Corry Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Corry, Pennsylvania.
- Location
- 640 Worth Street, Corry, Pennsylvania 16407
- CMS Provider Number
- 395489
- Inspections on file
- 23
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Corry Manor during CMS and state inspections, most recent first.
Surveyors found that staff did not consistently document ordered medications and treatments on MARs and TARs for multiple residents with complex conditions, including dementia, COPD, diabetes, epilepsy, Down syndrome, and A-fib. Despite a facility policy requiring nurses to record all administered medications immediately and before leaving duty, records showed numerous blank entries for wound care, catheter care, respiratory treatments, oxygen use and saturation checks, enteral feeding and related flushes, IV antibiotics and flushes, pain monitoring, seizure medications, psychotropics, cardiac drugs, thyroid replacement, and various skin and pressure-relief interventions. The DON acknowledged that these clinical records were incomplete.
A resident admitted with A-fib and peripheral vascular disease had an active physician order for the anticoagulant Rivaroxaban and received it daily, as documented on the MAR. Despite this, the admission MDS section N0415E for anticoagulant use was coded as "No," contrary to MDS instructions requiring coding based on pharmacologic class use during the look-back period. A staff interview confirmed the resident had been receiving an anticoagulant since admission and that the MDS coding was inaccurate.
A resident with atrial fibrillation and peripheral vascular disease was prescribed Rivaroxaban 15 mg daily, but the facility failed to include the use and management of this anticoagulant therapy in the resident’s comprehensive, person-centered care plan as required by facility policy. Review of the clinical record and care plan showed no anticoagulant-related interventions or measurable objectives, and a Social Worker confirmed that an anticoagulant care plan should have been initiated but was not.
Surveyors found that care plans for two residents were not reviewed or revised by the required target dates, contrary to facility policy requiring periodic, team-based review of comprehensive, person-centered care plans. One resident with A-fib, PVD, and pain had nine care plan areas, including allergies, self-care deficit, skin breakdown risk, falls risk, pain, nutrition/hydration, discharge, elopement, and code status, all past due for review. Another resident with COPD, bipolar disorder, and diabetes had nine care plan areas, including discharge planning, psychotropic medications, altered nutrition/hydration, skin breakdown risk, self-care deficit, falls risk, smoking, code status, and altered respiratory status, also past due. A staff Social Worker confirmed that these care plans were not reviewed or revised within required timeframes.
Physicians did not review, sign, and date orders at each required visit for multiple residents with complex medical conditions, resulting in overdue physician orders. The DON confirmed that these orders were past due and not in compliance with the facility's policy for timely physician review and signature.
Two residents had inconsistencies between their physician orders and POLST forms regarding life-sustaining treatment, with one case showing a mismatch between CPR and DNR directives. The DON confirmed these discrepancies, indicating the facility did not ensure residents' treatment preferences were accurately documented and followed.
A resident with anxiety, bipolar disorder, and hypertension received PRN Ativan for over 14 days without a required stop date or documented clinical rationale for continued use, as confirmed by the DON and in violation of facility policy.
Three residents with complex medical conditions were transferred to the hospital without evidence that their necessary clinical information, including orders and medications, was communicated to the receiving health care provider. The DON confirmed that required information was not provided at the time of transfer, as facility policy mandates.
A resident admitted with anxiety, bipolar disorder, and hypertension did not receive a written summary of the baseline care plan and order summary within 48 hours of admission, as required. The DON confirmed that the clinical record lacked documentation showing these documents were provided to the resident or their representative.
A resident with respiratory failure, COPD, and hypertension had physician orders for PRN oxygen and used oxygen on multiple days, but the facility did not develop a care plan addressing respiratory care or oxygen use. The DON confirmed the absence of a required respiratory care plan, resulting in a deficiency.
The facility did not update care plans to reflect changes in a resident's catheter type and failed to hold timely care plan meetings for two residents with complex medical needs. The DON and Social Worker confirmed that care plans and meetings were not managed according to policy.
A resident with respiratory failure and COPD did not receive oxygen therapy as ordered by the physician. The oxygen flow rate was set below the prescribed amount, and the oxygen concentrator was missing both the water bottle and filter over several days. The DON confirmed these deficiencies during an interview.
Surveyors found that outdated and improperly labeled medications, including insulin pens and a vial of Tubersol, were not discarded as required. An LPN confirmed that some medications were past their recommended usage period or lacked open dates, and staff could not determine appropriate discard dates, resulting in noncompliance with facility policy and manufacturer guidelines.
A resident with multiple serious diagnoses was admitted to hospice care, but the facility failed to maintain required hospice documentation in the clinical record. The record lacked evidence of ongoing collaboration or communication from hospice, and the physician's order for hospice services was not obtained at admission, as confirmed by the DON.
A resident with multiple medical conditions experienced a significant change in condition, including confusion and respiratory symptoms, which led to an ER transfer and hospital admission. The facility did not notify the resident's emergency contact or representative of the transfer or the change in condition in a timely manner, with documentation showing a delay of approximately 21 hours after symptom onset.
The facility failed to meet the required nurse aide (NA) staffing ratios during various shifts over a 14-day period. The day, evening, and overnight shifts experienced staffing shortages, with the number of NAs consistently below the required number for the resident census. The Nursing Home Administrator confirmed these shortages.
The facility did not meet the required LPN staffing ratios on several occasions, failing to provide the mandated number of LPNs per residents during both day and overnight shifts. The shortages were confirmed by the Nursing Home Administrator.
The facility did not meet the required RN staffing ratio during an evening shift, with only 0.49 RNs available for 107 residents, instead of the required 1.00 RN. This deficiency was confirmed by the Nursing Home Administrator.
The facility did not meet the required 3.2 hours of direct resident care per resident per day for 10 out of 14 days reviewed. Staffing documents showed care hours fell below the minimum on several dates, with the lowest being 2.62 hours. This was confirmed by the Nursing Home Administrator.
The facility failed to develop timely and comprehensive care plans for two residents. One resident, admitted with multiple health issues, did not have care plans for pain, skin breakdown, and other critical areas until months after admission. Another resident with an indwelling catheter lacked a care plan for its management, despite documentation of its presence. These deficiencies highlight lapses in the facility's care planning process.
The facility failed to review and revise comprehensive care plans for two residents. One resident's care plan for skin breakdown was not updated, and another resident's care plan had not been reviewed or revised since May, with no care plan meeting conducted. The RNAC and Regional Director of Clinical Services confirmed these deficiencies.
The facility failed to provide necessary care for three residents, including inadequate repositioning and transfer assistance for two residents with severe cognitive impairment, and a lack of physician's orders and care for a resident with an indwelling catheter for nearly a year. Observations showed residents in discomfort and staff not adhering to care plans.
The facility failed to enforce its smoking policy, allowing three residents to smoke in an unauthorized area without supervision, creating a safety hazard. Despite the policy requiring residents to smoke in designated areas and be accompanied by staff or trained volunteers, these residents were observed smoking on the front patio entrance, against facility rules. The Nursing Home Administrator confirmed the residents' non-compliance and access to their own smoking materials, posing a risk to safety.
A facility failed to ensure a resident's physician thoroughly documented the resident's current condition and medical regimen. The physician progress notes for a resident with a complex medical history did not accurately reflect the resident's health status, including outdated lab values and COVID status. The Nursing Home Administrator confirmed the inaccuracies, leading to a deficiency citation.
The facility failed to store and label food according to safety standards, with expired items found in the cooler and pantry. Staff were observed without hair nets, and open food carts left the kitchen with uncovered beverages, violating sanitation policies.
A facility failed to ensure consistency between physician orders and the POLST for a resident. The resident's clinical record showed two POLST forms with conflicting life-sustaining treatment preferences. The first form indicated a Full Code status and was signed by a physician, while the second form indicated a DNR status but lacked a physician's signature. An LPN confirmed the discrepancy and acknowledged the need for a physician's signature to reflect the resident's current wishes accurately.
The facility failed to maintain a sanitary environment for two residents. A resident with end-stage renal disease had dialysis equipment left uncleaned in their room, while another resident's wheelchair was observed with layers of dirty, dried food. Both instances were confirmed by LPNs, and no facility policy on housekeeping was provided.
A facility failed to provide appropriate urinary catheter care for a resident with an indwelling catheter. The resident's urinary drainage bag was observed lying on the floor with the valve touching the floor. The DON confirmed the improper placement and acknowledged that the drainage bag should not be on the floor.
A facility failed to provide a clinical rationale and duration for the continued use of PRN psychotropic medications beyond 14 days for a resident with Alzheimer's Disease and agitation. The resident's orders for Hydroxyzine and Lorazepam lacked the required stop date or justification for extended use, as confirmed by the DON during an interview.
The facility failed to label and store medications properly, with undated and expired insulin pens found in a medication cart. Additionally, a resident with diabetes, anxiety, and hypertension had an unauthorized bottle of Robitussin Congestant at their bedside, lacking a physician's order or self-administration evaluation. An LPN and the DON confirmed these deficiencies.
The facility failed to provide sufficient and appropriately trained dietary staff, leading to repetitive, cold, and unappealing meals. Observations showed understaffing and use of untrained staff from other departments. Residents and families reported dissatisfaction with meal quality and temperature.
A facility failed to follow infection control practices for a graduate used by a resident with multiple health issues, including atrial fibrillation and COPD. The graduate was left on the bedside table for an extended period without proper sanitation. A nurse confirmed the oversight and was unaware of the graduate's purpose, despite the resident having a urinary catheter bag.
Incomplete MAR and TAR Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records, specifically MARs and TARs, for multiple residents as required by facility policy and professional standards. The facility’s medication administration policy dated 12/2/25 states that the individual who administers a medication must record it on the MAR directly after administration, review the MAR at the end of each pass, and never leave duty without documenting all administered medications. Despite this, surveyors found numerous missing entries for ordered medications and treatments across several residents’ records. The DON confirmed that the clinical records for the affected residents were incomplete regarding treatment and medication documentation. For one resident with dementia, osteoarthritis, and hypertension, there was a physician’s order for Dakins solution wound care to the coccyx every shift, including cleansing, packing, and dressing changes twice daily and as needed. Review of this resident’s TAR from 12/11/25 to 2/3/26 showed 16 missing documentation entries out of 109 opportunities for the ordered wound treatment. Another resident with A-fib, PVD, and pain had an order for Triad Hydrophilic Wound Dressing to the buttocks every shift for wound healing, but the TAR from 1/2/26 to 2/3/26 lacked documentation for seven of 65 opportunities. The DON acknowledged that these treatment records were incomplete. A resident with COPD, bipolar disorder, and diabetes had extensive medication and treatment orders, including oxygen as needed, pulse oximetry every shift, multiple psychotropic and cardiac medications, insulin (Novolog and Toujeo), inhalers, diuretics, seizure medications, pain monitoring, oxygen maintenance, skin care, bruising/bleeding monitoring, compression stockings, head-of-bed elevation, and a pressure-reducing cushion. Review of this resident’s MAR from 12/1/25 to 2/3/26 revealed numerous blank entries: missing documentation for Gabapentin, Metoprolol, Toujeo, Anoro Ellipta, Atorvastatin, Nortriptyline, Risperdal, Lasix, oxygen use, Levetiracetam, chin tuck maneuver, pulse oximetry, pain monitoring, Novolog, and Baclofen. The TAR for the same period also had multiple blanks for oxygen maintenance, application of Gold Bond lotion, monitoring for bruising/bleeding, compression stockings, elevating the head of bed, and use of a pressure-reducing cushion. Another resident with epilepsy, Down syndrome, and hypothyroidism had numerous physician orders for catheter-related care, skin protection, pain monitoring, intake and output, wound care products, and multiple daily medications including Aricept, Flomax, Trazodone, Baclofen, Lamictal, Memantine, Zonisamide, Tylenol, Renacidin irrigation, Nystatin-Triamcinolone, artificial tears, Levothyroxine, and a one-time Ceftriaxone injection. Review of this resident’s MAR from 12/1/25 to 2/3/26 showed missing documentation for the Ceftriaxone dose, several doses of Levothyroxine, Aricept, Flomax, Trazodone, Baclofen, Lamictal, Memantine, Zonisamide, artificial tears, pain monitoring, and Tylenol. The TAR review showed missing entries for cleansing a skin tear, Triad paste, skin prep to foot blisters, Renacidin irrigation, Phytoplex ointment, catheter care, bleeding monitoring, Nystatin-Triamcinolone, pressure-reducing cushion, catheter securement, privacy bag, intake and output, and maintaining the Foley catheter to gravity. A further resident with COPD, diabetes, and A-fib had complex orders related to respiratory care, tracheostomy care, enteral feeding, pain monitoring, multiple oral and inhaled medications, catheter care, skin protection, and IV therapy. Orders included weekly changes of oxygen and nebulizer tubing and trach mask, oxygen saturation checks every four hours, trach care twice daily, pain monitoring, enteral feeding equipment changes, Trazodone, Apixaban, Bactroban to the tube site, water flushes before and after medications, continuous Diabetasource AC at specified rates, Clonazepam, Docusate, nasal saline spray, documentation of total enteral intake and flushes, Baclofen, Metoprolol, Nexium, catheter care, pressure-relieving devices, privacy bag, head-of-bed elevation, gastric residual checks, Acetylcysteine inhalation, zinc oxide to coccyx/buttocks, skin prep to toes, Piperacillin IV, saline IV flushes, midline dressing changes, and infection monitoring. From 12/1/25 to 2/3/26, the MAR showed multiple blank entries for Piperacillin, IV flushes, enteral syringe and bag changes, Trazodone, Nexium, Diabetasource at both 50 cc/hr and 60 cc/hr, Bactroban, Apixaban, Clonazepam, Docusate, nasal spray, Baclofen, Metoprolol, pain monitoring, gastric residual checks, water flushes, Acetylcysteine, and documentation of total enteral intake and flushes. The TAR showed missing documentation for midline dressing changes, weekly oxygen/nebulizer/trach tubing changes, infection site monitoring, pressure-reducing devices, skin prep to toes, trach care, privacy bag, head-of-bed elevation, catheter care, bruising/bleeding monitoring, oxygen at 5L, zinc oxide application, maintaining Foley drainage to gravity, triple antibiotic to tube site, and oxygen saturation checks. The DON confirmed that the MARs and TARs for this resident and others were incomplete.
Inaccurate MDS Coding of Anticoagulant Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s Minimum Data Set (MDS) assessment accurately reflected the resident’s medication regimen, specifically the use of an anticoagulant. MDS instructions for section N0415E1 require that anticoagulant use be coded based on whether the resident is taking any medications in that pharmacological class during the last seven days or since admission if less than seven days. One resident was admitted with diagnoses including atrial fibrillation, peripheral vascular disease, and pain. The admission MDS, with an Assessment Reference Date (ARD) of 12/30/25, coded section N0415E for anticoagulant use as “No,” indicating that the resident was not receiving anticoagulant medication during the look-back period. However, the resident’s physician orders showed that on 12/28/25 there was an active order for Rivaroxaban 15 mg once daily, and the Medication Administration Record documented that the resident received this anticoagulant from 12/28/25 through 12/31/25. During an interview, the Social Worker confirmed that the resident had been receiving an anticoagulant since admission and that the admission MDS was coded inaccurately regarding anticoagulant use. This discrepancy between the clinical record, medication administration documentation, and the MDS coding resulted in an inaccurate assessment for this resident, in violation of applicable state regulations governing licensee responsibility and medical records documentation.
Failure to Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan that addressed all of a resident’s needs, specifically the use and management of anticoagulant therapy. Facility policy dated 12/2/25 required a comprehensive care plan for each resident, including measurable objectives and timetables to meet medical, nursing, mental, and psychosocial needs. One resident, admitted on 12/27/25 with diagnoses including atrial fibrillation, peripheral vascular disease, and pain, had a physician’s order dated 12/28/25 for Rivaroxaban 15 mg once daily. Review of this resident’s comprehensive care plan showed no care plan addressing the anticoagulant medication or how to manage anticoagulant therapy. In a telephone interview, the Social Worker confirmed that the comprehensive care plan did not include a care plan for anticoagulant use and stated that such a care plan should have been initiated for this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(3)(5) related to nursing services.
Failure to Timely Review and Revise Comprehensive Care Plans for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive, person-centered care plans within required timeframes for two residents. Facility policy dated 12/2/25 states that a comprehensive care plan with measurable objectives and timetables must be developed for each resident based on the comprehensive assessment and must be periodically reviewed and revised by a team of qualified persons after each assessment. For one resident admitted on 12/27/25 with diagnoses including A-fib, peripheral vascular disease, and pain, review of the comprehensive care plan on 2/5/26 showed nine active care plans (covering allergies, self-care deficit, risk for skin breakdown, risk for falls, pain, nutrition/hydration needs, discharge, elopement, and code status), all of which had an outstanding target review date of 1/13/26 and had not been updated. For another resident admitted on 6/15/25 with COPD, bipolar disorder, and diabetes, review of the comprehensive care plan on 2/5/26 showed nine care plans (covering discharge plan, psychotropic medications, altered nutrition and hydration, risk for skin breakdown, self-care deficit, risk for falls, smoker, code status, and altered respiratory status), all with an outstanding target review date of 1/11/26 that had not been met. During a telephone interview on 2/5/26 at 11:30 a.m., the Social Worker confirmed that the care plans for these two residents were not reviewed and/or revised within the required timeframes, in violation of the facility’s policy and 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Physician Orders Not Reviewed and Signed at Required Intervals
Penalty
Summary
The facility failed to ensure that physicians reviewed, signed, and dated all orders during each required visit for five out of 25 residents reviewed. According to the facility's policy, physicians are required to see residents every 30 days for the first 90 days after admission and every 60 days thereafter, with all orders to be reviewed and renewed at each scheduled visit. However, clinical record reviews revealed that for several residents with complex medical conditions such as congestive heart failure, COPD, diabetes, hypertension, hyperlipidemia, hypothyroidism, hypotension, and dementia, the last physician review, signature, and date on their orders were overdue and not in compliance with the required schedule. Specifically, the records for these residents showed significant lapses since the last physician review and signature, with some orders not reviewed for several months. During an interview, the DON confirmed that the physician orders for these residents were past due and acknowledged that orders should be reviewed and signed at every required physician visit. The deficiency was cited under relevant state codes for responsibility of the licensee, management, and medical records.
Inconsistent Physician Orders and POLST Forms for Life-Sustaining Treatment
Penalty
Summary
The facility failed to ensure that physician orders and Physician Order for Life Sustaining Treatment (POLST) forms were consistent for two residents. According to facility policy, documentation of informed consent to withhold or withdraw treatment must be placed in the resident's clinical record, along with the attending physician's order, and this information should be reflected in the resident's plan of care. For one resident with diagnoses including anxiety, hyperlipidemia, and hypertension, the physician's order indicated cardiopulmonary resuscitation (CPR), while the POLST form indicated Do Not Resuscitate-Allow Natural Death (DNR). For another resident with heart failure, hypertension, and muscle weakness, the physician's order indicated DNR, but the POLST form indicated CPR. These inconsistencies were confirmed during an interview with the Director of Nursing, who acknowledged that the physician orders and POLST forms for the two residents did not match. The deficiency was identified through review of facility policy, clinical records, and staff interviews, and it was determined that the facility did not honor the residents' rights to have their treatment preferences accurately documented and followed as required by state regulations.
Failure to Provide Clinical Rationale for Continued PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to provide a clinical rationale for the continued use of a PRN psychotropic medication beyond 14 days for one resident. According to facility policy, PRN orders for anti-psychotic medications are limited to 14 days and cannot be renewed without an evaluation by the attending physician for appropriateness. Review of the clinical record for a resident with diagnoses including anxiety, bipolar disorder, and hypertension showed an order for Ativan 0.5mg every eight hours as needed, which was administered multiple times over two months. However, the order lacked the required 14-day stop date or documented clinical justification for continued use beyond this period. The DON confirmed during interview that the necessary documentation and evaluation were not present.
Failure to Communicate Clinical Information During Resident Transfers
Penalty
Summary
The facility failed to ensure that necessary clinical information was communicated to the receiving health care provider when three residents were transferred to the hospital. According to facility policy, clinical records describing the residents' needs, including a list of orders and medications as directed by the attending physician, should accompany the resident upon transfer. However, for three residents with complex medical histories—including conditions such as congestive heart failure, COPD, diabetes, hypertension, dementia, hypothyroidism, and dependence on renal dialysis—there was no evidence in their clinical records that this information was provided to the hospital at the time of transfer. Review of the clinical records for these residents showed documentation of their transfer to the hospital, but lacked any indication that their necessary clinical information was communicated to the receiving provider. The Director of Nursing confirmed during an interview that there was no evidence of this required communication for the affected residents and acknowledged that clinical information should have been provided at the time of transfer.
Failure to Provide Baseline Care Plan and Order Summary Upon Admission
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to a resident and/or their representative within 48 hours of admission. Review of the clinical record for a resident admitted with diagnoses including anxiety, bipolar disorder, and hypertension showed no evidence that these documents were given as required. This was confirmed during an interview with the Director of Nursing, who acknowledged that the clinical record lacked documentation of the written summary of the baseline care plan and order summary being provided to the resident or their representative upon admission.
Failure to Develop Comprehensive Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident who required oxygen therapy. According to the facility's own Care Plan Policy, each resident should have a care plan that includes measurable objectives and timetables to address their medical, nursing, and psychosocial needs. Review of the clinical record for a resident admitted with diagnoses of respiratory failure, chronic obstructive pulmonary disease, and hypertension revealed a physician's order for oxygen therapy as needed. Documentation showed that the resident used oxygen on 31 days during the review period. Despite the resident's ongoing need for oxygen therapy, there was no evidence in the care plan that respiratory care or the use of oxygen was addressed. This omission was confirmed by the Director of Nursing, who acknowledged that a respiratory care plan should have been developed for the resident. The deficiency was cited under relevant state codes for responsibility of licensee, management, and nursing services.
Failure to Update Care Plans and Hold Timely Care Plan Meetings
Penalty
Summary
The facility failed to review and revise care plans to reflect residents' current conditions and did not ensure that care plan meetings were held in a timely manner for two residents. For one resident with a history of obstructive and reflex uropathy, benign prostatic hyperplasia, weakness, and dementia, the clinical record showed a change in catheter type from a Foley catheter to a suprapubic catheter. However, the care plan was not updated to reflect this change, and the care plan continued to reference the Foley catheter despite a physician's order for a suprapubic catheter. The Director of Nursing confirmed that the care plan did not accurately reflect the resident's current status and care needs. For another resident with diagnoses including heart failure, hypertension, and muscle weakness, the clinical record lacked evidence that care plan meetings were scheduled in accordance with facility policy. There was a significant gap between care plan meetings, with the next meeting not scheduled or completed within the expected timeframe. The Social Worker confirmed that the care plan meeting was not held as required. These findings were based on review of facility policy, clinical records, and staff interviews.
Failure to Provide Oxygen Therapy per Physician's Orders
Penalty
Summary
The facility failed to provide oxygen therapy according to physician's orders for a resident with respiratory failure, COPD, and hypertension. The physician's orders specified oxygen at two liters per minute as needed via nasal cannula, with instructions to change the oxygen tubing and supply bag weekly, wipe down the concentrator and clean the filter weekly, and change the water jug weekly. Over a period of several days, observations revealed that the resident was receiving oxygen at one and a half liters per minute, which was not in accordance with the prescribed flow rate. Additionally, the oxygen concentrator was missing both the water bottle and the external filter, contrary to facility policy and physician's orders. Repeated observations confirmed that the deficiencies persisted over multiple days, with the resident consistently receiving oxygen at the incorrect flow rate and without the required water bottle and filter attached to the concentrator. The DON confirmed during an interview that the oxygen was not set per the physician's order and that the necessary equipment was missing. These findings were based on review of facility policy, clinical records, direct observation, and staff interview.
Failure to Discard Outdated Medications and Ensure Proper Labeling
Penalty
Summary
The facility failed to properly discard outdated medications and ensure appropriate labeling and storage of drugs and biologicals, as required by facility policy and manufacturer guidelines. During a review of the medication room and a medication cart, surveyors observed an open vial of Tubersol without a date indicating when it was opened, as well as an open Lantus insulin pen with no open date. Additionally, two open Aspart insulin pens were found with open dates that indicated they were past the 28-day usage period recommended by the manufacturer. The facility policy requires that outdated, contaminated, or deteriorated medications be immediately removed from stock, and manufacturer guidelines specify discard dates for these medications. During interviews, an LPN confirmed the presence of the undated and outdated medications and acknowledged that staff were unable to determine the appropriate discard dates for the Tubersol and Lantus insulin pen. The LPN also confirmed that the Aspart insulin pens, Lantus insulin pen, and Tubersol should have been discarded according to policy and manufacturer instructions. These findings demonstrate that the facility did not consistently follow procedures for labeling, dating, and discarding medications, resulting in the presence of outdated and improperly labeled drugs in both the medication room and on the medication cart.
Failure to Maintain Required Hospice Documentation in Clinical Record
Penalty
Summary
The facility failed to ensure that hospice documentation was properly maintained in the clinical record for one resident. Review of the hospice contract and facility policy indicated that coordination of care between facility staff and the hospice interdisciplinary team was required, and that hospice documentation should be incorporated into the facility's medical record. For the resident in question, who was admitted with diagnoses including interstitial pulmonary disease, chronic respiratory failure with hypoxia, pulmonary hypertension, and diabetes, there was a physician's order to admit the resident to hospice services. The clinical record included a hospice plan of care and a nurse's visit assessment, but lacked further evidence of ongoing collaboration or communication from hospice, such as communication sheets or detailed documentation of hospice services and service dates. During staff interviews, the DON confirmed that there was no additional hospice communication documentation in the resident's record beyond the initial nurse's assessment, and also confirmed that the physician's order for hospice services was not obtained at the time of admission. This lack of required documentation and timely physician order constituted a failure to comply with both the facility's policy and state regulations regarding hospice care coordination and record-keeping.
Failure to Timely Notify Emergency Contact of Resident Transfer and Change in Condition
Penalty
Summary
The facility failed to notify a resident's emergency contact or representative in a timely manner regarding both a transfer to the emergency room and a significant change in condition. According to facility policy, immediate notification is required when there is a significant change in a resident's physical, mental, or psychosocial status. Review of the clinical record for a resident with diagnoses including hypertension, muscle weakness, and a history of aortocoronary bypass graft revealed that the resident experienced hallucinations, unsteady gait, and increased confusion, which led to a transfer to the emergency room. There was no evidence in the clinical record that the emergency contact or representative was notified of this transfer. Further review showed that the same resident developed respiratory symptoms, including wheezing, fatigue, non-productive cough, and required breathing treatments and cough medicine. Despite these ongoing symptoms and interventions, the emergency contact or representative was not notified of the change in condition until approximately 21 hours after the onset of symptoms. The delay in notification was confirmed by the Nursing Home Administrator, who acknowledged the lack of timely communication and documentation in the clinical record.
Nurse Aide Staffing Shortages in Facility
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios during various shifts over a 14-day period. Specifically, the facility did not have the minimum number of NAs per resident for the day, evening, and overnight shifts on multiple days. For the day shift, the facility was short of the required NAs on three days, with the census ranging from 107 to 108 residents, but the number of NAs working was consistently below the required number. Similarly, for the evening shift, the facility did not meet the required NA ratios on four days, with the census ranging from 107 to 109 residents, and the number of NAs working was below the required number. The overnight shift experienced the most significant staffing shortages, with the facility failing to meet the required NA ratios on nine days. The census during these days ranged from 105 to 109 residents, but the number of NAs working was consistently below the required number. The Nursing Home Administrator confirmed these staffing shortages during a telephone interview, acknowledging that the NA ratios were not met on the specified days.
Plan Of Correction
Plan of Correction: P 5520 Nursing Services 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Nursing home administrator/NHA or designee to in-service staffing coordinator, director of nursing, staff educator and assistant director of nursing and charge nurses on the state required minimum staffing ratios for nursing assistants. 2. How the care community will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Nursing Home Administrator/NHA or designee to conduct staffing meetings 3 times/week to ensure the state required minimum staffing ratios for nursing assistants are met throughout the week, weekends and holidays. 3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur? NHA/ designee to review staffing sheets 3x weekly to ensure the state required minimum staffing ratios for nursing assistants are met for the day/ shifts prior. Staffing meeting includes discussion of open shifts, vacation coverage, review of current nursing staff schedule and what is needed to meet state required nurses aide ratio and PPD, interviews scheduled, new hires and orientation date. NHA/ designee to utilize corporate hiring and recruitment platform and Indeed for job applicants, attend job fairs, corporate talent acquisition specialist, newspaper ads, employee referral bonus program and tuition reimbursement for recruitment efforts. STNA's are offered call-in bonus pay and incentive programs for picking up additional shifts. NHA or designee will host open interview hours to increase recruitment efforts. The admission team will review potential admissions based on the ability to meet the care needs of the resident and meet minimum staffing needs. 4. How will the corrective action(s) be monitored to ensure that deficient practice will not recur, i.e., what quality assurance program will be put into place; and NHA/designee to meet 3x weekly with director of nursing/DON or designee and staffing coordinator to review nursing assistant ratios, staffing meeting and audit will continue to ensure sustained compliance. All audits will be reviewed through the quality and performance improvement process. 5. Dates when corrective action will be completed. March 3, 2025
LPN Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required Licensed Practical Nurse (LPN) staffing ratios as mandated by regulations effective July 1, 2023. Specifically, the facility did not maintain the minimum LPN-to-resident ratios on both the day and overnight shifts during the period from January 8, 2025, to January 21, 2025. On the day shift, the facility was short of the required LPNs on January 15 and January 20, with a census of 107 residents, where 4.28 LPNs were required, but only 4.05 and 4.27 LPNs worked, respectively. On the overnight shift, the facility was deficient on January 11, 12, 13, and 19, with a census of 108 residents requiring 2.70 LPNs, but only 2.13 LPNs worked on the first three dates, and with a census of 107 residents requiring 2.68 LPNs, only 1.07 LPNs worked on January 19. The Nursing Home Administrator confirmed these staffing shortages during a telephone interview on January 27, 2025.
Plan Of Correction
Plan of Correction: P 5530 Nursing Services 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Nursing Home Administrator/NHA or designee to in-service staffing coordinator, director of nursing/DON, staff educator and assistant director of nursing and charge nurses on the state required minimum staffing ratios for licensed practical nurses. 2. How the care community will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. NHA/ designee to conduct staffing meetings 3 times/week to ensure the state required minimum staffing ratios for licensed practical nurses are met throughout the week, weekends and holidays. 3. What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur? NHA/designee to review staffing sheets 3x weekly to ensure the state required minimum staffing ratios for licenses practical nurses are met for the day/ shifts prior. Staffing meeting includes discussion of open shifts, vacation coverage, review of current nursing staff schedule and coverage needed to meet state required LPN ratio and PPD, interviews scheduled, new hires and orientation date. NHA/designee to utilize corporate recruitment platform and Indeed for job applicants, attend job fairs, corporate talent acquisition specialist, newspaper ads, employee referral bonus program and tuition reimbursement for recruitment efforts. Licensed Nurses are offered call-in bonus pay and incentive programs for picking up additional shifts. NHA or designee will host open interview hours to increase recruitment efforts. The admission team will review potential admissions based on the ability to meet the care needs of the resident and meet minimum staffing needs. 4. How will the corrective action(s) be monitored to ensure that deficient practice will not recur, i.e., what quality assurance program will be put into place; and NHA/designee to meet 3x weekly with DON/designee and staffing coordinator to review licenses practical nurse's ratios. Staffing meetings will continue to ensure sustained compliance. All audits will be reviewed through the quality and performance improvement process. 5. Dates when corrective action will be completed. March 3, 2025
RN Staffing Shortage During Evening Shift
Penalty
Summary
The facility failed to meet the regulatory requirement of having a minimum of one Registered Nurse (RN) per 250 residents during the evening shift on one of the days reviewed. Specifically, on January 18, 2025, the facility had a census of 107 residents but only 0.49 RNs were on duty, whereas 1.00 RN was required. This staffing shortage was confirmed by the Nursing Home Administrator during a telephone interview on January 27, 2025.
Plan Of Correction
Plan of Correction: P 5540 Nursing Services 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Nursing Home Administrator/NHA or designee to in-service staffing coordinator, staff educator, DON/director of nursing and assistant director of nursing and charge nurses on the state required minimum staffing ratios for registered nurses. 2. How the care community will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. NHA/designee to conduct staffing meetings 3 times/week to ensure the state required minimum staffing ratios for registered nurses are met throughout the week, weekends and holidays. 3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. NHA/designee to review staffing sheets 3x weekly to ensure the state required minimum staffing ratios for registered nurses are met for the day/ shifts prior. Staffing meeting includes discussion of open shifts, vacation coverage, review of current nursing staff schedule and coverage needed to meet state required registered nurse ratio and PPD, the interviews scheduled, new hires and orientation date. NHA/ designee to utilize corporate recruitment platform and Indeed for job applicants, attend job fairs, corporate talent acquisition specialist, newspaper ads, employee referral bonus program and tuition reimbursement for recruitment efforts. Registered Nurses are offered call-in bonus pay and incentive programs for picking up additional shifts. NHA or designee will host open interview hours to increase recruitment efforts. The admission team will review potential admissions based on the ability to meet the care needs of the residents and meet minimum staffing needs. 4. How will the corrective action(s) be monitored to ensure that deficient practice will not recur, i.e., what quality assurance program will be put into place; and NHA/designee to meet 3x weekly with DON/designee and staffing coordinator to review registered nurse's ratios. Staffing meetings will continue to ensure sustained compliance. All audits will be reviewed through the quality performance and improvement process. 5. Dates when corrective action will be completed. March 3, 2025
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period for 10 out of 14 days reviewed. The deficiency was identified through a review of nursing staffing documents covering the period from January 8, 2025, to January 21, 2025. On several specific dates, the facility's direct care hours per patient per day (PPD) fell below the required minimum, with the lowest being 2.62 hours on January 11, 2025. This shortfall was confirmed by the Nursing Home Administrator during a telephone interview on January 27, 2025.
Plan Of Correction
Plan of Correction: P 5640 Nursing Services 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Nursing Home Administrator/NHA or designee to in-service staffing coordinator, staff educator, Director of Nursing/DON and assistant director of nursing and charge nurses on the state required minimum staffing levels of 3.2 hours per patient day. 2. How the care community will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. NHA/designee to conduct staffing meetings 3 times weekly to ensure the state required minimum number of general nursing care hours are met through the week, weekends and holidays. 3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. NHA/designee to review staffing sheets 3x weekly to ensure adequate nursing coverage is scheduled to meet the minimum number of general nursing care hours. Staffing meeting includes discussion of open shifts, vacation coverage, review of current nursing staff schedule and coverage needed to meet state required minimum staffing hours of 3.2, interviews scheduled, new hires and orientation date. NHA/ designee to utilize corporate recruitment platform and Indeed for job applicants, attend job fairs, corporate talent acquisition specialist, newspaper ads, employee referral bonus program and tuition reimbursement for recruitment efforts. Nursing staff are offered call-in- bonus pay and incentive programs for picking up additional shifts. NHA or designee will host open interview hours to increase recruitment efforts. The admission team will review potential admissions based on the ability to meet the care needs of the residents and meet minimum staffing needs. 4. How the corrective action(s) will be monitored to ensure that deficient practice will not recur, i.e., what quality assurance program will be put into place; NHA/designee to meet 3x weekly with DON/designee and staffing coordinator to review nursing schedule and projected daily minimum number of general nursing care hours to ensure the minimum 3.2 hours are met. Staffing meetings will continue to ensure sustained compliance. All audits will be reviewed through the quality and performance improvement process. 5. Dates when corrective action will be completed. March 3, 2025
Failure to Develop Timely and Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for residents, as evidenced by the cases of two residents. Resident R95, who was admitted with diagnoses including a compression fracture, hip and back pain, and major depressive disorder, did not have timely care plans developed for several critical areas. Despite multiple refusals of care and behaviors indicating distress, care plans for pain, skin breakdown, self-care deficit, impaired coping, mood disorder, and behavior management were not developed until several months after admission. Additionally, the care plan for code status was delayed, highlighting a significant lapse in timely care planning. Similarly, Resident CR12, admitted with conditions such as stroke and hydronephrosis, did not have a care plan developed for the management of an indwelling catheter, despite its documented presence in progress notes and physician's notes over several months. The Director of Nursing confirmed the absence of a comprehensive care plan for the catheter, indicating a failure to address this critical aspect of the resident's care needs. These deficiencies reflect a broader issue with the facility's adherence to its policy on developing and maintaining comprehensive care plans.
Failure to Review and Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to review and revise comprehensive care plans to reflect the current care and services for two residents. Resident R51's clinical record showed an admission with diagnoses including hyperlipidemia, hypertension, and gastroesophageal reflux disease. The care plan for risk of skin breakdown had a target date for review, but it was confirmed by the Registered Nurse Assessment Coordinator (RNAC) that the care plan was not reviewed or revised to reflect the current resident care and services. For Resident R91, a family member revealed that the care plan had not been reviewed or revised, and no care plan meeting had taken place since May. The clinical record lacked evidence of any care plan meeting or revisions since that time. The Regional Director of Clinical Services confirmed that the care plan was not reviewed or revised and that no care plan meeting was conducted since May, despite the requirement for quarterly reviews.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being of its residents, as evidenced by deficiencies in the care of three residents. One resident with severe cognitive impairment required extensive assistance for bed mobility and transfers, as outlined in their care plan. However, observations over several days revealed that the resident remained in bed without being repositioned or transferred to a wheelchair as required, and there was no documentation of refusal to get out of bed. Another resident, also with severe cognitive impairment, was observed sitting in a wheelchair for extended periods without being repositioned, despite verbalizing discomfort and requesting to be laid down. The resident's care plan indicated a need for assistance with mobility and positioning, yet staff failed to respond to the resident's requests for repositioning, resulting in prolonged discomfort. Additionally, a third resident with an indwelling catheter did not have an active physician's order for catheter care for nearly a year. Despite the presence of the catheter being documented in progress notes, there was no evidence of catheter care or changes being performed during this period. The Director of Nursing confirmed the lack of physician's orders and the oversight in providing necessary catheter care, which was a significant lapse in the resident's medical management.
Failure to Enforce Smoking Policy Creates Safety Hazard
Penalty
Summary
The facility failed to ensure a safe environment related to smoking for three residents who smoke at the facility. The facility's smoking policy, dated December 26, 2023, mandates that residents must smoke in designated areas only and must be accompanied by staff, family, or properly trained volunteers. Smoking materials are to be kept in a designated area accessible only by staff, and residents are required to provide their own smoking materials. However, observations by surveyors over several days revealed that three residents were smoking outside on the front patio entrance to the facility, which is an unauthorized smoking area and against the facility's policy. The Nursing Home Administrator confirmed that these residents often refuse to adhere to the facility's smoking policy and have access to their own lighters and cigarettes, creating a safety hazard and unsafe environment. This non-compliance with the smoking policy poses a risk to the safety of the residents, staff, and visitors, as the residents are not being supervised in a designated smoking area as required by the facility's policy.
Inadequate Physician Documentation for Resident Care
Penalty
Summary
The facility failed to ensure that a resident's physician thoroughly documented a review of the resident's current condition, progress, and problems in maintaining or improving their physical, mental, and psychosocial well-being. This deficiency was identified for one resident, referred to as Closed Record Resident CR12, out of 25 residents reviewed. The facility's policy on Physician Services required that the resident's total plan of care, including medications and treatments, be reviewed with each scheduled visit, and that a progress note be written, signed, and dated for each physician visit. These progress notes were expected to contain an evaluation of the resident's condition, treatment, and a review of the continued appropriateness of the resident's current medical regimen. Resident CR12 had a complex medical history, including diagnoses of stroke, hydronephrosis, epilepsy, and hemorrhagic cystitis. The clinical record revealed that the resident had been admitted with these conditions and had undergone various diagnostic labs. However, the physician progress notes did not accurately reflect the resident's current health condition at the time of the physician's visits. The notes included outdated information, such as the resident's last COVID positive status and hemoglobin A1C and Dilantin levels, which were not reflective of the most recent values prior to the physician visits. During an interview, the Nursing Home Administrator confirmed that the physician progress notes did not accurately reflect Resident CR12's current health condition. The administrator acknowledged that the resident's last COVID positive status was from a previous year, and the lab values mentioned in the notes were not up-to-date. This lack of accurate documentation and review of the resident's condition and medical regimen led to the deficiency cited in the report.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to food safety standards in several areas, as observed during a survey. In the walk-in cooler, an open container of sour cream and a container of potato salad were found beyond their expiration dates, which was confirmed by a dietary employee. Additionally, the resident pantry contained a frozen bag of green beans, a frozen bag of tortellini, and an open bottle of ranch salad dressing, all lacking resident names, with the salad dressing also being expired. These findings indicate a failure to properly label and discard perishable food items as per the facility's policies. Furthermore, during observations of the kitchen, two staff members were seen without hair nets, which is against the facility's dress code policy. Additionally, three open food carts left the kitchen with glasses of milk and juice uncovered, exposing them during transport to the units. These actions were confirmed by a dietary employee, highlighting a lack of adherence to sanitation standards in food handling and staff attire within the kitchen environment.
Inconsistent POLST Documentation for Resident
Penalty
Summary
The facility failed to ensure consistency between physician orders and the Pennsylvania Orders for Life Sustaining Treatment (POLST) for a resident, identified as Resident R80. The facility's policy on advance directives requires that physician orders be documented on the resident's plan of care and clinical record. However, a review of Resident R80's clinical record revealed discrepancies between two POLST forms. The first POLST form, dated and signed by the physician, indicated a Full Code status for Cardiopulmonary Resuscitation (CPR). The second POLST form, which indicated a Do Not Attempt Resuscitation (DNR) status, lacked a physician's signature, thus failing to reflect the resident's current wishes accurately. During an interview, an LPN confirmed that in emergent situations, staff refer to the resident's paper chart to determine life-sustaining wishes. The LPN acknowledged that Resident R80's POLST form should have been signed by a physician to accurately reflect the resident's DNR wishes. This inconsistency in documentation and lack of a physician's signature on the updated POLST form led to the deficiency, as it did not align with the facility's policy and the resident's rights to have their treatment preferences accurately documented and respected.
Failure to Maintain Sanitary Conditions for Residents
Penalty
Summary
The facility failed to maintain a sanitary and orderly environment for Resident R36 and Resident R4. Resident R36, who has end-stage renal disease and requires dialysis, was found with a full dialysate drainage bag in a blue plastic tote, an empty dialysate infusion bag and tubing on the floor, and another empty bag on the bedside stand. This observation was made in the afternoon, despite the dialysis being completed during the night shift. Both Resident R36 and an LPN confirmed that the dialysis equipment should have been cleaned up and disposed of in hazardous waste. Resident R4, diagnosed with parkinsonism and other conditions, was observed sitting in a wheelchair covered with layers of dirty and dried food on the metal frame. This unsanitary condition was noted on two separate occasions, and an LPN confirmed that the wheelchair should have been cleaned. The facility did not provide a policy regarding housekeeping services, which contributed to the failure to maintain a clean and comfortable environment for these residents.
Inappropriate Urinary Catheter Care for a Resident
Penalty
Summary
The facility failed to provide appropriate urinary catheter care for a resident, identified as R44, who was admitted with diagnoses including obstructive and reflux uropathy, retention of urine, urinary tract infection, and overactive bladder. A physician's order dated 9/11/23 indicated the use of an indwelling catheter for this resident. On 11/05/24, observations revealed that the resident's urinary drainage bag was lying on the floor with the valve touching the floor. During an interview and observation, the Director of Nursing confirmed the improper placement of the urinary drainage bag and acknowledged that it should not be on the floor.
Lack of Clinical Rationale for Extended Use of PRN Psychotropic Medications
Penalty
Summary
The facility failed to provide a clinical rationale and duration for the continued use of PRN psychotropic medications beyond 14 days for a resident diagnosed with Alzheimer's Disease, restlessness, agitation, and hyperlipidemia. The resident's clinical record showed medication orders for Hydroxyzine and Lorazepam, both prescribed for restlessness and agitation, without the required stop date or clinical justification for extending use beyond the 14-day limit. During an interview, the Director of Nursing confirmed the absence of a stop date or clinical rationale for the continued use of these medications beyond 14 days. This oversight was identified during a review of the resident's clinical records and staff interviews, indicating non-compliance with the regulatory requirements for psychotropic medication management.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols, as evidenced by the presence of two opened and undated multi-dose Lantus insulin pens in the Unit C medication cart. Additionally, a multi-dose Humalog insulin pen was found to be 10 days past its expiration date, contrary to the manufacturer's instructions to discard within 28 days of opening. During an interview, an LPN confirmed that multi-dose vials should be dated upon opening to ensure timely disposal and prevent usage past expiration. Furthermore, the facility did not comply with its policy regarding the storage of medications at a resident's bedside. A resident, diagnosed with diabetes, anxiety, and hypertension, was found to have an open half-empty bottle of Robitussin Congestant on their tray table without a physician's order or a self-administration evaluation. The DON confirmed the absence of a physician's order for bedside medication storage and acknowledged that medications should not be kept at the bedside without proper authorization and evaluation.
Dietary Staffing and Competency Deficiency
Penalty
Summary
The facility failed to provide sufficient staff with appropriate competencies to carry out the functions of the food and nutrition services in the kitchen. Observations and interviews revealed that the dietary department was understaffed, leading to the use of a low staffing menu that repeated weekly. The dietary staff were observed leaving food carts uncovered and waiting for extended periods between tasks, which contributed to delays in meal service. Residents reported receiving cold, repetitive, and unappealing meals, with some resorting to purchasing food from outside the facility due to dissatisfaction with the meals provided. Interviews with staff and residents indicated that the facility was using staff from other departments, such as Nursing, Housekeeping, and Administration, to work in the dietary department without appropriate training or competencies. The Dietary Manager and Director of Nursing confirmed the staffing shortages and the use of untrained staff in the dietary department. Residents and their families expressed concerns about the quality and temperature of the food, as well as the inconsistency in staffing levels during survey periods compared to regular operations.
Infection Control Lapse in Graduate Storage
Penalty
Summary
The facility failed to adhere to appropriate infection control practices concerning the disinfection and storage of a graduate, a measuring device, for a resident. The resident, who was admitted with multiple diagnoses including atrial fibrillation, chronic obstructive pulmonary disease, and neuromuscular dysfunction of the bladder, had a graduate left on their bedside table with a date written on it, indicating it had been there since September. During an interview, a registered nurse confirmed that the graduate should have been discarded due to infection control risks and admitted to being unaware of whether it had been sanitized. The nurse also did not know the purpose of the graduate, despite the resident having a urinary catheter bag that is typically emptied with such a device.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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