Complete Care At Harston Hall Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Flourtown, Pennsylvania.
- Location
- 350 Haws Lane, Flourtown, Pennsylvania 19031
- CMS Provider Number
- 395791
- Inspections on file
- 27
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Complete Care At Harston Hall Llc during CMS and state inspections, most recent first.
Surveyors identified that a resident room was not maintained in a safe, clean, and homelike condition. The room had a phone jack with a missing face plate and exposed wires, multiple stained ceiling tiles, and a bathroom with broken bathtub tiles and exposed holes in the wall around the faucet. These conditions were confirmed by the ADON.
A resident with multiple cardiac conditions and intact cognition had a standing order for Eliquis 5 mg BID that was held for surgery and then not resumed for approximately nine weeks, despite multiple hospital discharge orders directing continuation of the medication. Facility policy required thorough medication reconciliation using discharge summaries, prior MARs, and admission orders, but Eliquis was not re-entered into the EHR or administered. The DON confirmed the lapse, and an LPN acknowledged responsibility for verifying post-hospital medications and stated the Eliquis order was unintentionally missed during reconciliation.
A resident with paraplegia and a pressure ulcer was left exposed during wound care for several minutes while multiple staff members entered and exited the room without providing privacy or introducing themselves. The resident, who is cognitively intact, reported that this lack of privacy and staff introductions happens frequently and causes discomfort.
A resident with end stage renal disease, who was cognitively intact, reported being treated poorly by a CNA, including being denied assistance to use the bathroom and being spoken to in a demeaning manner. The family filed a grievance, but there was no documented evidence that the facility conducted a required investigation into the alleged abuse and neglect, despite facility policy mandating such action.
The facility did not maintain and inspect emergency lighting as required, affecting the entire facility. Documentation for monthly and annual testing was missing, as confirmed by the Maintenance Director.
The facility did not maintain and inspect exit signs according to NFPA 101 standards, as they failed to provide documentation of monthly inspections. This issue was confirmed during an interview with the Maintenance Director.
The facility failed to maintain and inspect the kitchen exhaust hood suppression system, affecting the entire facility. Documentation for semi-annual maintenance and testing, as well as cleaning of the kitchen exhaust hood, was missing. Additionally, the kitchen hood exhaust suppression system lacked monthly inspections. These issues were confirmed during an exit interview with the Maintenance Director.
The facility failed to maintain and inspect its fire alarm system, affecting the entire facility. It lacked documentation for required fire alarm system testing and smoke detector sensitivity testing. Additionally, the fire alarm panel was observed to be in a trouble state. These issues were confirmed during an interview with the Maintenance Director.
The facility did not comply with NFPA 101 requirements when the fire alarm system was out of service for over four hours. They failed to notify the authority, evacuate the building, or provide a fire watch, as revealed through document review and interviews, showing a lack of necessary policies affecting the entire facility.
The facility failed to provide a fire watch policy and maintain documentation for the sprinkler system's maintenance. The facility could not provide a fire watch policy or documentation for quarterly sprinkler inspections for the 1st quarter of 2025 and the 4th quarter of 2024, as well as the 5-year internal valve and pipe inspection. These deficiencies were confirmed during an exit interview with the Maintenance Director.
The facility did not maintain proper documentation for the annual maintenance of portable fire extinguishers, as they could not provide the technician's certification. This issue was confirmed during an interview with the Maintenance Director.
The facility did not maintain its HVAC systems as required by NFPA 101, failing to provide documentation of fire/smoke damper testing within the past four years. This was confirmed during an interview with the Maintenance Director.
The facility was found deficient in providing required policies for snow removal and fire evacuation, affecting the entire facility. During a document review, the facility could not produce these essential policies, which was confirmed by the Maintenance Director. This indicates a gap in the facility's preparedness for emergency situations.
The facility failed to maintain and inspect the emergency generator, lacking documentation for critical tests and inspections such as weekly battery voltage checks and monthly generator load tests. This deficiency was confirmed during an interview with the Maintenance Director.
The facility failed to ensure staff knew the code to unlock a Special Needs Locking Arrangement on the first floor in the Physical Therapy area. During an observation, it was found that staff did not know the code to unlock the exit door, confirmed by the Maintenance Director. This affects one of the three levels in the facility.
The facility failed to maintain hazardous areas, as observed in the Kitchen on the second floor, where the Storage Closet next to the Janitor's Closet lacked a self-closer. This was confirmed by the Maintenance Director.
The facility did not maintain the fire resistance of smoke barriers, as observed on the second floor where a smoke barrier near a resident room was blocked open by a patient lift. This was confirmed by the Maintenance Director.
The facility was found non-compliant with NFPA 70, National Electric Code, due to a non-GFCI outlet near a sink, improper storage near electrical panels, and an unsecured junction box. These issues were confirmed by the Maintenance Director.
The facility did not maintain the fire resistance of its trash chutes, affecting one level. An observation revealed that the trash chute door on the second floor failed to close and latch, which was confirmed by the Maintenance Director.
The facility improperly stored approximately 72 E-sized oxygen tanks in a first-floor Conference Room lacking a 1-hour fire resistance rating, as observed during a survey. This deficiency was confirmed in an interview with the Maintenance Director.
The facility did not review and update its Emergency Preparedness Plan annually, as required. A document review revealed this deficiency, and the Maintenance Director confirmed the lack of documentation.
The facility failed to conduct the required annual full-scale exercise or an accepted substitution, as well as an additional exercise, within the previous 12 months. This deficiency affects the entire facility, as it did not meet the emergency preparedness testing requirements. The lack of documentation confirmed during an exit interview with the Maintenance Director further substantiates the facility's non-compliance.
The facility failed to comply with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act by not having a Carbon Monoxide Evacuation Plan in place. This deficiency was identified during a document review and confirmed in an interview with the Maintenance Director.
The facility's Emergency Preparedness Plan was found lacking in comprehensive policies and procedures for addressing the patient population, particularly persons at-risk, and ensuring continuity of operations during emergencies. This deficiency was confirmed during a document review and an exit interview with the Maintenance Director.
The facility failed to develop emergency preparedness policies and procedures that included a system of medical documentation to preserve and protect patient information. This deficiency was confirmed during a document review and an exit interview with the Maintenance Director, affecting the entire facility.
The facility's emergency preparedness communication plan lacked a means of providing information about the ASC's needs and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. This deficiency was confirmed during an exit interview with the Maintenance Director, affecting the entire facility.
The facility's food and nutrition services department was found deficient in maintaining food safety and sanitation standards. The dish machine was non-functional, leading to inadequate sanitization of dishes. The kitchen lacked a water softener, resulting in mineral deposits, and had significant water damage and mold issues. The walk-in refrigerator was heavily soiled, and the reach-in units were non-functional. Leaking sinks and steam tables further compromised the kitchen's sanitation.
The facility failed to maintain a clean and homelike environment on the third-floor nursing unit. Room 304B had a significant urine smell, and Room 304A, where a resident had passed away, was not cleaned or cleared of personal belongings. The room contained a broken chair, dusty dressers, and a broken television. Observations confirmed that housekeeping staff were not consistently maintaining cleanliness, as tray tables had food spills and windowsills were dusty.
Two residents in a LTC facility experienced misappropriation of narcotic medication, specifically morphine sulfate, which was found to be tampered with and diluted. Despite the tampering, one resident reported adequate pain management. The facility confirmed the misappropriation, conducted drug tests on nurses, and contacted local police, who declined to investigate further.
The facility failed to provide sufficient nursing staff, leading to delayed responses to call bells and unmet resident needs. A resident, who is non-verbal, was left waiting for a transfer to her wheelchair after a nurse turned off the call bell without assisting. The facility also did not meet state-required staffing levels, as confirmed by staff interviews.
The facility did not complete the required 12 hours of annual in-service training for three nurse aides. A review of documentation and staff interviews revealed that Employees E21, E22, and E23 did not receive the mandated training, as confirmed by the Development Coordinator.
The facility failed to serve food and drinks at safe and appetizing temperatures due to malfunctioning equipment, including a broken refrigerator and non-operational steam tables. This resulted in meals being served below the required temperatures, with residents expressing dissatisfaction with the quality and presentation of the food.
The facility failed to store bed linens in a sanitary environment, increasing the risk of infection. New linens were found unfolded on the bare floor in the laundry area, and clean pillows and extra pads were stored directly on the floor in the linen closet. These practices did not comply with the facility's policy to prevent pathogen transmission.
The facility failed to maintain dignity and respect for two residents, as staff did not display identification badges and were reported to be disrespectful. One resident with Parkinson's and diabetes felt staff were uncooperative, while another with a femur fracture and heart disease reported being woken at night without explanation. Observations confirmed staff did not properly display identification, violating the facility's policy on resident dignity.
The facility failed to conduct timely criminal background checks for two newly hired employees, an LPN and an RN, as required by its abuse prohibition policy. The LPN's background check was completed a month after their hire date, and the RN's was done a week after hiring. This deficiency was confirmed through a review of personnel records and staff interviews.
A facility failed to thoroughly investigate an incident where a resident with Alzheimer's and other conditions was found with wet sheets, indicating neglect in incontinence care. The investigation lacked comprehensive witness statements, and it was confirmed that a nurse aide did not complete the required care rounds.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in their care. A resident with emphysema did not have a care plan for prescribed oxygen therapy. Another resident at risk for elopement lacked a care plan for a safety device. A third resident with pressure ulcers had no care plan for repositioning, despite needing assistance. These omissions were confirmed by facility staff.
A facility failed to provide necessary ADL assistance for grooming to a resident with chronic health conditions, who was cognitively intact and required maximum assistance with personal hygiene. Observations revealed the resident had long and dirty fingernails, and despite expressing a desire to have them trimmed, the issue was not fully addressed by the staff.
A facility failed to provide appropriate pressure ulcer treatment for a resident with a Stage 3 ulcer on the right heel. Despite a care plan requiring offloading and heel protectors, the resident was observed without a heel boot, and the heel was not offloaded. Staff confirmed the boot was only applied at night, contrary to the care plan.
A resident with cognitive impairment and multiple diagnoses, including malnutrition and a swallowing disorder, experienced significant weight loss and worsening pressure ulcers due to the facility's failure to implement prescribed nutritional interventions. Despite being at high risk for pressure ulcer development, the facility did not consistently administer a prescribed nutritional supplement, nor did they document necessary assessments and notifications, leading to the resident's declining health.
The facility failed to provide proper respiratory care for four residents, including incorrect oxygen levels, unlabeled tubing, and lack of bedside suction equipment. A resident with a tracheostomy was left without necessary supplies, and another was found with an empty oxygen tank. These issues reflect non-compliance with physician orders and facility policies.
A resident with COPD, knee contracture, and shoulder osteoarthritis did not receive proper pain management. Despite being cognitively intact and expressing pain when rolled to the right side, the facility lacked a care plan addressing this issue. The resident's care plan did not prevent rolling to the painful side, leading to a deficiency in pain management services.
A facility failed to ensure nursing staff were competent in tracheostomy care and suctioning for a resident with a tracheostomy. The LPN had to leave the resident's bedside to retrieve suctioning equipment, which was not available as required. Interviews and personnel file reviews confirmed the absence of documented competencies for these procedures among licensed staff.
The facility failed to ensure complete narcotic reconciliation records, with missing signatures and initials on narcotic count sheets for three medication carts. Observations revealed multiple missing signatures for oncoming and outgoing nurses, confirmed by LPNs and a Clinical Regional Nurse. This violates the facility's procedures and regulatory requirements.
The facility failed to label opened medications with the date they were opened, as observed in two medication carts and one medication room. This included various medications such as B12, Cranberry, Vitamin D, Ferrous Sulfate, B1, and Tuberculin. Staff interviews confirmed the absence of open date labels.
A resident with cognitive impairment and pressure ulcers was not documented as being turned and repositioned every 2-3 hours as required by facility policy. Interviews confirmed the absence of documentation, indicating a failure to adhere to care protocols.
Essential kitchen equipment in the facility was not maintained in safe operating condition. The dish machine was non-functional, failing to sanitize dishes properly, and cold food items were not stored at safe temperatures due to broken refrigeration units. Additionally, the lowerator and steam tables were not fully operational, leading to unsafe handling practices. These issues were confirmed by the facility administrator.
The facility failed to maintain an effective pest control program, with gnat flies observed in a resident's room and pest issues in the kitchen. Despite claims of weekly treatments, records showed bi-monthly treatments, and there was no documentation of gnat treatment in the affected room. The kitchen had significant cleanliness and maintenance issues, contributing to pest problems, with active roach and mice observations documented.
The facility did not provide timely abuse, neglect, and exploitation training to four newly hired staff members, as required by regulations. The training for these employees was either delayed or not documented, contrary to the facility's policy. An HR staff member confirmed these findings.
The facility inaccurately reported an incident of narcotics misappropriation involving tampered morphine bottles for two residents. The incident was incorrectly categorized in the state reporting system, as confirmed by interviews with the Nursing Home Administrator and the DON.
Environmental Hazards and Poor Maintenance in a Resident Room
Penalty
Summary
Surveyors determined that the facility failed to maintain a safe, clean, and homelike environment in one of five resident rooms observed. During an initial tour of the facility, room [ROOM NUMBER] was found to have a phone jack with the face plate missing and wires hanging from the wall. Further observation of the same room revealed multiple stained ceiling tiles. In the bathroom of room [ROOM NUMBER], surveyors observed broken tiles in the bathtub, with holes exposed in the wall around the faucet. These environmental deficiencies were confirmed in an interview with the Assistant Director of Nursing (Employee E1).
Failure to Resume Ordered Anticoagulant After Hospital Discharge
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for an anticoagulant medication during admission/readmission medication reconciliation and subsequent care. Facility policy on medication reconciliation, revised July 2017, requires staff to gather all relevant documentation (including discharge summaries, admission orders, previous MARs, and medication history), compile a complete and accurate list of medications with dose, route, frequency, and indication, and review this list for discrepancies, documenting all findings and provider communications. Resident R1, cognitively intact with a BIMS score of 13, had multiple cardiovascular diagnoses including peripheral vascular disease, chronic heart failure, acute ischemic heart disease, coronary artery disease, cardiomyopathy, and endocarditis, as well as anxiety. Physician orders from July through September 2025 included Eliquis (apixaban) 5 mg to be administered twice daily. Review of the MAR showed Eliquis was held for an upcoming surgery and last administered on July 14, 2025, with no further doses given until September 26, 2025. Hospital discharge orders dated 7/22/25, 8/4/25, and 9/26/25 each directed that Eliquis 5 mg be continued, including twice daily dosing. Despite these orders, the medication was not re-entered into the electronic health record or administered for approximately nine weeks. The DON confirmed that Eliquis had not been given during this period and believed it had been discontinued prior to surgery and never reordered. A licensed nurse acknowledged it was her responsibility to verify all medications post-hospitalization and stated that the Eliquis order was unintentionally missed, despite standard protocol to confirm medications with hospital staff at discharge and upon the resident’s return.
Failure to Provide Privacy and Dignity During Wound Care
Penalty
Summary
A deficiency was identified when a resident with diagnoses of sepsis, paraplegia, and a pressure ulcer of the left buttocks was not treated with dignity and respect during wound care. The facility's policy requires staff to explain procedures and provide privacy by screening the resident. However, during an observed wound care procedure, the resident was left with exposed buttocks for approximately two minutes after perineal care while staff prepared for a dressing change. During this time, multiple unnamed staff members entered and exited the room without introducing themselves or providing privacy for the resident. The resident, who was cognitively intact according to a recent assessment, reported that this lack of privacy and failure of staff to introduce themselves occurs frequently during care. The resident expressed discomfort and a sense that staff did not care about his privacy, as people would come and go during care without explanation or introduction, including staff delivering trays and housekeeping personnel. These actions were found to be inconsistent with the facility's policy and the resident's rights to dignity and respect.
Failure to Investigate Alleged Abuse and Neglect
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of potential abuse and neglect involving a resident with end stage renal disease who was cognitively intact. The incident was reported by the resident's family, who described that the resident requested assistance from a CNA to use the bathroom but was told to get into bed instead. After being put in bed, the resident had an accident, and when the aide returned, she reportedly used a demeaning tone and was forceful while providing care, leaving the resident feeling hurt and embarrassed. The family formally requested an apology and assurance of safety for the resident. Despite the grievance being documented and the staff member identified, there was no documented evidence that an investigation was completed regarding the concern of abuse and neglect. The only action noted was that the CNA received education on customer service and perineal care. The Director of Nursing confirmed that no investigation documentation existed for this incident, which is contrary to the facility's policy requiring immediate and thorough investigation of all alleged violations.
Failure to Maintain and Inspect Emergency Lighting
Penalty
Summary
The facility failed to maintain and inspect emergency lighting as required by NFPA 101, affecting the entire facility. During a document review on May 1, 2025, it was found that the facility could not provide documentation for monthly testing and annual 90-minute testing of emergency lighting. This deficiency was confirmed during an exit interview with the Maintenance Director on the same day.
Plan Of Correction
The facility will maintain and inspect emergency lighting, affecting the entire facility. The Director of Maintenance or designee will audit emergency lighting of at least 1-1/2-hour duration, monthly testing for 30 seconds and annual 90-minute testing weekly x4 then monthly x2. All findings will be brought to QAPI for review.
Failure to Maintain and Inspect Exit Signs
Penalty
Summary
The facility failed to maintain and inspect exit signs as required by NFPA 101 standards. During a document review on May 1, 2025, it was discovered that the facility did not provide documentation of monthly exit sign inspections. This deficiency affects the entire facility, as confirmed during an exit interview with the Maintenance Director on the same day.
Plan Of Correction
The facility will maintain documentation of monthly exit sign inspection. NHA or designee will audit weekly x4 then monthly x2. All findings will be brought to QAPI for review.
Failure to Maintain Kitchen Exhaust Hood Suppression System
Penalty
Summary
The facility failed to maintain and inspect the kitchen exhaust hood suppression system, which affects the entire facility. During a document review on May 1, 2025, it was found that the facility could not provide documentation for the semi-annual maintenance and testing of the kitchen exhaust hood suppression system, which was due within six months after May 29, 2024. Additionally, the facility lacked documentation for the semi-annual cleaning of the kitchen exhaust hood, which was due within six months prior to March 20, 2025. An observation on the same day revealed that the kitchen hood exhaust suppression system lacked monthly inspections. These deficiencies were confirmed during an exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., who acknowledged the absence of the required documentation and inspections.
Plan Of Correction
The facility will maintain and inspect the kitchen exhaust hood suppression system, affecting the entire facility. Contracted service called for updated visit and servicing the semi-annual kitchen exhaust hood suppression system maintenance and testing within 6 months after and will be coming out the week of 5/29/24. They will also complete a cleaning. Director of Maintenance will audit monthly x2, to ensure systems are checked and in place. Results will be brought to QAPI for review. Life Safety book will be updated.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain and inspect its fire alarm system, which affected the entire facility. During a document review on May 1, 2025, it was found that the facility lacked documentation for annual and semi-annual fire alarm system testing, as well as smoke detector sensitivity testing within the past two years. Additionally, an observation on the same day revealed that the fire alarm panel was in a trouble state. These findings were confirmed during an exit interview with the Maintenance Director.
Plan Of Correction
The facility will maintain and inspect the fire alarm system, affecting the entire facility. Outside contracted service was called to complete the Annual and semi-annual fire alarm system testing and Smoke detector sensitivity testing within the past 2 years. Outside company called to inspect fire panel for service and or replace. The Director of Maintenance will audit fire alarm systems 2x weekly for 2 months. All findings will be brought to QAPI for review. Any issues arise, outside company notified.
Fire Alarm System Out of Service Without Proper Protocols
Penalty
Summary
The facility failed to meet the requirements of NFPA 101 regarding the fire alarm system. Specifically, the fire alarm system was out of service for more than four hours within a 24-hour period. During this time, the facility did not notify the authority having jurisdiction, nor did they evacuate the building or provide an approved fire watch for the safety of all parties left unprotected by the shutdown. This deficiency was identified based on document review and interviews, indicating a lack of required policies affecting the entire facility.
Plan Of Correction
Facility will maintain a fire watch policy and update in EP book. The Director of Maintenance will audit EP book for updated policies 2x weekly for 2 months. All findings will be brought to QAPI for review.
Deficiencies in Fire Safety Documentation and Sprinkler System Maintenance
Penalty
Summary
The facility failed to provide a fire watch policy and maintain proper documentation for the sprinkler system's maintenance and testing. During a document review on May 1, 2025, at 8:15 a.m., it was revealed that the facility could not provide a fire watch policy. This was confirmed during an exit interview with the Maintenance Director at 10:30 a.m. on the same day. Additionally, the facility was unable to provide documentation for quarterly sprinkler inspections for the 1st quarter of 2025 and the 4th quarter of 2024, as well as the 5-year internal valve and pipe inspection. These deficiencies were confirmed during the exit interview with the Maintenance Director.
Plan Of Correction
The facility will maintain and inspect the sprinkler system, affecting the entire facility. Outside contracted service called and scheduled for quarterly sprinkler inspection and 5 year internal valve and pipe inspection. The Director of Maintenance or designee will audit inspect sprinkler systems 2x weekly for 2 monthly. All findings will be brought to QAPI for review.
Failure to Maintain Fire Extinguisher Documentation
Penalty
Summary
The facility failed to maintain and inspect portable fire extinguishers in accordance with NFPA 10, affecting the entire facility. During a document review, it was found that the facility could not provide a copy of the fire extinguisher technician's certification for the annual maintenance of the fire extinguishers. This deficiency was confirmed during an exit interview with the Maintenance Director.
Plan Of Correction
Facility received a copy of the fire extinguisher technician's certification that conducted our annual fire extinguisher maintenance. Copy was updated in EP book. The Director of Maintenance or designee will audit certifications monthly x2. All findings will be brought to QAPI for review.
Failure to Maintain HVAC Systems
Penalty
Summary
The facility failed to maintain its HVAC systems in compliance with NFPA 101 standards, specifically regarding the testing and exercising of fire/smoke dampers. During a document review on May 1, 2025, it was found that the facility could not provide documentation that these dampers had been tested or exercised within the past four years. This deficiency was confirmed during an exit interview with the Maintenance Director on the same day.
Plan Of Correction
Facility will provide documentation that the fire/smoke dampers had been tested/exercised within the past 4 years. Outside company called for service to complete testing and update EP book. NHA will audit EP book monthly x2 for documentation. Results will be reviewed in QPAI.
Deficiency in Required Policies for Snow Removal and Fire Evacuation
Penalty
Summary
The facility was found deficient in providing required policies during a document review conducted on May 1, 2025. Specifically, the facility failed to produce policies related to snow removal and fire evacuation, which are essential for ensuring the safety and operational readiness of the facility. This deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the absence of the necessary documentation. The lack of these critical policies affects the entire facility, indicating a gap in the facility's preparedness for emergency situations.
Plan Of Correction
Facility will provide required policies, snow removal and fire evacuation affecting the entire facility. Snow removal contract was received, and the fire evacuation was completed and updated in the EP book.
Failure to Maintain and Inspect Emergency Generator
Penalty
Summary
The facility failed to maintain and inspect the emergency generator, which is crucial for the safety and operation of the entire facility. During a document review, it was found that the facility could not provide documentation for several critical tests and inspections. These included the weekly inspection of battery voltage, monthly testing of battery conductance, monthly testing of the generator under load, monthly operation of the automatic transfer switch (ATS), and an annual 90-minute load bank test. Additionally, there was no evidence of preventative maintenance indicating the absence of wet stacking. The lack of documentation was confirmed during an exit interview with the Maintenance Director. This deficiency indicates that the facility did not adhere to the required maintenance and testing protocols as outlined by NFPA standards, which are essential for ensuring the reliability of the emergency power system. The failure to maintain proper records and conduct necessary inspections and tests could potentially compromise the facility's ability to provide essential services during a power outage.
Plan Of Correction
Facility will maintain and inspect the emergency generator, affecting the entire facility. a. Weekly inspection of battery voltage was completed. Maintenance Director will audit weekly x4 then monthly x2. b. Monthly testing of battery conductance was completed. Maintenance Director will audit weekly x4 then monthly x2. c. Monthly testing of the generator under load was completed. Maintenance Director will audit weekly x4 then monthly x2. d. Monthly operation of the ATS was completed. Maintenance Director will audit weekly x4 then monthly x2. e. Annual 90 minute load bank was completed. Maintenance Director will audit weekly x4 then monthly x2. f. Preventative maintenance of wet stacking was completed by Powerhouse Company. All documents are added to our Life Safety Book.
Staff Unaware of Special Needs Locking Code
Penalty
Summary
The facility failed to maintain proper knowledge of Special Needs Locking Arrangements on the first floor in the Physical Therapy area. During an observation on May 1, 2025, at 10:08 a.m., it was noted that the staff was unaware of the code required to unlock the exit door. This lack of knowledge could potentially hinder the rapid removal of occupants in case of an emergency, as the staff did not have immediate access to the necessary unlocking mechanism. An exit interview with the Maintenance Director on the same day at 10:30 a.m. confirmed the deficiency, as the director acknowledged that the staff did not know the unlock code. This oversight affects one of the three levels in the facility, indicating a lapse in ensuring that all staff members are adequately trained and informed about the security protocols necessary for the safety and security of the residents and staff in the facility.
Plan Of Correction
The facility will maintain doors with Special Needs Locking Arrangements, affecting all of three levels in the facility. The Director of Maintenance will in-service the Physical Therapy department on the codes on all doors.
Deficiency in Hazardous Area Maintenance
Penalty
Summary
The facility failed to maintain hazardous areas as required, specifically on the second floor in the Kitchen. During an observation on May 1, 2025, it was noted that the Storage Closet next to the Janitor's Closet lacked a self-closing mechanism. This deficiency was confirmed during an exit interview with the Maintenance Director on the same day.
Plan Of Correction
Facility will maintain hazardous areas, affecting all of two levels in the facility. Maintenance will audit all self closers for proper use weekly x2, then monthly x2. Results will be brought to QAPI for review. Door self closer was ordered and installed for proper use.
Smoke Barrier Blocked by Patient Lift
Penalty
Summary
The facility failed to maintain the fire resistance of smoke barriers, specifically affecting one of the three levels in the building. During an observation on May 1, 2025, at 9:58 a.m., it was noted that the smoke barrier near resident room 216 on the second floor was blocked open by a patient lift. This deficiency was confirmed during an exit interview with the Maintenance Director on the same day at 10:30 a.m.
Plan Of Correction
The facility will maintain the fire resistance of smoke barriers, affecting all of three levels in the facility. Blockage was removed. Staff in-serviced on the importance of keeping the smoke barrier doors free from any items. The Director of Maintenance or designee will audit smoke barrier doorways 3x weekly for 2 monthly. All findings will be brought to QAPI for review.
Non-Compliance with NFPA 70 Electrical Code
Penalty
Summary
The facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting two of three levels in the facility. On the second floor, a non-GFCI outlet was observed within 6 feet of a sink in the Mechanical Room, which is a violation of NFPA 70 210.8(B)5 that requires a GFCI outlet in such locations. Additionally, storage was found within three feet of electrical panels in several locations, including the third floor Mechanical Room and next to Clean Linen areas on both the second and third floors, violating NFPA70 110.26(A)(1) which mandates a 3 ft. clearance in front of electrical equipment. Furthermore, an unsecured junction box was observed above the smoke barrier next to a resident room on the third floor. These deficiencies were confirmed during an exit interview with the Maintenance Director.
Plan Of Correction
1: Outlet was changed to a GFCI over the sink. 2: Storage was removed from the room. National Electric Code, for electrical wiring and equipment, affecting two of three levels in the facility. a. 9:39 a.m., on the third floor, Mechanical Room; box was removed and in-serviced staff on the importance of keeping that area free from items. b. 9:45 a.m., on the third floor, next to Clean Linen; wheelchair was in the cubby hole, was removed and staff in-serviced on the importance of keeping that area free from items. c. 9:50 a.m., on the second floor, next to Clean Linen; wheelchair was in the cubby hole/chair removed and staff in-serviced on the importance of keeping that area free from items. Unsecured junction box above the smoke barrier next to resident room 312 was fixed and secured.
Trash Chute Door Fails to Close and Latch
Penalty
Summary
The facility failed to maintain the fire resistance of its trash chutes, specifically affecting one of the three levels in the facility. During an observation on May 1, 2025, at 9:55 a.m., it was noted that the trash chute door on the second floor did not close and latch as required. This deficiency was confirmed during an exit interview with the Maintenance Director on the same day at 10:30 a.m.
Plan Of Correction
On the second floor, the trash chute door was fixed and is able to close and latch. It was clean and clear of debris. Staff in-serviced on the importance to keep it clean and free from debris. The Director of Maintenance or designee will audit trash chute 3x weekly for x2 monthly. All findings will be brought to QAPI for review.
Improper Storage of Oxygen Tanks in Conference Room
Penalty
Summary
The facility failed to maintain proper storage conditions for gas cylinders exceeding 3,000 cubic feet. During an observation on May 1, 2025, it was noted that the Conference Room on the first floor was being used to store approximately 72 E-sized oxygen tanks. This room did not have the required 1-hour fire resistance rating, which is necessary for the safe storage of such a large volume of gas cylinders. The deficiency was confirmed during an exit interview with the Maintenance Director on the same day. The improper storage of oxygen tanks in a room lacking adequate fire resistance poses a significant safety concern, as it does not comply with the standards set forth in NFPA 101 for gas equipment storage.
Plan Of Correction
Facility will maintain storage areas for gas cylinder storage over 3,000 cubic feet. Oxygen bottles were removed from the conference room and relocated to the Oxygen room. Staff in-service on the proper location of the oxygen bottles. The Director of Maintenance or designee will audit Oxygen bottle location 3x weekly for 2 monthly. All findings will be brought to QAPI for review.
Failure to Annually Update Emergency Preparedness Plan
Penalty
Summary
The facility failed to ensure that its Emergency Preparedness Plan was reviewed and updated at least annually, as required by federal regulations for long-term care facilities. During a document review conducted on May 1, 2025, it was discovered that the plan had not been reviewed and updated within the required timeframe. This oversight affects the entire facility, as the emergency preparedness plan is a critical component of ensuring the safety and well-being of all residents and staff in the event of an emergency. An exit interview with the Maintenance Director on the same day confirmed the lack of documentation regarding the review and update of the Emergency Preparedness Plan. This indicates a lapse in the facility's compliance with federal emergency preparedness requirements, which mandate that such plans be maintained and updated annually to address potential hazards and ensure readiness for emergencies.
Plan Of Correction
Facility established and maintaining a comprehensive emergency preparedness program that meets the requirements. The Director of Maintenance or designee will audit to ensure Emergency Preparedness Plan policies and procedures are reviewed and updated at least annually, weekly x2, then monthly x2. All findings will be brought to QAPI for review.
Failure to Conduct Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to conduct the required annual full-scale exercise or an accepted substitution, as well as an additional exercise or accepted substitution, within the previous 12 months. This deficiency was identified during a document review conducted on May 1, 2025, at 8:15 a.m. The review revealed that the facility did not meet the emergency preparedness testing requirements outlined in §483.73(d)(2), which mandates that long-term care facilities conduct exercises to test their emergency plans at least twice per year. The deficiency affects the entire facility, as the lack of proper emergency preparedness exercises could impact the facility's ability to effectively respond to emergencies. The regulations require participation in a community-based full-scale exercise annually, or if not accessible, a facility-based functional exercise. Additionally, an extra exercise, such as a mock disaster drill or tabletop exercise, must be conducted annually. The facility's failure to conduct these exercises indicates non-compliance with federal regulations. During the exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., it was confirmed that there was a lack of documentation to support the completion of the required exercises. This lack of documentation further substantiates the facility's failure to adhere to the emergency preparedness requirements, as there is no evidence to demonstrate that the necessary exercises were conducted or that the emergency plan was adequately tested and revised as needed.
Plan Of Correction
The facility will conduct the Emergency Plan's required annual full-scale exercise, a mock disaster drill, and a tabletop exercise affecting the entire facility. These will be done within the next 2 months. NHA will audit monthly x2; results will be brought to QAPI for review.
Facility Lacks Carbon Monoxide Evacuation Plan
Penalty
Summary
The facility was found deficient in adhering to the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act, which affects the entire facility. During a document review conducted on May 1, 2025, it was discovered that the facility failed to update its policies in accordance with the Act. Specifically, the facility lacked a Carbon Monoxide Evacuation Plan, which is a requirement under the Act. This deficiency was confirmed during an exit interview with the Maintenance Director on the same day, who acknowledged the absence of the necessary documentation.
Plan Of Correction
Facility will update facility policies in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act, affecting the entire facility. The facility will develop a Carbon Monoxide Evacuation Plan and add it to the EPP book.
Emergency Preparedness Plan Lacks Comprehensive Policies
Penalty
Summary
The facility failed to ensure that its Emergency Preparedness Plan included comprehensive policies and procedures addressing the patient population, particularly persons at-risk, the types of services the facility could provide during an emergency, and the continuity of operations. This deficiency was identified during a document review conducted on May 1, 2025, at 8:15 a.m., which revealed that the plan did not adequately cover these critical areas, affecting the entire facility. An exit interview with the Maintenance Director on the same day at 10:30 a.m. confirmed the absence of necessary documentation in the Emergency Preparedness Plan. The lack of documentation indicates that the facility did not have a structured approach to managing emergencies, particularly concerning at-risk individuals and operational continuity, which is a requirement under §483.73(a)(3).
Plan Of Correction
The facility will ensure policies and procedures were in place addressing patient population, including, but not limited to, persons at-risk; the type of services the facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans, affecting the entire facility. Facility updated Emergency Preparedness Plan to include policies and procedures that addressed persons at-risk, affecting the entire facility.
Failure to Develop Emergency Plan Policies for Medical Documentation
Penalty
Summary
The facility failed to develop and implement emergency preparedness policies and procedures that included a system of medical documentation. This system is required to preserve patient information, protect the confidentiality of patient information, and secure and maintain the availability of records. The deficiency was identified during a document review conducted on May 1, 2025, at 8:15 a.m., which revealed the absence of such policies and procedures in the facility's Emergency Plan. An exit interview with the Maintenance Director on the same day at 10:30 a.m. confirmed the lack of documentation. This deficiency affects the entire facility, as it does not have the necessary policies and procedures in place to ensure the protection and availability of patient information during emergencies.
Plan Of Correction
Facility developed Emergency Plan policies and procedures that included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records, affecting the entire facility. The Director of Maintenance or designee will audit to ensure Emergency Preparedness Plan policies and procedures are reviewed and preserves patients information and confidentiality at least annually, weekly x2, then monthly x2. All findings will be brought to QAPI for review.
Deficiency in Emergency Preparedness Communication Plan
Penalty
Summary
The facility's emergency preparedness communication plan was found to be deficient as it did not include a means of providing information about the Ambulatory Surgical Center's (ASC) needs and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. This deficiency was identified during a document review conducted on May 1, 2025, at 8:15 a.m. During an exit interview with the Maintenance Director on the same day at 10:30 a.m., it was confirmed that the documentation necessary to meet this requirement was lacking. This oversight affects the entire facility, as the communication plan is a critical component of emergency preparedness and response.
Plan Of Correction
The facility's emergency preparedness communication plan will include a developed means of providing information about the LTC needs and its ability to help the authority having jurisdiction, the Incident Command Center, or designee. The facility will update the EP Book and add it to QAPI for review.
Deficiencies in Food Safety and Sanitation
Penalty
Summary
The facility was found to have significant deficiencies in its food and nutrition services department, particularly concerning food storage, preparation, and sanitation. Observations revealed that the low-temperature dish machine had not been fully functional since March 14, 2025, and the Director of Dietary Services was unable to demonstrate that the hypochlorite sanitizer was effectively sanitizing dishes and utensils. Additionally, the kitchen lacked a water softener, resulting in calcium and magnesium deposits on dome lids and plate holders. The dish room area had water damage, missing and broken tiles, and a buildup of food debris and sludge. The ceiling tiles above the dish machine and cooking areas were stained with food debris and grease, and the wall behind the dish machine showed signs of mold. Further issues were noted in the adjacent alcove, where water was constantly flowing onto the floor, creating a film of white, green, and black substances, and causing water damage to the wall. The walk-in refrigerator was heavily soiled with dirt, food spillage, and dust, and the reach-in refrigerator and freezer units were non-functional. The preparation sink and steam table were leaking water onto the floor, requiring staff to use bins to collect the water. These conditions indicate a failure to maintain professional standards for food service safety, as required by regulations.
Plan Of Correction
A - The heated pellet warmer was assessed and not able to be repaired. A replacement warmer was ordered and expected to arrive on 05/27/25. The steam table and bistro steam table were assessed and service call placed for repair. B - Audit of new/repaired equipment to ensure proper function once installed/repaired. C - Dietary manager educated on checking for proper food temperatures prior to delivery to residents. D - Weekly x 4 then monthly x 2 audits by dietary manager or designee to ensure foods are at proper temperature. Results discussed during QAPI meetings.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary, clean, comfortable, and homelike environment on the third-floor nursing unit. Observations revealed that Room 304B had a significant urine smell, indicating a lack of cleanliness. Additionally, Room 304A, which was occupied by a resident who had passed away, had not been cleaned or cleared of personal belongings. The room contained a broken reclining chair used to store random items, including ankle protectors and uncovered pillows. Both bedside dressers were covered with a noticeable layer of dust, and a broken television was stored behind one of the dressers. Dried-out flowers contributed to dirt and debris on the floor and on top of the television stand. Further observations of Room 304 showed that four bedside dressers were dusty, tray tables had visible food spills, and the windowsills were dusty and uncleaned. These findings were confirmed by a licensed nurse and the housekeeping supervisor, who acknowledged that Room 304A had not been cleaned or sanitized since the resident's passing. The facility's administrator confirmed that housekeeping staff were not consistently maintaining resident rooms, including regular dusting and wiping of tray tables.
Plan Of Correction
A – Room 304 was cleaned and sanitized upon notification. B - All resident rooms given a deep clean of bedside dressers, tray tables, and windowsills. All discharged resident rooms cleaned and sanitized. C - Director of housekeeping and housekeeping staff educated on cleaning of bedside dressers, tray tables, and windowsills in resident rooms and all discharged resident rooms will be cleaned and sanitized within 24 hours. D - Weekly x 4 then monthly x 2 audits by the Director of Housekeeping or designee to ensure bedside dressers, tray tables, and windowsills are clean and free of dust and all discharged resident rooms will be cleaned and sanitized within 24 hours. Results discussed during QAPI meetings.
Misappropriation of Narcotic Medication in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from misappropriation of resident property, specifically involving the diversion of narcotic medication for two residents. Resident R69, who was admitted with diagnoses including dementia, chronic pain, and arthritis, was receiving hospice care and had a physician order for morphine sulfate to manage pain. Similarly, Resident R262, also with dementia and chronic pain, was on hospice care and had a physician order for morphine sulfate for pain and shortness of breath. An incident was reported when a nurse noticed that the morphine for Resident R262 appeared altered, with a paler color and a mint-like smell, which was consistent with mouthwash. Further investigation revealed that the morphine for Resident R69 was also tampered with, and laboratory testing confirmed that the morphine concentration for Resident R262 was diluted. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the misappropriation of morphine for both residents. Despite the tampering, Resident R69 reported adequate pain management and did not experience increased pain. The facility conducted drug tests on all nurses with access to the medication, which returned negative results for opiates. The local police department was contacted but declined to investigate the matter further.
Plan Of Correction
A - Resident R262 expired and cannot be corrected. Resident R69 had a replacement bottle of morphine ordered and charged to the facility. B - Audit of all incidents of misappropriation of narcotics in last 30 days to ensure facility replaced medication at facility's cost. C - Previous DON and NHA educated on process of replacing any misappropriated narcotic medications at the cost of the facility. Current DON and NHA are aware of this process. D - Weekly x 4 then monthly x 2 audits by DON or designee of misappropriated narcotic medications to ensure replacement at the cost of the facility. Results discussed during QAPI meetings.
Insufficient Staffing and Delayed Call Bell Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of its residents, as evidenced by the delayed response to call bells and inadequate staffing levels. During a resident council meeting, several residents reported that call bells were not answered promptly, and staff would turn off the call bells without providing the necessary assistance. Specifically, Resident R29, who is non-verbal and communicates through head nods and facial expressions, was observed pressing the call bell to request a transfer to her wheelchair. Although a licensed nurse responded to the call, the nurse did not assist with the transfer and instead turned off the call bell, leaving the resident's need unmet. It was only after a surveyor's intervention that the resident was eventually transferred to her wheelchair. The facility also failed to maintain the state-required minimum staffing levels, as evidenced by the review of nursing care staffing levels. The facility did not meet the required minimum number of care hours per patient per day on several occasions and failed to meet the minimum nurse aide staffing ratios on multiple days. Interviews with staff, including the staffing coordinator, confirmed that the facility was consistently understaffed, which contributed to the inability to meet residents' needs in a timely manner.
Plan Of Correction
A - N/A B - Staffing Coordinator will staff the daily nursing staff to meet the required CNA to resident ratio of 1:10 on 7-3, 1:11 on 3-11, and 1:15 on 11-7. C - NHA, DON, and Staffing Coordinator educated on minimum staff to resident ratio. D - Weekly x4 then monthly x2 random audits by DON or designee of CNA staff ratio on 50% of days to ensure compliance with ratios.
Failure to Complete Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations and the required 12 hours of in-service training were completed for three nurse aides, identified as Employees E21, E22, and E23. This deficiency was identified through a review of facility-provided documentation and interviews with staff. The facility's policy, revised in 2024, mandates that nurse aides receive at least 12 hours of in-service training annually based on their employment date. However, the performance evaluations reviewed on April 25, 2025, showed that these nurse aides did not receive the required training. An interview with the Development Coordinator confirmed the absence of the annual in-service training for these employees.
Plan Of Correction
A- Facility contracted with Healthcare Academy platform to provide required trainings for staff. B- Audit completed on all facility CNAs to evaluate hours of training received in past year or since hire date. C- All CNAs educated on requirement of 12 hours of annual training and the use of Healthcare Academy. D- Weekly x 4 then monthly x 2 audits by DON or designee to ensure CNAs meet the required 12 hours of annual education. Results discussed during QAPI meetings.
Food Service Temperature and Quality Deficiency
Penalty
Summary
The facility failed to ensure that foods and drinks were served palatable, attractive, and at safe and appetizing temperatures during meal times for residents. Observations revealed that cold food items were not being held at the appropriate temperatures due to a broken reach-in refrigerator unit. Additionally, the lowerator, a heated pellet drop-in dispenser unit, was not fully functioning, resulting in cool pellets that should have been hot. The steam table in the main kitchen was also not fully operational, with staff having to use a bucket to catch leaking water, and two of the four wells in the bistro's steam table were not functioning. These equipment failures led to hot foods being served below the required temperature of 130 degrees Fahrenheit and cold foods above the required 45 degrees Fahrenheit. During a test tray evaluation on the third floor, it was found that the glazed ham was served at 115 degrees Fahrenheit, and vegetables were at 116 degrees Fahrenheit, both below the facility's policy for hot food temperatures. The dessert served did not match the menu, and the presentation was poor due to a lack of appropriate serving plates. Milk was served at 60 to 67 degrees Fahrenheit, above the safe temperature for cold foods. Residents reported dissatisfaction with the food, describing it as cold, uncooked, and unappetizing. The facility's failure to maintain food service equipment and adhere to its own policies resulted in meals that were not safe or satisfying for residents.
Plan Of Correction
A - The heated pellet warmer was assessed and not able to be repaired. A replacement warmer was ordered and expected to arrive on 05/27/25. The steam table and bistro steam table were assessed and service call placed for repair. B - Audit of new/repaired equipment to ensure proper function once installed/repaired. C - Dietary manager educated on checking for proper food temperatures prior to delivery to residents. D - Weekly x 4 then monthly x 2 audits by dietary manager or designee to ensure foods are at proper temperature. Results discussed during QAPI meetings.
Inadequate Linen Storage Practices
Penalty
Summary
The facility failed to maintain a sanitary environment for storing bed linens, which increased the risk of infection and contamination. During a tour of the laundry area, it was observed that new linens were unfolded and placed directly on the bare floor inside the extra linen closet. These linens were neither boxed nor covered, leaving them exposed to potential contamination. This practice was confirmed during the tour with the housekeeping supervisor, Employee E4. Additionally, an inspection of the second-floor linen closet revealed that clean pillows, although sealed in plastic bags, were stored directly on the floor. Extra pads used for mechanical lifts were also found stored on the floor without being sealed or protected. These observations indicate a failure to adhere to the facility's policy, which states that linens and clothing should be laundered and delivered in accordance with current CDC guidelines to prevent the transmission of pathogens.
Plan Of Correction
A - At the time reported, bed linens in the laundry room and pillows and additional lift pads in the 2nd floor linen room that were stored on the floor were removed and laundered. Proper equipment to store linen was added in the areas to prevent it from touching the floor. B - Audit conducted to ensure any other areas that store linen did not have linen stored directly on the floor. C - Laundry and nursing staff educated on proper linen storage which is not to store items even if bagged on the floor. D - Weekly x 4 then monthly x 2 audits by Environmental services director or designee of linen storage areas to ensure linens are not stored on the floor. Results discussed during QAPI meetings.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to promote and maintain dignity and respect for two residents, as evidenced by observations, policy reviews, and resident interviews. Resident R100, who was admitted with Parkinson's Disease and Type 2 Diabetes, reported feeling disrespected by staff who refused to provide their names or show identification upon request. The resident described the staff as 'mean' and uncooperative when assistance was needed. Similarly, Resident R40, admitted with a left femur fracture, Type 2 Diabetes, and heart disease, expressed that staff were disrespectful, waking the resident at night without explanation and refusing to answer questions. The resident also noted that staff did not wear name tags and became defensive when asked for their names. Observations confirmed that staff members, including Licensed Nurses E10, E9, and E5, were not displaying their identification badges properly, with badges either hidden or not worn at all. This lack of identification contributed to the residents' feelings of disrespect and lack of dignity. The facility's policy on promoting and maintaining resident dignity, which involves all staff in providing respectful care, was not adhered to, leading to the deficiency noted in the report.
Plan Of Correction
A - Staff E10, E5, and E9 issued identification badges. B - All staff checked for identification badges and new identification badges were issued to any staff missing a badge. C - Staff educated on importance of wearing identification badges during shift. Staff educated on placing badge in an easily invisible area. D - Weekly x 4 then monthly x 2 audits by DON or designee of staff during a shift for presence of identification badge during shift worked. Results will be discussed in QAPI meetings.
Failure to Conduct Timely Background Checks for New Hires
Penalty
Summary
The facility failed to develop and implement an abuse prohibition policy that required a thorough investigation of prospective employees' employment history. Specifically, the facility did not conduct criminal background checks for two newly hired employees, an LPN and an RN, before their hire dates. The LPN was hired on March 1, 2025, but their criminal background check was not completed until April 1, 2025. Similarly, the RN was hired on January 1, 2025, with their background check completed on January 8, 2025. This deficiency was identified through a review of facility policies and procedures, employee personnel records, and staff interviews. The facility's policy titled "Abuse," revised on June 30, 2023, mandates the screening of potential hires as part of its abuse prohibition program. However, the failure to adhere to this policy was confirmed during an interview with a Human Resources staff member, who acknowledged that the criminal background checks for the LPN and RN were conducted after their respective hire dates.
Plan Of Correction
A - Employees identified E26 and E30 are already hired and have background checks completed. B - Audit of all current employees to ensure a background check was completed. C - Educate HR that all new hires require a background check completed prior to official hire date. D - Weekly x 4 then monthly x 2 audits by DON or designee of all new hires to ensure background check completed prior to hire date. Results discussed during QAPI meetings.
Incomplete Investigation of Incontinence Care Incident
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an incident involving incontinence care for a resident. The resident, who was admitted with a BIMS score of 8 and diagnoses including Alzheimer's Disease, encephalopathy, Parkinson's disease, and angina, was found with wet sheets and stated he did not know when he was last changed. The nurse manager discovered the situation after responding to the resident's call bell and noted darker stains on the sheets. The resident's roommate confirmed that he was changed but could not recall the time. The investigation into the incident was incomplete, as it only included a statement from one nurse and lacked witness statements from other staff and residents. Interviews with staff revealed that a nurse aide failed to complete the required two-hour round and check and change for the resident. The Director of Nursing confirmed the investigation's incompleteness due to missing witness statements.
Plan Of Correction
A - Employee E14 was terminated following incident. Unable to complete investigation further at this time due to time lapse since incident. B - All allegations of abuse or neglect in last 30 days reviewed to ensure completion of investigation. C - Previous DON and NHA educated on Investigation process with completion of investigation including witness statements from all possible witnesses. Current DON and NHA are aware of the process for investigation. D - Weekly x 4 then monthly x 2 audits by DON or designee of abuse and neglect investigations to ensure completeness of investigation. Results discussed during QAPI meetings.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in their care. Resident 10, who was diagnosed with emphysema and dyspnea, was prescribed oxygen therapy at 2 Liters/Min via nasal cannula. However, there was no care plan developed for this oxygen therapy, as confirmed by a registered nurse. Resident 73, admitted with a risk for elopement, had a physician's order for a safety device (wander guard) on the left ankle, but there was no care plan addressing the use of this device or the resident's elopement risk, as confirmed by the Director of Nursing. Resident 82, who was not cognitively intact and had multiple diagnoses including dementia, heart failure, and diabetes, also had a Stage III pressure ulcer. Despite the facility's policy requiring a turning and repositioning program for residents at risk of pressure injuries, there was no care plan in place for Resident 82's repositioning needs. The Rehab Director confirmed that the resident needed prompting to reposition, yet the care plan did not reflect this requirement. The Director of Nursing confirmed the absence of a care plan for turning and positioning for this resident.
Plan Of Correction
A - Resident R10 had a comprehensive care plan added for oxygen use. Resident R73 had a comprehensive care plan added for safety and elopement. Resident R82 had a comprehensive care plan added for repositioning. B - All residents requiring oxygen, at risk for elopement, and requiring a repositioning program audited to ensure comprehensive care plan in place for oxygen use, elopement risk, and repositioning program. C - Staff educated on completion of comprehensive care plans for oxygen use, elopement risk, and repositioning programs. D - Weekly x 4 then monthly x 2 audits by DON or designee of comprehensive care plans for new resident needs for oxygen use, elopement risk, and repositioning programs. Results discussed during QAPI meetings.
Failure to Provide ADL Assistance for Grooming
Penalty
Summary
The facility failed to provide necessary activities of daily living (ADL) assistance to maintain good grooming for Resident R24. The resident, who was admitted on August 31, 2022, has diagnoses including chronic atrial fibrillation, osteoarthritis, adult failure to thrive, and low back pain. According to the quarterly Minimum Data Set (MDS) dated March 7, 2025, Resident R24 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 and required maximum assistance with personal hygiene. On April 22, 2025, an observation by Licensed Nurse Employee E12 revealed that Resident R24 had long and dirty fingernails, and the resident expressed a desire to have them trimmed. A follow-up observation on April 23, 2025, showed that the resident's right thumbnail remained untrimmed and dirty, and Employee E12 was unsure why all the nails had not been cut.
Plan Of Correction
A - Resident R24 had their fingernails cleaned and trimmed. B - An audit of all dependent residents was completed to ensure fingernails were cleaned and trimmed. C - Staff educated on providing proper fingernail care to dependent residents. D - Weekly x 4 then monthly x 2 audits completed by DON or designee on all dependent residents to ensure fingernails are clean and trimmed. Results discussed during QAPI meetings.
Failure to Adhere to Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to provide pressure ulcer treatment consistent with professional standards of practice for a resident identified as R106. The facility's policy on 'Pressure Ulcer Prevention' mandates the implementation of evidence-based interventions for residents at risk or with existing pressure injuries. Resident R106, admitted on January 30, 2025, had a Stage 3 pressure ulcer on the right heel. The comprehensive care plan, revised on February 4, 2025, included interventions such as offloading the heel when in bed and using heel protectors. On April 25, 2025, an observation revealed that Resident R106 was in bed without a heel boot, and the right heel was not offloaded, contrary to the care plan. A nurse aide, Employee E22, reported that the boot was stored in the resident's closet and was only applied at nighttime. The nurse unit manager, Employee E3, confirmed that the resident's right heel was not offloaded during the observation, indicating a failure to adhere to the prescribed care plan and facility policy.
Plan Of Correction
A - Resident R106 has been discharged from the facility. B - Audit of all residents with orders for pressure relieving devices to the heels to ensure device in place. C - All nursing staff educated on pressure wound prevention devices for the heels. D - Weekly x 4 then Monthly x 2 audits by DON or designee of pressure wound prevention devices for the heels to ensure compliance with interventions/orders. Results discussed during QAPI meetings.
Failure to Implement Nutritional Interventions for Resident at Risk
Penalty
Summary
The facility failed to implement nutritional interventions for a resident identified as being at nutritional risk, which contributed to the development and deterioration of pressure sores. The resident, who was cognitively impaired and had diagnoses including dementia, anemia, malnutrition, and a swallowing disorder, was assessed to be at high risk for pressure ulcer development. Despite being prescribed a mechanically altered diet and a nutritional supplement to promote weight gain and skin healing, the facility did not ensure these interventions were consistently administered. Clinical records indicated a significant weight loss for the resident over a short period, dropping from 172 pounds to 162 pounds, which was a 5% weight loss in one month. The facility's policies required notification of the dietitian and physician for unplanned weight changes, but there was no documentation that this occurred. Additionally, there was no evidence of a nutritional assessment being completed after the weight loss was identified, nor was there documentation of the administration of the prescribed nutritional supplement during March and April. Interviews with staff confirmed the lack of administration of the nutritional supplement and the absence of necessary documentation related to nutritional assessments and care planning. The resident's condition worsened, with the development of Stage III pressure ulcers, which were attributed to poor nutritional status and protein-calorie malnutrition. The facility's failure to adhere to its policies and ensure proper nutritional interventions contributed to the resident's declining health status.
Plan Of Correction
A - Resident R82 is receiving prosource and house supplement shakes with nursing documentation of percent consumed as nutritional interventions to assist with wound healing. B - All residents at nutritional risk with wounds audited to ensure nutritional interventions are in place. C - Educated dietitian on nutritional interventions for at risk residents and nutritional assessments. D - Weekly x 4 then monthly x 2 audit by DON or designee of newly at risk residents for nutritional interventions in place. Results discussed during QAPI meetings.
Deficiencies in Respiratory and Tracheostomy Care
Penalty
Summary
The facility failed to provide appropriate respiratory care, including tracheostomy care and tracheal suctioning, for four residents. Resident R10, diagnosed with emphysema and dyspnea, was observed receiving oxygen at a higher level than prescribed, and the oxygen tubing was not labeled as required. The nurse confirmed that the oxygen level was changed without updating the clinical record, and there was no order to change the oxygen tubing weekly. Resident R72, with acute respiratory failure and COPD, had an order for weekly oxygen tubing changes and labeling, but the tubing was not labeled during observation. Resident R1, who has a tracheostomy and is not cognitively intact, was observed without suctioning equipment at the bedside during trach care, leading to a delay in care when the nurse had to leave to retrieve necessary supplies. The Director of Nursing confirmed that suction supplies should be readily available at the bedside for residents with tracheostomies. Resident R51, with respiratory failure and COPD, was found in the dining room with an empty oxygen tank and no staff present, despite having an order for continuous oxygen therapy. The LPN confirmed the resident was without adequate oxygen therapy. These deficiencies indicate a failure to adhere to physician orders and facility policies, compromising the respiratory care of the residents involved.
Plan Of Correction
A - Resident R1 suction machine obtained at the time identified. E20 was educated at the time this was reported. R51 oxygen tank was exchanged for a new tank at the time noted empty. E19 educated on ensuring 02 tanks are full when a resident is taken to the dining room. R10 obtained physician order to change tubing and tubing was changed. R72 oxygen tubing was changed at the time identified. B - Audit of all residents who require suctioning to ensure they have a suction machine at bedside and audit of all who require oxygen to ensure they have orders to change tubing weekly. C - All nursing staff educated on weekly oxygen tubing change orders, ensuring suction machine is present at bedside for residents requiring suctioning, and ensuring oxygen tanks are not empty when in use by resident in dining room. D - Weekly x 4 then monthly x 2 audits by DON or designee to ensure oxygen tubing has weekly change orders and is changed weekly, residents in dining room who use oxygen do not have empty tanks, and a suction machine is present at bedside for those who require suction.
Deficiency in Pain Management for a Resident
Penalty
Summary
The facility failed to provide appropriate pain management interventions for Resident R48, who was admitted with diagnoses including COPD, contracture of the left knee, and osteoarthritis of the right shoulder. Despite the resident's comprehensive care plan indicating a risk for alterations in functional mobility due to contracture deformity, there was no documented evidence of a care plan specifically addressing pain management. The resident, who is cognitively intact with a BIMS score of 12, reported experiencing significant pain when rolled to the right side and had communicated this discomfort to multiple staff members. Interviews with the Clinical Regional Nurse confirmed that the resident expressed pain related to the contracture on the right side, which increased when rolled to that side. Despite this, the clinical record included a task for the resident to be rolled to both the left and right sides every 2-3 hours, without any adjustments to prevent rolling onto the painful side. This lack of a tailored care plan and failure to heed the resident's expressed pain and preferences led to the deficiency in pain management services.
Plan Of Correction
A - Resident R48 plan of care and point of care were updated at the time noted to ensure turn and reposition avoids the right side. B - Audit of all residents with turn and reposition programs to ensure resident has no pain with turning with care plan updated as appropriate. C - All nursing staff educated to monitor for signs of pain with repositioning resident and avoid positions that cause pain to the resident. D - Weekly x 4 then monthly x 2 audits by DON or designee of residents with positional pain for pain management. Results discussed during QAPI meetings.
Deficiency in Tracheostomy Care Competency
Penalty
Summary
The facility failed to ensure that nursing staff were qualified and competent to perform tracheostomy care and suctioning for a resident with a tracheostomy. The facility's policy on orientation and competency evaluation was not effectively implemented, as evidenced by the lack of documented competencies for tracheostomy care and suctioning among licensed nursing staff. During an observation, it was noted that suctioning equipment was not available at the bedside of a resident who required tracheostomy care, leading to a situation where the resident experienced coughing and desaturation after the inner cannula was replaced. The LPN had to leave the resident's bedside to retrieve the necessary equipment, indicating a lapse in preparedness and competency. Interviews with the Director of Nursing and the LPN revealed that the staff did not receive training or in-service to confirm competency in tracheostomy care or suctioning. Further review of employee personnel files confirmed the absence of documented evidence of completed competencies for these procedures among the licensed nursing staff. This deficiency was identified through observations, policy reviews, and staff interviews, highlighting a significant gap in staff development and competency assurance in the facility.
Plan Of Correction
A - Resident R1 suction supplies obtained and placed at bedside. Employee E2 was competent after the event was reported. B - N/A C - All nursing staff completed competencies on suctioning of resident with tracheostomy prior to next shift worked. New Jersey Respiratory Association completed additional in-services with staff. D - Weekly x 4 then monthly x 2 audits by DON or designee of new staff to ensure trach care training and competency is completed. Results discussed during QAPI meetings.
Narcotic Reconciliation Deficiency
Penalty
Summary
The facility failed to ensure the completion of narcotic reconciliation records, as evidenced by missing signatures and initials on the narcotic count sheets for three medication carts reviewed. This deficiency was identified during a review of facility records and staff interviews. The facility's in-service policy, implemented in October 2024, requires nursing staff to count controlled medications at the end of each shift, with both the oncoming and outgoing nurses participating in the count. However, observations on April 24, 2025, revealed multiple missing signatures for oncoming and outgoing nurses on the narcotic reconciliation sheets for the 2nd Floor Medication Cart and two medication carts on the 3rd Floor. Licensed Practical Nurses (LPNs) confirmed the missing signatures during the observations. Specifically, LPN Employee E9 confirmed the missing signatures on the 2nd Floor Medication Cart, while LPN Employees E10 and E20 confirmed the missing signatures on the two 3rd Floor Medication Carts. An interview with the Clinical Regional Nurse, Employee E13, further confirmed the missing signatures and initials on the narcotic reconciliation sheets. This failure to maintain accurate narcotic reconciliation records is a violation of the facility's procedures and regulatory requirements.
Plan Of Correction
A - N/A B - Narcotic reconciliation records audited for missing signatures. C - All nurses educated on Narcotic count and reconciliation process. D - Weekly x 4 then monthly x 2 audits by DON or designee of narcotic counts and reconciliation to ensure completion. Results discussed during QAPI meetings.
Failure to Label Opened Medications with Open Date
Penalty
Summary
The facility failed to ensure that opened medications were properly labeled with the date they were opened, as required by regulations. During an observation of the medication cart on the 2nd floor, five opened bottles of medication, including B12, Cranberry, Vitamin D, Ferrous Sulfate, and B1, were found without an open date label. This was confirmed by an interview with a licensed nurse, Employee E9. Similarly, on the 3rd floor, an opened bottle of Vitamin D 1250mg was also found without an open date label, confirmed by Employee E10. Additionally, in the 2nd floor medication room, an open bottle of Tuberculin was observed without an open date label, which was again confirmed by Employee E9. These observations indicate a failure to comply with the requirement to label drugs and biologicals with the appropriate accessory and cautionary instructions, including the expiration date when applicable, as per §483.45(g). This deficiency was noted in two of the three medication carts reviewed and one medication room.
Plan Of Correction
A- Medications identified at the time of survey that were not dated were removed from the med carts and replaced with new medications. B- Audit of med carts and all undated multidose containers of meds removed with new ones obtained. New meds dated when opened. C- All nurses educated on dating multidose medication containers when opened. D - Weekly x 4 then monthly x 2 audits by DON or designee of multidose med containers to ensure open containers are dated. Results discussed during QAPI meetings.
Incomplete Clinical Records for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure that clinical records were completed for a resident, identified as R82, who was admitted with multiple diagnoses including dementia, heart failure, type 2 diabetes, and acute kidney failure. The resident had a BIMS score of 6, indicating cognitive impairment, and was documented to have a Stage III pressure ulcer on the right buttocks and sacrum. The facility's policy required residents at risk of pressure injuries to be turned and repositioned regularly, with the frequency documented in the resident's plan of care. Despite the policy, there was no documented evidence that Resident R82 was turned and repositioned every 2-3 hours as required. Interviews with the Rehab Director and the Director of Nursing confirmed the absence of documentation for this task. The lack of documentation suggests that the facility did not adhere to its policy, potentially compromising the resident's care.
Plan Of Correction
A - CNAs assigned to Resident R82 were educated on completing documentation for turning and repositioning. B - Audited all residents with turn and repositioning programs to ensure documentation is being completed. C - All nursing staff educated on documentation requirements for turning and positioning in point of care. D - Weekly x 4 then monthly x 2 audits by DON or designee to ensure documentation of turning and repositioning in point of care is completed. Results discussed during QAPI meetings.
Deficient Maintenance of Kitchen Equipment
Penalty
Summary
Essential food service equipment in the facility's main kitchen was not maintained in safe operating condition, as observed on March 22, 2025. The dish machine, crucial for sanitizing dishes and utensils, was not functioning properly since March 14, 2025, due to a missing customized part. The director of dietary services was unable to demonstrate that the hypochlorite level was at the required 50 ppm for effective sanitization. Additionally, cold food items were not held at safe temperatures due to broken reach-in refrigerator and freezer units, leading to improper storage during meal preparation and delivery. Further observations on April 22 and 23, 2025, revealed additional equipment failures. The lowerator, used for heating pellets, was not fully operational, resulting in dietary staff handling cool pellets without proper protection. The steam table in the main kitchen was leaking, requiring a bucket to catch water, and the steam table in the bistro had two non-functioning wells. These deficiencies were confirmed by the facility administrator, indicating a lack of maintenance to ensure the safe operation of essential food service equipment.
Plan Of Correction
A - The heated pellet warmer was inspected and unable to be repaired. A replacement warmer was ordered and expected on 5/27/25. The steam table and bistro steam table had service calls placed for repair or replacement. The squeeze tube and rinse assembly metal connector was replaced and functioning now. B - N/A C - The dietary manager and dietary staff educated on safe food handling temperatures of cold and hot foods. D - Weekly x 4 then monthly x 2 audits by dietary manager to ensure pellet warmer and steam tables are functioning and to ensure foods are handled at proper temperatures (hot or cold). Results discussed at QAPI meetings.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program in the kitchen and one of the nursing units, specifically the 3rd Floor Nursing Unit. Observations and interviews revealed that a resident had gnat flies in their room, and staff confirmed ongoing issues with gnat flies. Despite the Maintenance Director's claim of weekly pest control treatments, records showed treatments were conducted only twice a month. Additionally, there was no documentation of gnat fly treatment in the affected room, and pest control logs did not reflect the reported gnat activity. The kitchen area was found to have significant maintenance and cleanliness issues, contributing to pest problems. The flooring under the dish machine was heavily soiled, with pooling water and food debris, and the area had water damage and missing tiles. The ceiling tiles above the dish machine and hot food preparation area were dirty, providing food sources for pests. Equipment such as the preparation sink and steam table were leaking, further facilitating pest access. Pest control reports indicated active roach and mice observations in the kitchen, highlighting the facility's failure to effectively manage pest control.
Plan Of Correction
A - The flooring directly underneath the dish machine was scrubbed and cleaned. Floor in dish machine area was cleaned and repaired with new tiles. The adjacent alcove was repaired and free from any holes and wall board fastened. Pipe fixed and realigned to floor drain. B - Preparation sink in the main kitchen being repaired by outside plumbing vendor. C - All state educated on pest control interventions and utilization of the pest control binders to report concerns to the pest control service technician. D - Weekly x 4 then monthly x 2 audits by maintenance director of pest control binders to ensure concerns are addressed and audits of the kitchen floor for maintenance concerns. Results discussed in QAPI meetings.
Failure to Provide Timely Abuse Training to New Hires
Penalty
Summary
The facility failed to provide timely abuse, neglect, and exploitation training to new hires, as required by §483.95(c). Specifically, four out of six newly hired staff members did not receive this training at the time of hire. Employee records revealed that a Licensed Practical Nurse (E26) hired on March 1, 2025, completed the training on April 2, 2025. A Registered Nurse (E27) hired on February 10, 2025, completed the training on March 14, 2025. A Nurse Aide (E28) hired on March 1, 2025, completed the training on April 11, 2025. Another Registered Nurse (E29), hired on January 1, 2025, had no documented evidence of completing the training. An interview with Human Resources staff, Employee E30, confirmed the delay in training for these employees and the lack of training documentation for one Registered Nurse. The facility's policy, revised on June 30, 2023, mandates the implementation of an abuse prohibition program, which includes the training of new employees. However, the facility did not adhere to this policy, resulting in a deficiency in meeting the regulatory requirements for staff training on abuse, neglect, and exploitation.
Plan Of Correction
A - Employee E29 received the appropriate abuse, neglect, and misappropriation training. B - Audit of all employees hired in 2025 education files to ensure the abuse, neglect, and misappropriation training has been completed. Completion of training for anyone not completed. C - Staff Development Coordinator and Human Resources Director educated on ensuring training is completed upon hire. D - Weekly x4 then monthly x2 audits by administrator or designee of new hires to ensure completion of required trainings. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE
Misappropriation of Narcotics Misreported
Penalty
Summary
The facility failed to accurately report an incident involving the misappropriation of narcotics, specifically morphine 20MG/ML bottles, for two residents. During a clinical record review and staff interviews, it was discovered that the morphine bottles for these residents had been tampered with. The facility had entered this incident into the state reporting system under the incorrect category of "other" instead of "misappropriation of patient/resident property." Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the misclassification of the incident. This misreporting was identified during a review of four facility-reported incidents, highlighting a deficiency in the facility's reporting practices. The failure to accurately categorize the incident in the state reporting system indicates a lapse in the facility's management and responsibility to ensure proper documentation and reporting of significant events.
Plan Of Correction
A - Resident's morphine was replaced at the cost of the facility and not charged to resident's insurance. B - Audit of all reportable incidents in last 30 days to ensure reported accurately. C - Previous DON and NHA educated on proper classification of reportable incidents of misappropriation in the PA event reporting system. Current DON and NHA aware of reporting category. D - Weekly x 4 then monthly x 2 audits by regional nurse or designee of reportable incidents to ensure accurate reporting. Results discussed during QAPI meetings.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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