delay in reporting was confirmed during an interview with the Nursing Home Administrator and Director of Nursing, indicating a failure to comply with the external abuse reporting requirements as outlined in the facility's policy and state regulations.
Failure to Include Hemodialysis in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with end stage renal disease and acute respiratory failure with hypoxia. The resident, who was admitted with a midline catheter and required dialysis treatment three times a week, did not have documented physician orders for hemodialysis or care needs related to dialysis in their clinical record. Additionally, the baseline care plan did not include necessary information regarding hemodialysis and the associated care requirements. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that the omission of hemodialysis care in the baseline care plan was contrary to the facility's expectations for accurate care planning.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for two residents accurately reflected their current medical and psychological needs. Resident 56, who has Alzheimer's disease and type two diabetes mellitus, was prescribed antipsychotic medications, including Rexulti and risperidone, over a period of time. However, the comprehensive care plan for Resident 56 did not include any mention of the use of these antipsychotic medications, which was confirmed during a staff interview with the Director of Nursing. Similarly, Resident 83, diagnosed with post-traumatic stress disorder (PTSD) and generalized anxiety disorder, had a comprehensive care plan that included a focus area for PTSD. Despite this, the care plan failed to identify specific triggers for the resident's PTSD, even though these triggers had been assessed and identified upon the resident's admission in March 2023. This oversight was acknowledged during an interview with the Nursing Home Administrator and the Director of Nursing, who stated that it was the facility's expectation for care plans to be completed accurately.
Improper Bedside Medication Storage for a Resident
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards for a resident diagnosed with vascular dementia, cognitive communication deficit, and muscle contractures. The facility's policy on the storage and expiration dating of medications and biologicals specifies that medications should not be administered or stored at the bedside without a physician's order and approval by the interdisciplinary care team and facility administration. Additionally, medications should be stored in a locked compartment within the resident's room. However, observations revealed that the resident had an opened box of individually wrapped Ocusoft lid scrubs and two tubes of Ammonium Lactate at their bedside without the necessary orders or approvals. The resident's clinical record did not contain an order allowing medications to be stored at the bedside, nor did it indicate that the resident was capable of independently administering or utilizing the Ocusoft Lid Cleanser or Ammonium Lactate, given their physical and mental status. During an interview, the Director of Nursing confirmed that these medications were prescribed and should not have been kept at the bedside, indicating a failure to adhere to the facility's medication storage policy.
Failure to Ensure Proper Treatment Orders for Residents
Penalty
Summary
The facility failed to ensure that two residents received treatment in accordance with professional standards of practice. Resident 113, who had diagnoses including acute renal failure, short bowel syndrome, and protein-calorie malnutrition, had a PICC line inserted but lacked physician orders for monitoring the PICC line site and dressing changes. Additionally, there was no physician's order to carry out the resident's wishes in the event of cardiopulmonary arrest, despite the resident being DNR. Resident 378, diagnosed with end-stage renal disease and acute respiratory failure with hypoxia, had a midline catheter for dialysis treatment. However, there were no physician orders for dialysis treatment or dialysis access site care, even though the resident received dialysis three times a week. The facility's Director of Nursing confirmed the absence of these orders and acknowledged that it was expected for such orders to be accurate and in place.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections and complications related to the use of a Foley catheter for two residents. Resident 12, who had a diagnosis of malignant neoplasm of the bladder and urinary retention, was observed with a urinary catheter drainage bag lying on the floor next to her bed. This was noted during observations on July 15, 2024, at two different times. The Licensed Practical Nurse, upon being informed, placed a cover on the catheter bag and reattached it to the bed. The Director of Nursing confirmed that the catheter bag should not have been on the floor. Similarly, Resident 40, diagnosed with urinary retention, was observed on two occasions with their urinary catheter tubing touching the floor while they were in a wheelchair in the lounge. The Director of Nursing acknowledged that the catheter tubing should not have been in contact with the floor. These observations indicate a failure to adhere to the facility's policy, which requires that catheter tubing be secured to keep the drainage bag below the level of the resident's bladder and off the floor.
Failure to Monitor Resident's Fluid Restriction
Penalty
Summary
The facility failed to monitor the hydration status of a resident with a fluid restriction order due to congestive heart failure, chronic kidney disease, and hypertension. The physician's order specified a daily fluid restriction of 1800 ml, with specific allocations for each meal and shift. However, observations revealed that the resident had access to fluids exceeding the prescribed limits, including a 900 ml mug of ice water and a 600 ml bottle of soda. The resident was unsure about the fluid restriction details, and staff members were following outdated guidelines that did not match the current physician's order. The dietary department provided incorrect fluid amounts on meal trays, and the nursing staff did not adhere to the updated fluid restriction order. The resident's care plan included an intervention for no water pitcher in the room, but this was not effectively implemented. Interviews with staff, including a nurse aide and the dietary manager, highlighted discrepancies in the fluid management process. The Director of Nursing was informed of the issue, but the resident expressed a desire not to comply with the fluid restriction, prompting a request for the physician to reconsider the order.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to provide foods and beverages that are palatable and at a safe and appetizing temperature during a meal observed on the Arcadia unit. The facility's policy on food handling, dated May 1, 2023, requires that hot foods remain hot and cold foods remain cold during transportation to various dining locations. Additionally, the facility's HACCP Food Flow Chart specifies that ground and portioned meats should be maintained at a temperature of 145 degrees Fahrenheit or above. However, during an observation on May 6, 2024, it was found that the temperatures of several food items did not meet these guidelines. Specifically, the milk was at 47.6 degrees Fahrenheit, Salisbury steak at 137.6 degrees Fahrenheit, mashed potatoes at 130.8 degrees Fahrenheit, and California blend vegetables at 133.1 degrees Fahrenheit, all of which were outside the acceptable temperature ranges as per the facility's Food and Nutrition Services Test Tray Evaluation form. Employee 1, the Dietary Manager, acknowledged during an immediate interview that the food and beverage temperatures did not meet the specified guidelines. The goal for passing trays was stated to be 15 minutes after arrival to the unit to ensure food temperatures are maintained for point of service. The Nursing Home Administrator (NHA) and the Director of Nursing (DON) confirmed that they would expect food to be served at appropriate temperatures. The NHA reiterated this expectation in a follow-up interview, indicating that the facility would work to address the concern promptly.
Delayed Response to Resident's Fracture and Pain Management
Penalty
Summary
The facility failed to provide timely care and services following a fall with a fracture for a resident, resulting in harm due to uncontrolled fracture-related pain and delayed corrective treatment. The resident, who had a history of atrial fibrillation, congestive heart failure, and chronic obstructive pulmonary disease, experienced an unwitnessed fall in the early morning hours. The resident was found on the bathroom floor with discomfort in her left wrist, which was swollen and bruised. Despite the resident's pain and abnormal appearance of the wrist, neurovascular assessments were not completed, and the resident's pain was not effectively managed. The resident's pain was initially assessed at a level of 3 out of 10, and Norco was administered, but it was ineffective. An X-ray was ordered and completed over three hours later, revealing a fracture with mild displacement. The resident's pain increased to a level of 5 out of 10, and Tylenol was administered, which was also ineffective. The resident refused wound care due to the pain and requested to be sent to the hospital. However, there was a delay of approximately two hours before the physician responded to the notification of the X-ray results and ordered the transfer to the hospital. Interviews with staff revealed that the resident was in significant pain and had requested to be taken to the hospital multiple times. Despite this, there was no evidence that the physician was notified of the unmanaged pain, and no additional steps were taken to manage the pain during the nearly eight-hour period between the fall and the hospital transfer. The facility also failed to complete necessary neurovascular assessments to ensure proper circulation following the injury.
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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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