Chambersburg Skilled Nursing And Rehabilitation Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Chambersburg, Pennsylvania.
- Location
- 1070 Stouffer Avenue, Chambersburg, Pennsylvania 17201
- CMS Provider Number
- 395348
- Inspections on file
- 29
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Chambersburg Skilled Nursing And Rehabilitation Ce during CMS and state inspections, most recent first.
A resident with chronic kidney disease, diabetes, and hypertension was treated for hypokalemia with potassium chloride ER 40 mEq three times daily. After the potassium level normalized, the high-dose supplementation continued without an end date and without further lab monitoring for several days, despite ongoing evidence of impaired renal function. When a follow-up potassium lab was ordered, the resident refused twice, and there was no documentation that the resident was informed of the risks of refusing this monitoring. The facility continued administering the same potassium dose without checking levels, and the resident was later transferred to the hospital with altered mental status and was found to have severe hyperkalemia, along with worsened renal function.
Surveyors found that food and beverages, including thickened liquids and items from outside sources, were not consistently labeled with open dates or resident information, and some were kept beyond the allowed time frames. Staff interviews confirmed these items should have been labeled and discarded per facility policy and professional standards.
A resident's bathroom was found to have wallpaper coming away from the wall, rippling under the sink, and torn behind the toilet, with no active maintenance work order in place and the issue persisting for several days despite facility policy requiring a clean and comfortable environment.
Two residents with significant medical histories experienced falls that were not accurately documented in their MDS assessments. Staff interviews confirmed that the assessments failed to reflect these incidents, resulting in inaccurate resident records.
A resident with CHF and atrial fibrillation did not have daily weights consistently documented as ordered, and a significant one-day weight gain was not reported to the practitioner or rechecked. The DON confirmed that daily weights and follow-up were expected but not completed.
The facility failed to maintain and install emergency lighting as required by NFPA 101. There was no documentation of annual maintenance for battery-powered emergency lighting sources, and no battery-powered emergency lighting was installed at the automatic transfer switch, affecting all six smoke compartments. These issues were confirmed by the Assistant DON and Maintenance Director.
The facility was found non-compliant with NFPA 101 smoking regulations due to the absence of a documented smoking policy, lack of no smoking signs in hazardous areas, and failure to provide proper receptacles for cigarette disposal in designated smoking areas. These deficiencies were confirmed through document review, observations, and interviews with facility staff.
The facility did not perform required maintenance and testing of its Essential Electrical System, including missing monthly and annual generator tests. This was confirmed during a review and interview with the Assistant DON and Maintenance Director.
The facility was found non-compliant with GFI protection requirements for power receptacles within six feet of a water source in three smoke zones. Observations revealed non-GFI protected outlets in the D Hall Nurses' Station Nourishment Area, B Hall Beauty Shop, and Main Kitchen Prep Area. This was confirmed by the Assistant DON and Maintenance Director.
The facility failed to maintain smoke-tight doors in a hazardous area, specifically the Boiler Room, where a gap greater than 1/2-inch was observed due to a removed astragal. This was confirmed by the Assistant DON and Maintenance Director.
The facility did not conduct and document the owner's checks of the fixed chemical fire suppression system in one of the smoke compartments. During a review, it was found that the facility lacked documentation for the required quick checks on the kitchen's fire suppression system, which was confirmed by the Assistant DON and Maintenance Director.
The facility did not provide documentation verifying the semi-annual testing and inspection of the fire alarm system within the previous twelve months. This deficiency was confirmed during a document review and an exit conference with the Assistant DON and Maintenance Director.
The facility failed to conduct required fire drills, missing drills for the 2nd shift in the 1st quarter of 2025, and the 1st and 3rd shifts in the 3rd quarter of 2024. This was confirmed by the Assistant DON and Maintenance Director, acknowledging non-compliance with NFPA 101 standards.
The facility failed to provide documentation of the annual fire-rated door inspection for six smoke compartments. This deficiency was identified during a document review, and the absence of documentation was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director. The lack of documentation indicates non-compliance with NFPA 80 requirements.
Two residents experienced significant unplanned weight loss due to the facility's failure to monitor nutritional status adequately. One resident, with muscle wasting and depressive disorder, lost 8.6 pounds without proper monthly weight checks or a timely nutrition assessment. Another resident, with dementia and intellectual disabilities, lost 16 pounds, and despite a dietician's recommendation, weekly weights were not recorded. The DON acknowledged the lapses in monitoring.
The facility failed to ensure accurate assessments for three residents, leading to deficiencies in care documentation. A resident with Alzheimer's and diabetes had unreported dental issues in their MDS due to off-site staff errors. Another resident developed a pressure injury post-admission, with incorrect MDS coding regarding the injury and weight loss. A third resident receiving hospice care was not accurately documented in MDS assessments. These issues were confirmed by facility staff during interviews.
The facility failed to document necessary wound care treatments for three residents with pressure ulcers, leading to potential lapses in care. A resident with dementia and muscle weakness had missing documentation for sacrum wound care, while another with dementia and intellectual disabilities had incomplete records for heel and ankle treatments. A third resident with peripheral vascular disease also had undocumented treatments for heel and buttocks wounds. The DON acknowledged the missing documentation and emphasized the expectation for proper record-keeping.
A facility failed to provide proper respiratory care for a resident with chronic lung conditions. The resident's nebulizer mask was left uncovered, and the tubing was not changed weekly as required. Staff interviews revealed that nebulizer equipment should be cleaned and changed regularly, but this was not consistently done. The resident reported having to remove the nebulizer mask herself after treatment, as staff did not return to do so.
A resident with neurogenic bladder and spina bifida did not have complete clinical records maintained, as staff failed to document the administration of prescribed treatments, including zinc paste and Ketoconazole cream, on several occasions. The DON confirmed that all treatments should be signed off on the TAR.
The facility failed to maintain a safe, clean, comfortable, and homelike environment in three of the four nursing units observed. Observations included black substances on air vents, debris in heating/cooling units, and missing plastic grates. The Nursing Home Administrator and DON acknowledged the concerns during a tour.
Failure to Adjust Potassium Supplementation and Ensure Informed Refusal of Lab Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to discontinue or adjust potassium chloride ER dosing and to ensure a resident was informed of the risks of refusing laboratory monitoring, resulting in unmonitored treatment for hypokalemia in a resident with chronic kidney disease. The resident had diagnoses including chronic kidney disease, diabetes, and hypertension, and was cognitively intact per an admission BIMS score of 13. Laboratory results showed hypokalemia with a potassium level of 2.8, along with elevated BUN and creatinine and a reduced eGFR, indicating impaired renal function. In response, the physician ordered potassium chloride ER 20 mEq tablets, 40 mEq three times daily, without an end date. A repeat lab two days later showed a normal potassium level of 4.5, but BUN and creatinine remained elevated and eGFR remained low. No labs were ordered for the next two days. A lab was ordered for a subsequent date to recheck potassium, but the resident refused two attempts to obtain the specimen, and there was no documentation that the resident was made aware of the risks of declining the lab test. When the physician was notified of the refusal, the lab was simply reordered for a later date, and the facility continued administering potassium chloride ER 40 mEq three times daily over several days without any potassium level monitoring. The resident was later sent to the hospital for altered mental status, where admission labs revealed hyperkalemia with a potassium level of 7.1, along with further elevated BUN and creatinine and a lower eGFR. The hyperkalemia was treated in the emergency department, and the resident was admitted for continued monitoring and evaluation of altered mental status and possible infection. The deficiency was cited under 28 Pa. Code 211.2(d)(3)(9) Medical Director, 28 Pa. Code 211.10(c) Resident Care Policies, and 28 Pa. Code 211.12(c) Nursing Services.
Failure to Properly Store and Label Food and Beverages
Penalty
Summary
The facility failed to store food and beverages in accordance with professional standards for food service safety in the main kitchen and three of four nourishment areas. Observations revealed multiple instances where thickened beverages and food items were either not labeled with an open date or were kept beyond the allowable time frames specified by both facility policy and product labeling. Specifically, containers of thickened lemon water and apple juice were found open and either undated or dated beyond the seven-day limit for use after opening. Additionally, food items brought in from outside sources were not consistently labeled with the resident's name and the date the food was brought in, nor were they always discarded after the three-day holding period as required by facility policy. Interviews with the Food Service Director confirmed that these items should have been properly labeled and discarded according to the established time frames. The Nursing Home Administrator also stated that it was the facility's expectation for expired items to be discarded and for all food and beverages to be labeled and stored per policy and professional standards. These findings indicate a failure to adhere to both internal policies and professional standards regarding the safe storage and handling of food and beverages.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in one of the resident rooms reviewed. Facility policy requires that residents have a right to a safe, clean, and comfortable environment, and that housekeeping and maintenance services are provided to maintain a sanitary and orderly interior. A resident reported disappointment with the condition of the wallpaper in his bathroom, which had been in poor condition since his admission to the room. Observations confirmed that the wallpaper was coming away from the wall in several areas, was rippling under the sink, and was torn behind the toilet. A review of the facility's maintenance work order report did not show any active work order for the bathroom in question, despite the issue being present for several days. The Nursing Home Administrator stated that staff are responsible for identifying and reporting environmental concerns in resident rooms daily, but there was no evidence that this process was followed for this resident's bathroom. Follow-up observations showed that the wallpaper remained in poor condition several days after the initial report and observation.
Inaccurate MDS Coding for Resident Falls
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the status of two residents. For one resident with diagnoses including COPD, end stage renal disease, and difficulty walking, clinical records showed a fall with no injuries occurred. However, the resident's Minimum Data Set (MDS) assessment did not document this fall, indicating inaccurately that no falls had occurred since the prior assessment. This discrepancy was confirmed during staff interviews. Another resident, with a history of muscle weakness, difficulty walking, and traumatic brain injury, experienced a fall with injury and was sent to the emergency room. Despite this, the resident's MDS assessment also failed to document the fall, incorrectly stating that no falls had occurred since the previous assessment. Staff interviews confirmed the inaccuracy in the MDS coding for this resident as well.
Failure to Document and Respond to Significant Weight Changes in Resident with CHF
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for a resident diagnosed with congestive heart failure and atrial fibrillation. Physician orders required daily weights and notification of the practitioner if the resident gained 2 pounds or more in a day or 5 pounds in a week. Documentation showed that daily weights, or refusals, were not recorded for multiple days across three months. Additionally, a significant weight gain of 11.7 pounds in one day was documented, but there was no evidence that the practitioner was notified or that a reweigh was performed. The Director of Nursing confirmed that daily weights should have been recorded and appropriate follow-up should have occurred when the weight gain was identified.
Deficiency in Emergency Lighting Maintenance and Installation
Penalty
Summary
The facility was found to be deficient in maintaining and installing emergency lighting as required by NFPA 101. During a document review and observation, it was discovered that the facility lacked documentation verifying the annual maintenance of battery-powered emergency lighting sources. Additionally, it was observed that there was no installed battery-powered emergency lighting at the automatic transfer switch, affecting all six smoke compartments within the component. These findings were confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director.
Plan Of Correction
1. and 2. Maintenance Director has completed annual maintenance of battery-powered emergency lighting and installed battery-powered emergency lighting at the automatic transfer switch. 3. Maintenance department will be educated on the standards of ensuring the facility has completed the annual maintenance of battery-powered emergency lighting and ensuring there is a battery back-up emergency lighting at the automatic transfer switch. 4. Maintenance or facility designee will audit the facilities battery-powered emergency lighting weekly x2 for 2 months, then every 60 days throughout the year and results of the audit will be reported to the QA Committee.
Non-Compliance with Smoking Regulations
Penalty
Summary
The facility was found to be non-compliant with NFPA 101 smoking regulations due to several deficiencies. During a document review, it was discovered that the facility did not have a documented smoking policy available for review. This was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director. Additionally, the facility failed to post no smoking signs in areas where flammable liquids, combustible gases, or oxygen are used or stored, which was also confirmed during the exit conference interview. Furthermore, observations revealed that the facility did not provide metal containers with self-closing cover devices for ashtrays, nor did it have fire-resistant ashtrays in the designated smoking area behind the facility at the picnic table. This area was found to have an abundance of cigarette butts discarded on the ground, indicating a lack of proper receptacles. The absence of these required receptacles was confirmed during the exit conference interview with the Assistant Director of Nursing and the Maintenance Director.
Plan Of Correction
1 and 2. Maintenance Director will print smoking policy for life safety binder, will post non-smoking signs in rooms, wards, or compartments where flammable liquids, combustible gases or oxygen is used or stored and will provide metal receptacles to be available where smoking is permitted. 3. Maintenance department will be educated on the standards of the facilities smoking policy, need for non-smoking signs, and providing metal receptacles where smoking is permitted. 4. Maintenance or facility designee will audit facilities smoking policy, metal receptacles, and non-smoking signs to ensure it is checked off weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Failure to Maintain Essential Electrical System
Penalty
Summary
The facility failed to perform the required maintenance and testing of its Essential Electrical System (EES), which is crucial for ensuring the safety and functionality of the power supply in emergency situations. Specifically, the facility did not conduct the necessary weekly, monthly, and annual inspections and testing of the generator and associated equipment. This includes the failure to perform a monthly 30-minute load test using the transfer switches and an annual 90-minute load bank test. During a document review and interview conducted on April 16, 2025, it was confirmed by the Assistant Director of Nursing and the Maintenance Director that these essential maintenance activities were not carried out as required. The lack of adherence to the maintenance schedule outlined in NFPA 101 and related standards indicates a significant oversight in the facility's operational procedures, potentially compromising the reliability of the emergency power system.
Plan Of Correction
1 and 2. 4 hour building load test performed 3/8/2024 by GenServ. Maintenance Director has performed the monthly 30 min. test and will complete the annual 90 minute load bank inspection and testing of the facilities generator. 3. Maintenance department will be educated on the standards of completing weekly, monthly and annual inspections and testing of generator. 4. Maintenance or facility designee will audit facilities generator weekly for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Non-Compliance with GFI Protection Near Water Sources
Penalty
Summary
The facility failed to maintain power receptacles with Ground Fault Interruption (GFI) protection within six feet of a water source in three of six smoke zones. During an observation on April 16, 2025, between 12:30 PM and 12:45 PM, it was noted that various outlets were not GFI protected. Specifically, at 12:30 PM, one outlet in the D Hall Nurses' Station Nourishment Area was found to be non-compliant. At 12:40 PM, three outlets in the B Hall Beauty Shop, located by sinks, were also not GFI protected. Additionally, at 12:45 PM, two outlets in the Main Kitchen Prep Area, near the coffee machine and ice machine, were identified as lacking GFI protection. This was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director at the time of the exit conference on the same day.
Plan Of Correction
1 and 2. Maintenance Director has updated GFI's in D hall nurses station nourishment room (1 outlet), B hall beauty shop (3 outlets), and main kitchen prep area (2 outlets). 3. Maintenance department will be educated on the standards of maintaining power receptacles to be GFI within six feet of a water source. 4. Maintenance or facility designee will audit facilities GFI receptacles weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Deficiency in Smoke-Tight Integrity of Boiler Room Doors
Penalty
Summary
The facility failed to maintain the smoke-tight integrity of hazardous area doors in one of six smoke compartments. During an observation on April 16, 2025, at 11:55 AM, it was noted that there was a gap greater than 1/2-inch between the double doors of the Boiler Room due to a removed astragal. This deficiency was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director at the exit conference on the same day at 1:45 PM.
Plan Of Correction
1 and 2. Maintenance Director installed astragal between the double doors in the boiler room. 3. Maintenance department will be educated on the standards of ensuring the facility's corridor doors do not have a gap greater than 1/2in. and to not remove astragal. 4. Maintenance or facility designee will audit the facilities corridor doors weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Failure to Document Fire Suppression System Checks
Penalty
Summary
The facility failed to conduct and document the owner's checks of the fixed chemical fire suppression system in one of the six smoke compartments within the component. During a document review and interview conducted on April 16, 2025, it was revealed that the facility could not provide documentation of the owner's quick check for the fixed chemical fire suppression system installed in the kitchen. This deficiency was confirmed during an exit conference with the Assistant Director of Nursing and the Maintenance Director, who acknowledged the lack of documentation for the required quick checks on the kitchen's fire suppression system.
Plan Of Correction
1 and 2. Maintenance Director completed the monthly check of the chemical fire suppression system. 3. Maintenance department will be educated on the standards to ensure we are checking the chemical fire suppression system monthly. 4. Maintenance or facility designee will audit facilities chemical fire suppression system to ensure it is checked off weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Failure to Document Fire Alarm System Testing
Penalty
Summary
The facility failed to provide documentation verifying that the semi-annual testing and inspection of the fire alarm system had occurred within the previous twelve months. This deficiency was identified during a document review conducted on April 16, 2025, between 9:00 AM and 11:15 AM. The absence of this documentation affects the entire component of the fire alarm system. During an exit conference on the same day at 1:45 PM, the Assistant Director of Nursing and the Maintenance Director confirmed the lack of documentation for the required semi-annual testing and inspection of the fire alarm system.
Plan Of Correction
1 and 2. Maintenance Director contracted Eastern Time, Inc. to revisit facility to complete semi-annual fire alarm system testing. 3. Maintenance department will be educated on the standards of the facilities fire alarm system inspection. 4. Maintenance or facility designee will audit facilities fire alarm system inspection located in the life safety book weekly x2 for 2 months then quarterly throughout the year to confirm fire alarm reports are still available for review and results of the audit will be reported to the QA Committee.
Failure to Conduct Required Fire Drills
Penalty
Summary
The facility failed to conduct and perform fire drills as required, with deficiencies noted in the documentation review. Specifically, the facility did not perform fire drills for the 2nd shift in the 1st quarter of 2025, the 1st shift in the 3rd quarter of 2024, and the 3rd shift in the 3rd quarter of 2024. This was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director, who acknowledged that the fire drills were not conducted as mandated by the NFPA 101 standards, which require fire drills to be held at least quarterly on each shift under varying conditions.
Plan Of Correction
1 and 2. Maintenance Director will complete monthly fire drills, one per shift, per quarter. 3. Maintenance department will be educated on the standards of the facilities monthly fire drill policy ensuring they are being conducted one per shift, per quarter. 4. Maintenance or facility designee will audit facilities fire drills to ensure it is checked off weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Failure to Document Annual Fire Door Inspections
Penalty
Summary
The facility failed to provide documentation of the annual fire-rated door inspection for six smoke compartments. This deficiency was identified during a document review conducted on April 16, 2025, between 9:00 AM and 11:15 AM. The absence of documentation was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director at the exit conference on the same day at 1:45 PM. The lack of documentation indicates that the required annual inspections of fire door assemblies, as mandated by NFPA 80, were not properly recorded or possibly not conducted, leading to non-compliance with the Life Safety Code requirements.
Plan Of Correction
1 and 2. Maintenance Director has completed the annual fire door inspection in six of six smoke compartments. 3. Maintenance department will be educated on the standards of the facility's annual fire door inspection. 4. Maintenance or facility designee will audit facilities annual fire door inspection in life safety binder weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Failure to Monitor Nutritional Status Leads to Significant Weight Loss
Penalty
Summary
The facility failed to ensure proper monitoring of nutritional status for two residents, leading to significant unplanned weight loss. Resident 60, diagnosed with muscle wasting, atrophy, muscle weakness, and major depressive disorder, experienced an unplanned weight loss of 8.6 pounds (4.9%) between March and April 2024. The facility did not obtain monthly weight measures for November 2023 and January 2024, nor did they conduct a re-weigh for the weight change in April 2024. Additionally, there was no nutrition assessment conducted between March 22, 2024, and April 26, 2024, despite the resident's weight loss. Resident 72, diagnosed with dementia and moderate intellectual disabilities, experienced an unplanned significant weight loss of 16 pounds (approximately 10%) between March and April 2024. Although a dietician noted the weight loss and recommended weekly weight monitoring, the facility failed to obtain or record these weekly weights between April and May 2024. The Director of Nursing acknowledged the expectation for weekly weights following the significant weight loss, which was not met.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate resident assessments for three residents, leading to deficiencies in care documentation. Resident 12, diagnosed with Alzheimer's disease and type II diabetes mellitus, reported tooth pain due to poor dentition, which was confirmed by dental consults and a speech therapy evaluation. However, the comprehensive annual MDS for Resident 12 did not reflect the presence of obvious or likely cavities or broken teeth. This discrepancy arose because the MDS was completed by an off-site staff member who relied on an admission evaluation that inaccurately indicated the resident had dentures without other dental concerns. Resident 52, with diagnoses of dementia and type 2 diabetes, developed a pressure injury on the right heel after admission, which progressed to include necrotic tissue. The Discharge Return Anticipated MDS and Quarterly MDS for Resident 52 were incorrectly coded, indicating the pressure injury was present upon admission and misreporting weight loss. The Director of Nursing confirmed these coding errors during a staff interview. Resident 80, diagnosed with epileptic seizures and Alzheimer's disease, was admitted to hospice services, but the facility failed to indicate hospice care in two quarterly and one annual MDS assessments. This oversight was acknowledged by the Nursing Home Administrator and Director of Nursing during interviews with the surveyor, who highlighted the expectation for accurate MDS assessments.
Failure to Document Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that residents received necessary treatment and services to promote healing and prevent infection of pressure ulcers, as evidenced by missing documentation of wound care treatments for three residents. Resident 11, diagnosed with dementia and muscle weakness, had a stage III pressure injury on the sacrum. The treatment orders included cleansing with saline, applying skin prep, hydrogel, and a dry dressing. However, documentation was missing for several dates in March and May 2024, indicating that the treatments may not have been completed as ordered. Resident 72, with dementia and moderate intellectual disabilities, had stage III pressure injuries on the left heel, right heel, and right ankle. The treatment orders involved cleansing with wound cleanser, applying skin prep, hydrogel, and optifoam dressing. Documentation was missing for multiple dates in April 2024, suggesting a lack of adherence to the prescribed treatment schedule. The Director of Nursing acknowledged the missing documentation and expressed the expectation that treatments should be documented. Resident 110, diagnosed with a pressure ulcer of the left heel, peripheral vascular disease, and muscle weakness, also had missing documentation for wound care treatments. The treatment orders included cleansing with saline, applying wet gauze, and covering with ABD and kerlex. Documentation was absent for several dates from November 2023 to May 2024. The Director of Nursing was unable to provide additional information regarding the missing documentation and reiterated the expectation for wound treatments to be documented.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care and oxygen services consistent with professional standards for a resident with a history of pulmonary embolism, acute pulmonale, and chronic obstructive pulmonary disease. The resident had physician orders for Ipratropium-Albuterol Solution to be administered four times daily and as needed. Observations revealed that the nebulizer mask was left uncovered on the resident's nightstand with the medication reservoir still attached, and the tubing was not changed weekly as required. The resident reported that staff no longer cleaned or changed the mask frequently. Interviews with staff, including a registered nurse and a respiratory therapist, confirmed that nebulizer tubing should be changed weekly and masks should be cleaned after each treatment. However, the respiratory therapist, who had recently started working at the facility, was unaware of the current status of nebulizer equipment and was waiting for a list of nebulizers in the building. The resident also reported having to remove the nebulizer mask herself after treatment, as staff did not return to do so, and the mask was not cleaned afterward. The facility's nursing home administrator and director of nursing were informed of these observations and the resident's statements.
Incomplete Clinical Records for Resident Treatments
Penalty
Summary
The facility failed to maintain complete clinical records for a resident, identified as Resident 107, who has diagnoses including neurogenic bladder and spina bifida. The resident was cognitively intact and required specific treatments for moisture-associated skin damage (MASD) on his buttock and scrotum, which included the application of zinc paste every shift. Additionally, the resident was receiving Ketoconazole cream 2% for a skin condition on his head, face, and neck every shift. However, the Treatment Administration Record (TAR) for Resident 107 showed that staff did not initial and check the block confirming the administration of the Ketoconazole cream on three specific dates and shifts in April 2024. Similarly, the TAR also revealed that staff failed to document the administration of the zinc paste on three different dates and shifts in April 2024. During an interview, the Director of Nursing (DON) confirmed that all treatments should be signed off as completed on the TAR. This deficiency was identified through a review of clinical records and staff interviews, indicating a lapse in maintaining complete and accurate medical records in accordance with accepted professional standards.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in three of the four nursing units observed. Specific observations included the presence of a black, speckled substance on air vents in the dining room outside the main kitchen, black substance accumulations along the corners of walls beside heating vents/units in multiple residents' rooms, and debris in heating/cooling units. Additionally, some heating/cooling units had missing plastic grates, dried spill/splash spots, and crumbling walls with debris noted in and on the units. During a tour with the Nursing Home Administrator and Director of Nursing, they acknowledged the concerns. The Director of Nursing later revealed that work orders had been submitted for the required repairs, and staff were in the process of auditing rooms for cleanliness.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
