Crawford Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saegertown, Pennsylvania.
- Location
- 20881 State Highway 198, Saegertown, Pennsylvania 16433
- CMS Provider Number
- 395853
- Inspections on file
- 23
- Latest survey
- April 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Crawford Care Center during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in food storage, preparation, and sanitation practices, including unlabeled and improperly stored food, lack of an air gap for the ice machine drain, unsealed dry goods, food debris in utensil bins, unsanitary oven conditions, and staff handling clean silverware without gloves, all confirmed by dietary management.
Several residents with complex medical conditions were admitted without receiving a written summary of their baseline care plan and order summary within 48 hours, as required by facility policy. Clinical records lacked evidence that these documents were provided to the residents or their representatives, and this was confirmed by the DON.
Surveyors found that several residents did not receive respiratory care in accordance with physician orders and facility policy. Oxygen concentrators and related equipment were not cleaned or changed as required, with some devices missing filters or proper dating. In one case, a nebulizer was present in a resident's room without a physician order or documentation, and the resident was unaware of its presence. Staff confirmed these lapses in respiratory care and equipment maintenance.
Several residents had not been seen by a physician within the required 60-day interval after their previous physician stopped visiting the facility. Instead, they were only seen by a nurse practitioner, and clinical records lacked clear documentation of physician visits. The ADON confirmed that records did not specify who conducted the visits, resulting in uncertainty about whether residents were seen by a physician as required.
Waste was not properly contained or disposed of, as four plastic rolling carts near the loading dock were found overflowing with unsealed garbage bags containing food remnants and other facility waste. Facility leadership confirmed that the garbage had accumulated for more than one day and should have been placed in the dumpster, not left by the dock.
A resident with multiple diagnoses had conflicting code status documentation, with a physician's order indicating Full Code and a POLST form indicating DNR. The DON confirmed that both documents should match to ensure the resident's wishes are followed, but the facility failed to maintain consistency as required by policy.
A resident's room was found to have a sticky floor and a large yellow dried liquid substance, appearing to be urine, next to the bed. The ADON confirmed the unclean conditions, which were not in accordance with the facility's housekeeping policy. The resident had a history of COPD, anxiety, and hypertension.
Two residents with physician orders for oxygen therapy did not have corresponding respiratory care plans developed or implemented. Both residents had significant respiratory-related diagnoses and required oxygen via nasal cannula, but their care plans lacked documentation addressing this aspect of their care. The RN Assessment Coordinator confirmed the absence of these care plans.
A resident with multiple diagnoses, including dementia and dizziness, had a care plan intervention requiring their bed to be placed against the wall for safety. Observations on multiple occasions found the bed was not positioned as directed, with a bedside table between the bed and the wall. An LPN confirmed the bed was not placed according to the care plan.
Surveyors observed that open insulin pens and a vial of Tubersol were stored without open dates on two medication carts and in a medication room. LPNs confirmed that these medications were not labeled as required and should have been discarded, in violation of facility policy and manufacturer guidelines.
Crawford Care Center failed to ensure residents and/or their representatives were involved in care planning, as required by federal regulations. The facility did not hold care plan meetings for residents between May and October 2024, affecting at least three residents with various medical conditions. This deficiency was confirmed through staff interviews and a review of clinical records.
The facility did not follow its planned menu when five residents received mashed potatoes instead of oven browned potatoes due to a shortage. The Dietary Manager confirmed the substitution was made without notifying the residents, and the Nursing Home Administrator suggested the shortage might be due to not accounting for new admissions and an increased census.
The facility failed to deliver lunch on time to residents in the 300 and 400 units, which are secured dementia units. Meals were scheduled for 12:15 p.m. and 12:25 p.m., but were delivered 40 to 42 minutes late due to a late start in meal preparation. Staff interviews confirmed the delay, which was not in compliance with the facility's meal schedule.
The facility failed to provide quarterly financial statements to two residents, as required by their policy. A resident with heart disease and another with epilepsy had their finances managed by the facility, but the Business Office Manager confirmed that quarterly statements were not issued. This non-compliance with the facility's policy and federal regulations resulted in a deficiency finding.
The facility failed to meet the required NA staffing ratios on multiple occasions, with shortages on the day, evening, and overnight shifts. For example, on one day with 122 residents, only 10.28 NAs worked when 12.20 were required. The Assistant Director of Nursing confirmed these deficiencies.
The facility did not provide the required minimum of 3.2 hours of direct resident care per resident in a 24-hour period on six days within a specified review period. The lowest recorded care hours were 2.50 on one of these days. This was confirmed by the Assistant Director of Nursing.
A resident with dementia and mobility issues eloped from the facility, triggering alarms. Despite the incident, the facility did not develop a comprehensive care plan to address the elopement, as required by their policy. The DON confirmed the oversight.
A resident with dementia and mobility issues eloped from the facility, triggering alarms. The facility failed to follow its policy for investigating the incident, including examining the resident for injuries, notifying the physician and legal representative, and documenting the event. The DON confirmed the lack of documentation and investigation.
The facility failed to follow infection control guidelines during the COVID-19 pandemic, leading to inadequate testing and isolation of residents. Residents were not tested unless they had a fever, and COVID-19 positive residents were not isolated from their roommates, resulting in further spread of the virus. Additionally, there was a lack of appropriate signage and PPE for COVID-19 positive rooms, and not all staff wore N95 masks when entering these rooms.
The NHA and DON failed to manage the facility effectively, leading to inadequate infection control procedures. The facility did not maintain a consistent infection prevention program, failed to educate staff, and did not follow CDC guidelines, resulting in non-compliance with Federal and State regulations.
The facility failed to implement effective COVID-19 infection control measures, as the Infection Preventionist did not ensure proper isolation and testing of residents. COVID-positive residents were not isolated from their roommates, and symptomatic residents were not tested unless they had a fever. Additionally, rooms with COVID-positive residents lacked signage and PPE provision, and staff did not consistently wear N95 masks. These actions were confirmed by staff interviews and observations.
A resident, cognitively intact and desiring to return home, was not provided with an active discharge plan or necessary referrals by the facility, despite having a physician's order for discharge with home health. The facility's inaction violated the resident's right to self-determination.
The facility failed to issue the Notice of Medicare Non-Coverage and SNFABN to residents or their representatives following the end of Medicare covered services. This deficiency was identified for two residents who remained in the facility for long-term care and one resident who was discharged. The clinical records lacked evidence of acknowledgment that the residents had received the required notices.
The facility failed to provide written summaries of baseline care plans and order summaries to eight residents and/or their representatives within 48 hours of admission, despite having a policy in place. This deficiency affected residents with serious health conditions such as heart failure, end-stage renal disease, diabetes, and chronic obstructive pulmonary disease.
The facility failed to review and revise comprehensive care plans for nine residents, despite policy requirements to update care plans when there are significant changes in condition, unmet outcomes, hospital readmissions, and at least quarterly. The Registered Nurse Assessment Coordinator confirmed the non-compliance.
The facility failed to provide a clinical rationale for the continued use of PRN psychotropic medication beyond 14 days and did not attempt non-pharmacological interventions prior to administering the medication for four residents. The Assistant DON confirmed the deficiencies, acknowledging the lack of required documentation and non-pharmacological interventions.
The facility failed to prevent unauthorized access to medications, properly label a multi-dose insulin pen, and securely store controlled substances. An unlocked medication cart was found unattended, an opened insulin pen was not labeled with the date, and controlled medications were not stored in a permanently affixed compartment.
The facility failed to provide evidence of a QAPI Committee meeting for the First Quarter of 2024, as required by their policy. The Nursing Home Administrator confirmed the absence of the meeting during an interview.
The facility failed to inform and discuss treatment changes with a resident's representative, leading to a lack of informed consent and proper documentation for withholding bloodwork and diagnostic testing.
The facility failed to accurately complete the MDS for two residents. One resident receiving dialysis was incorrectly marked as not receiving it, and another resident's medication record incorrectly indicated insulin administration. These errors were confirmed by the RN Assessment Coordinator.
The facility failed to develop comprehensive care plans for two residents within the required timeframe. One resident with end-stage renal disease and another with Parkinson's Disease had care plans that only addressed nutrition, despite having multiple diagnoses. The RN Assessment Coordinator confirmed the care plans were not completed within 21 days of admission, as required by facility policy.
The facility failed to maintain cleanliness and prevent infection spread for respiratory care equipment for two residents with COPD and other conditions. Observations revealed undated and unclean equipment, contrary to physician orders, which was confirmed by an LPN.
The facility failed to maintain proper communication records between the facility and the dialysis clinic for a resident with end-stage renal disease, resulting in a deficiency in the coordination of care.
The facility failed to electronically submit direct care staffing information for Quarter Four of 2023 as required by Section 6106 of the ACA. The PBJ Staffing Data Reports review revealed non-compliance, and the Nursing Home Administrator confirmed the failed submission status.
The facility failed to provide a nourishing, well-balanced diet that meets residents' daily nutritional needs. Observations revealed inadequacies in meal components and pantry supplies, with residents reporting frequent shortages and lack of notification about menu changes. The Dietary Manager confirmed these issues, impacting the residents' dining experience and nutritional intake.
The facility failed to provide baths/showers according to residents' preferences, affecting four residents with various medical conditions. Documentation and interviews confirmed multiple missed scheduled baths/showers over a specified period.
The facility failed to follow physician orders for three residents, leading to deficiencies in medication administration. One resident did not receive their prescribed Levothyroxine Sodium for hypothyroidism, another did not receive Nubega Oral Tablet for a urinary tract infection, and a third did not receive Norco Oral Tablet for pain management. The DON confirmed these lapses in medication administration.
Deficient Food Storage, Preparation, and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's main kitchen regarding the safe storage, preparation, and handling of food and food-related equipment. Specifically, a clear plastic container with an orange/red liquid was found in the cooler without a label or date, and the drain hose from the ice machine storage bin lacked the required air gap from the floor drain, with dried food splatters present on the side of the ice machine. Additional findings included wet stacking and food crumbs between stored metal steam table inserts, opened and unsealed bags of sugar and flour in the dry storage area, and food crumbs in the bottom of clean utensil storage bins. The floor of two ovens was covered in a black substance and scattered with food pieces and crumbs. Dietary staff were observed rolling silverware in paper napkins without gloves and touching the eating end of the silverware when transferring items from the dishwasher basket to the utensil tray, creating a risk for cross contamination. Interviews with the Dietary Manager confirmed that opened food items should be sealed and dated, equipment should be cleaned between uses, and staff should not touch clean eating surfaces with bare hands. It was also confirmed that there was no schedule for cleaning kitchen appliances and that an air gap is required between the ice machine drain hose and the floor drain to prevent contamination.
Failure to Provide Baseline Care Plan Summaries Upon Admission
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to residents and/or their representatives within 48 hours of admission, as required by facility policy. This deficiency was identified for five residents whose clinical records were reviewed. The records for these residents did not contain evidence that the required documentation was given to the residents or their representatives. The policy in place specified that a written summary of the baseline care plan should be provided, but this was not reflected in the clinical records for the affected individuals. The residents involved had various medical conditions, including anxiety, hypertension, dementia, diabetes mellitus, gout, polyneuropathy, obstructive sleep apnea, chronic obstructive pulmonary disease, cellulitis, diverticulitis, and radiculopathy. During an interview, the DON confirmed that the clinical records for these residents lacked documentation showing that the written summaries were provided upon admission. The deficiency was cited under 28 Pa. Code 211.10(c)(d) and 28 Pa. Code 201.18 (b)(1).
Failure to Provide Safe and Appropriate Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents by not following physician orders and not maintaining cleanliness of respiratory equipment. For one resident with COPD, the oxygen concentrator was found to be dusty, had a dried substance on its surface, and was missing a filter, with the internal filter containing a dusty gray substance. The LPN confirmed the concentrator had not been cleaned weekly as required by facility policy. Two other residents receiving oxygen therapy had nasal cannulas that were not dated, and their humidification water bottles were not changed according to the required schedule, as the bottles were dated beyond the weekly change interval. The ADON confirmed these items should have been changed weekly and properly dated. Additionally, a nebulizer with a mask dated nearly a month prior was found in another resident's room, despite no physician order, care plan, or documentation indicating the resident required or used a nebulizer. The resident was unaware of the device, and the LPN confirmed there was no current order for its use. These findings demonstrate a failure to adhere to facility policy and physician orders regarding respiratory care and equipment maintenance for multiple residents.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were conducted at least once every 60 days for three residents. Interviews with the residents revealed that they had not seen their physician since their previous physician stopped coming to the facility, and had only been seen by a nurse practitioner. This was further corroborated during a resident council meeting, where the majority of residents present stated they had not seen a physician since the previous one stopped visiting, and had only seen the nurse practitioner. Review of the clinical records for the three residents showed a lack of physician visit documentation between August 2024 and December 2024. Subsequent physician notes were signed by both the nurse practitioner and the physician, but it was unclear who actually conducted the visits. The Assistant Director of Nursing confirmed that the physician and nurse practitioner visited on different days and that the records did not clearly indicate who saw the residents, nor was there evidence that the residents were seen by a physician during the specified period.
Improper Disposal and Containment of Facility Garbage
Penalty
Summary
The facility failed to properly contain and dispose of waste in accordance with its policy, which requires that outside refuse containers and dumpsters have tightly fitting lids and remain covered when not being loaded. During an observation, four plastic rolling carts near the loading dock were found overflowing with garbage bags, including clear unsealed bags containing cans with food remnants and other bags with dietary and housekeeping waste. The Director of Maintenance and the Nursing Home Administrator confirmed that the garbage present represented more than one day's accumulation and acknowledged that the bags should have been placed in the dumpster rather than left by the dock.
Inconsistent Documentation of Code Status Orders
Penalty
Summary
The facility failed to ensure that a resident's code status was consistently documented across all relevant medical records. Specifically, a physician's order indicated the resident was Full Code, while the POLST form documented the resident as Do Not Resuscitate (DNR). The resident's care plan further indicated the POLST was Full Code, creating conflicting information regarding the resident's wishes for life-sustaining treatment. The Director of Nursing confirmed the discrepancy between the physician's order and the POLST, acknowledging that both documents should be identical to accurately reflect the resident's wishes. The facility's policy requires that code status be clearly documented and communicated in all designated sections of the medical record, but this was not followed for the resident, who had multiple diagnoses including dementia, diabetes mellitus, gout, and polyneuropathy.
Failure to Maintain Clean Resident Environment
Penalty
Summary
The facility failed to provide adequate housekeeping services necessary to maintain a clean environment for a resident. Observations conducted at multiple times revealed that the floor in the resident's room was sticky when walked upon, and there was a large yellow dried liquid substance, appearing to be urine, on the floor next to the resident's bed. The Assistant Director of Nursing confirmed both the sticky condition of the floor and the presence of the dried liquid substance, acknowledging that resident rooms should be kept clean. The facility's own housekeeping policy requires that floors be dust mopped and disinfected, particularly in patient rooms, but these procedures were not followed in this instance. The resident involved had a clinical history including chronic obstructive pulmonary disease, anxiety, and hypertension, and was admitted to the facility prior to the observations.
Failure to Develop Respiratory Care Plans for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement a respiratory care plan for two residents who had physician orders for oxygen therapy. One resident had diagnoses including anxiety, obstructive sleep apnea, and hypertension, and had a physician's order for oxygen at 2 liters per minute via nasal cannula. The other resident had diagnoses of chronic obstructive pulmonary disease, anxiety, and hypertension, with a physician's order for oxygen at 2 liters per minute via nasal cannula as needed to maintain oxygen saturation above 90%. A review of both residents' care plans revealed no evidence of a care plan addressing respiratory care or oxygen administration, despite the presence of relevant physician orders. The Registered Nurse Assessment Coordinator confirmed during an interview that care plans for oxygen administration were not developed for these residents, and acknowledged that such care plans should have been in place.
Failure to Follow Care Plan for Bed Positioning
Penalty
Summary
The facility failed to follow the established plan of care for one resident diagnosed with polyosteoarthritis, dementia, and dizziness. The resident's care plan, dated 8/06/24, included an intervention to place the bed against the wall to address safety and fall risk. However, during observations on two separate occasions, the resident's bed was found not positioned against the wall as required, with a bedside table placed between the bed and the wall. This was confirmed by a Licensed Practical Nurse during an interview, verifying that the care plan intervention was not implemented as directed.
Failure to Discard Outdated Medications and Label Multi-Dose Vials
Penalty
Summary
The facility failed to appropriately discard outdated medications and ensure proper labeling of multi-dose vials and insulin pens. During observations of medication storage areas, including two medication carts and one medication room, surveyors found open insulin pens (Lispro, Basaglar, and Lantus) and an open vial of Tubersol that were not labeled with the date they were opened. Facility policy and manufacturer guidelines require that multi-dose vials and insulin pens be labeled with the date opened and discarded within a specified timeframe (28 days for insulin pens and 30 days for Tubersol), but these requirements were not followed. Staff interviews confirmed that the open insulin pens and Tubersol vial lacked open dates, making it impossible to determine appropriate discard dates. LPNs present during the observations acknowledged that the medications should have been discarded due to the absence of labeling, in accordance with both facility policy and manufacturer instructions. No information about specific residents or their medical conditions was provided in the report.
Failure to Facilitate Resident Participation in Care Planning
Penalty
Summary
Crawford Care Center was found to be non-compliant with the federal regulation 42 CFR Part 483, Subpart B, specifically regarding the residents' right to participate in the planning of their care. The facility failed to ensure that residents and/or their representatives were offered the opportunity to participate in the development, review, and revision of their person-centered care plans. This deficiency was identified through a review of facility policies, clinical records, and staff interviews, which revealed that care plan meetings were not held for residents between May 1, 2024, and October 1, 2024. Three residents were specifically noted in the findings. One resident, admitted in September 2020, had an annual MDS assessment in September 2024, but there was no evidence of a care plan meeting. Another resident, admitted in October 2021, had a quarterly MDS assessment in September 2024, also lacking evidence of a care plan meeting. The third resident, admitted in August 2022, had a quarterly MDS assessment in September 2024, with no record of a care plan meeting. Interviews with the Social Worker and Nursing Home Administrator confirmed the absence of care plan meetings during the specified period.
Plan Of Correction
1. Resident #1 had a care plan meeting invite sent/phoned to resident and/or responsible party and a care plan conference was held on 1/21/25. Resident #2 had a care plan meeting invite sent/phoned to resident and/or responsible party and a care plan conference was held on 11/19/24. A Social Service Progress note reflects the care plan being held with the responsible party. Resident #3 had a care plan meeting invite sent/phoned to resident and/or responsible party and a care plan conference will be held on 1/27/25. 2. All residents were reviewed to ensure that the resident and/or responsible party were invited to participate in planning of care meeting by Social Worker and residents that had not had in last 3 months were identified. Care plan conferences for any residents and/or responsible party that had not had a right to participate in their plan of care will have one completed. 3. All interdisciplinary team were educated by the Vice President of Clinical Services on the policy related to care planning. The Nursing Home Administrator and/or designee will audit and review 20 residents weekly x 4 weeks and to ensure all residents and/or responsible party receive and invite to participate in plan of care. 4. Findings will be presented to Quality Assurance Performance Improvement Committee for review and recommendations.
Failure to Follow Planned Menu Due to Food Shortage
Penalty
Summary
The facility failed to adhere to its planned menu, which is a requirement under §483.60(c) for meeting the nutritional needs of residents. The facility's policy, dated 1/18/24, mandates that menus be planned in advance and served as written unless a substitution is necessary due to preference, unavailability, or special meal requirements. On 12/30/24, the facility's menu indicated that residents were to receive a lunch meal consisting of smothered chicken thigh, whole kernel corn, oven browned potatoes, cornbread, sliced pears, and coffee or hot tea. However, during the meal service on the 400-unit, five residents were observed receiving mashed potatoes instead of the planned oven browned potatoes. The Dietary Manager explained that the substitution occurred because they ran out of oven browned potatoes and confirmed that the residents were not informed of this change. The Nursing Home Administrator was unsure why the dietary department ran out of food, suggesting it might be due to not accounting for new admissions and an increased census in recent weeks.
Plan Of Correction
1. There were no actual resident complaints when the substitution was made to the menu. Dietary staff were educated on Menus and Menu policy, meeting resident needs, resident notification when a change is made to the menu, preparation in advance, and followed by the regional dietary manager on January 14, 2025, which included notification of Menu Changes and Substitutions timely. 2. The Dietary Manager will monitor meal preparations to ensure that enough food is prepared for all meals. 3. Administrator/designee will audit random meals 5 times a week for 4 weeks, weekly for 4 weeks, then monthly ongoing to ensure menus are followed, that substitutions are posted timely, and that enough food was made to ensure dietary staff are following the menu. 4. The Administrator will submit Food Substitution Audits to the Quality Assurance Performance Improvement Committee (QAPI) for review and recommendations at the monthly meeting.
Delayed Meal Service in Dementia Units
Penalty
Summary
The facility failed to adhere to its meal distribution schedule, resulting in a delay in meal service for residents in the 300 and 400 units, which are secured dementia units. According to the facility's "Tray Service Schedule," lunch was supposed to be served at 12:15 p.m. for the 300 unit and 12:25 p.m. for the 400 unit. However, observations on December 30, 2024, revealed that the meal carts arrived significantly late, with the 300-unit meal cart arriving at 12:57 p.m. and the 400-unit meal cart at 1:05 p.m. The last meal tray was delivered at 1:15 p.m., which was 40 to 42 minutes beyond the scheduled service time. Interviews with staff, including a Registered Nurse and the Dietary Manager, confirmed the delay in meal service. The Dietary Manager acknowledged that the lunch meal preparation started late, which caused the delay in serving the main dining room and subsequently affected the meal delivery to the 300 and 400 units. This delay in meal service was not in compliance with the facility's policy and meal schedule, as meals are expected to be delivered in a timely manner to ensure proper nutrition and care for the residents.
Plan Of Correction
1. There were no adverse affects or issues with the residents meals not being served timely. Dietary staff will be educated on tray time and meal distribution policy by the Dietary Supervisor on January 14, 2025. 2. The Dietary Manager will monitor the tray line to ensure that the tray line starts timely for all meals. 3. Administrator/designee will audit random meals 5 times a week for 4 weeks, weekly for 4 weeks, then monthly ongoing to ensure meal distribution is timely as per meal teams. 4. Findings will be presented to Quality Assurance Performance Improvement Committee for review and recommendations at the monthly meeting.
Failure to Provide Quarterly Financial Statements to Residents
Penalty
Summary
The facility failed to ensure that resident financial records were made available through quarterly statements for two residents. The facility policy titled "Resident Personal Funds" mandates that residents have the right to manage their financial affairs, including receiving quarterly statements of their personal funds. However, the facility did not provide these statements to the residents, as confirmed by the Business Office Manager during an interview. The manager admitted that quarterly financial statements were not provided at the end of the quarter or within 30 days thereafter. Resident R1, who was admitted with diagnoses including heart disease and obstructive uropathy, had a trust fund account managed by the facility. The facility documentation showed discrepancies in the account balance over time, and there was no evidence that Resident R1 received a receipt for a transaction in June 2022. Similarly, Resident R3, admitted with conditions such as epilepsy and dysphagia, also had their finances managed by the facility, but there was no mention of quarterly statements being provided. This lack of compliance with the facility's policy and federal regulations led to the deficiency finding.
Plan Of Correction
1. Resident R1 $280.24 resident balance date 6/30/22 was previous ownership. New ownership did not occur until 11/1/23. New ownership although not their action made Resident R1 whole by placing $280.24 back in resident fund. 2. All residents were reviewed for any other like transactions from previous owners on 1/17/2025 by the Business Office Manager. Resident #3 received her statement on 1/17/2025. All residents and/or responsible party received their statement on 1/17/2025. 3. The Nursing Home Administrator will audit weekly to ensure resident funds have receipts for transactions weekly for four weeks then monthly ongoing. The Nursing Home Administrator will audit monthly to ensure that residents and/or responsible party receive their statement quarterly for resident funds. 4. Findings will be presented to the Quality Assurance Performance Improvement Committee for review and recommendations.
Nurse Aide Staffing Deficiencies
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios on multiple occasions, as evidenced by a review of nursing staffing documents and staff interviews. Specifically, the facility did not maintain the minimum required NA-to-resident ratios for the day, evening, and overnight shifts on several days. On the day shift, the facility was short of the required number of NAs on two days, with a census of 122 residents on one day and 120 residents on another, but only 10.28 and 9.28 NAs worked, respectively, when 12.20 and 12.0 were required. Similarly, the evening shift was understaffed on three days, with the facility failing to meet the required NA ratios. For instance, on one day with a census of 122 residents, only 9.15 NAs worked when 11.09 were required. The overnight shift also experienced staffing shortages on three days, with the facility not meeting the required NA ratios. On one occasion, with a census of 120 residents, only 7.78 NAs worked when 8.0 were required. The Assistant Director of Nursing confirmed these staffing deficiencies during an interview.
Plan Of Correction
1. Education will be provided to the Director of Nursing, Assistant Director of Nursing, and the Scheduler no later than 01/24/2025 on the regulatory requirements for Resident to Nursing Assistant Staffing Ratios. The facility is holding a 5-day-a-week Staffing Meeting and Quality Call to ensure compliance. 2. The nursing assistant schedule will be reviewed by the Director of Nursing, Assistant Director of Nursing, and Scheduler to ensure that Nursing Assistant ratios are met prior to posting of the schedule. In the event of call-offs by staff, all other staff/agency will be contacted to cover any open shifts to ensure ratios are met. 3. An audit will be conducted by the Director of Nursing and/or designee daily for 2 weeks, then 3 times a week for 2 weeks, then 2 times a week for one week then weekly ongoing, to ensure that nursing assistant ratios are met for the evening and overnight shifts. The audit will be monitored by the Director of Nursing or Designee. 4. The Director of Nursing will submit all Ratio Audits to the QAPI (Quality Assurance and Performance Improvement Committee) for review and recommendations at the monthly meeting.
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 on six specific days within the review period from December 10, 2024, to December 30, 2024. The nursing staffing documents revealed that on December 22, 23, 24, 25, 27, and 29, 2024, the hours of direct resident care fell below the required minimum, with the lowest being 2.50 hours on December 25, 2024. This deficiency was confirmed during an interview with the Assistant Director of Nursing on January 3, 2025, who acknowledged that the facility did not meet the required care hours on the specified dates.
Plan Of Correction
1. Additional Staffing Agencies have been added to the facility to provide additional nursing staff to meet the state minimum requirement of 3.20 hours of direct resident care for each resident in a 24-hour period. Education will be provided to the Director of Nursing, Asst. Director of Nursing and the Scheduler no later than 1/24/2025 to ensure that they understand the regulatory staffing requirement. 2. The nursing schedule consisting of all three (3) disciplines (RN/LPN/CNA) will be reviewed by the Scheduler, Director of Nursing and/or Asst. Director of Nursing to ensure that the requirement of 3.20 direct nursing care hours is met prior to posting of the schedule. In the event of call-offs by staff, all facility nursing staff and/or agency staff will be contacted to cover any open shifts to ensure the 3.20 direct nursing care ratio is met. The facility continues to utilize job boards and various recruiting venues to attract, interview, recruit, and hire new staff. The facility conducts Recruitment and Retention Committee meetings weekly and has adopted a monthly rewards and recognition programs to retain current staff. The facility will conduct Staffing Meetings and Quality Calls with upper management five (5) days per week to ensure compliance. 3. An audit will be conducted by the Director of Nursing and/or designee, daily for two (2) weeks, three (3) times per week for one (1) week, then weekly ongoing to ensure that 3.20 hours of direct nursing care ratio is met for the 24-hour period. The audit will be monitored by the Director of Nursing and/or Assistant Director of Nursing. 4. The Director of Nursing will submit all Staffing Audits will be submitted to the Quality Assessment and Performance Improvement (QAPI) Committee at the monthly meeting for review and recommendation.
Failure to Develop Comprehensive Care Plan After Resident Elopement
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who experienced an elopement incident. The resident, who had been admitted with diagnoses including dementia, weakness, unsteady gait, and repeated falls, was found outside the facility by a bridge after alarms were triggered. The incident occurred when the resident left the building, claiming they did not want to miss an appointment. Despite the incident, a review of the resident's care plans revealed no evidence of a comprehensive person-centered plan to address the elopement. The facility's policy requires that care plans include measurable objectives and timetables to meet residents' needs, developed after thorough data gathering and clinical decision-making. However, the care plan for this resident did not reflect these requirements following the elopement. The Director of Nursing confirmed that a comprehensive care plan should have been developed to address the resident's elopement, indicating a lapse in adhering to the facility's care planning policy.
Failure to Investigate Resident Elopement
Penalty
Summary
The facility failed to thoroughly investigate an elopement incident involving a resident identified as R30. The resident, who was admitted with diagnoses including dementia, weakness, unsteady gait, and repeated falls, was found outside the facility after an alarm was triggered. The resident claimed to have left the facility to avoid missing an appointment. Despite the incident, the facility did not follow its policy for handling elopements, which includes examining the resident for injuries, contacting the attending physician, notifying the resident's legal representative, completing an incident report, and documenting the incident in the resident's medical record. The clinical record of Resident R30 lacked evidence of these required actions. The Director of Nursing confirmed during an interview that there was no documentation of the necessary steps being taken following the elopement. The facility's failure to adhere to its own policy and regulatory requirements resulted in a deficiency related to the management and nursing services provided to the resident.
Inadequate COVID-19 Infection Control Measures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during the COVID-19 pandemic, as evidenced by their non-compliance with the Pennsylvania Department of Health's guidelines. The facility did not test residents for COVID-19 unless they presented with a fever, despite the guidelines recommending testing for a broader range of symptoms. This led to multiple residents being exposed to COVID-19 without appropriate testing or isolation measures being implemented in a timely manner. Several residents who tested positive for COVID-19 were not isolated from their roommates, leading to further spread of the virus. For instance, Resident R1 was readmitted with COVID-19 and remained with their roommate, who subsequently tested positive. Similarly, Resident R3 tested positive and remained with their roommate, who was not tested and was discharged home. This pattern of inadequate isolation and testing was observed across multiple resident cases, contributing to the outbreak within the facility. Additionally, the facility failed to provide appropriate signage and personal protective equipment (PPE) for rooms housing COVID-19 positive residents. Observations revealed that rooms lacked necessary signage indicating the presence of a respiratory infection and the required precautions. Staff interviews confirmed that not all personnel wore N95 masks when entering COVID-19 positive rooms, further exacerbating the risk of cross-contamination and spread of the virus among residents and staff.
Inadequate Infection Control Management
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to ensure proper infection control procedures were followed. This deficiency was identified through observations, review of facility records, and staff interviews. The facility did not consistently maintain an infection prevention and control program to mitigate or potentially control the spread of the coronavirus. Additionally, there was a failure to educate staff and adhere to CDC guidelines. These actions and inactions indicate that the NHA and DON did not fulfill their essential job duties to ensure compliance with Federal and State guidelines and regulations.
Inadequate COVID-19 Infection Control Measures
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) adequately performed their duties to implement an effective infection control program to detect and prevent the spread of COVID-19. The IP's job description emphasized the need for compliance with state and federal regulations, yet the facility did not adhere to the Pennsylvania Department of Health COVID-19 Infection Control and Outbreak Response Toolkit. Specifically, the facility did not isolate COVID-19 positive residents appropriately, as eight residents who tested positive remained cohorted with their roommates, who were not tested. Additionally, four residents exhibiting symptoms of COVID-19 were not tested, as the facility only tested residents presenting with a fever, contrary to broader symptom assessment guidelines. Observations revealed that rooms housing COVID-19 positive residents lacked necessary signage indicating respiratory infection precautions and did not provide appropriate personal protective equipment (PPE) for staff entering these rooms. Interviews with staff, including a registered nurse and the Assistant Director of Nursing, confirmed these deficiencies, noting that not all staff wore N95 masks when entering COVID-positive rooms. The facility's failure to follow proper infection control measures, as outlined in the CDC and state guidelines, contributed to the inadequate management of the COVID-19 outbreak within the facility.
Failure to Facilitate Resident Discharge Plan
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not facilitating a discharge plan for Resident R22, who was cognitively intact and expressed a desire to return home. Despite having a physician's order for a discharge plan with home health and multiple indications in the clinical record that Resident R22 wanted to be discharged to the community, the facility did not develop an active discharge care plan or make necessary referrals and post-discharge arrangements. This lack of action was confirmed during an interview with the Director of Nursing and the Care Consultant, who acknowledged the absence of an active discharge plan and noted that there was no Power of Attorney in place, which would only be relevant if the resident could not make day-to-day decisions. Resident R22 had been admitted with several diagnoses, including respiratory failure, Type 2 Diabetes, adjustment disorder, high blood pressure, and COPD. The resident's cognitive status was assessed as intact, with a BIMS score of 15, indicating the ability to make daily decisions. Despite this, the facility did not support the resident's choice to return home, as evidenced by the lack of documentation and planning for discharge, which is a violation of the resident's rights as outlined in the facility's policy and state regulations.
Failure to Issue Medicare Non-Coverage and SNFABN Notices
Penalty
Summary
The facility failed to issue the Notice of Medicare Non-Coverage liability and/or appeal notice, and the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to residents or their representatives following the end of Medicare covered services. This deficiency was identified for two residents who remained in the facility for long-term care and one resident who was discharged. Specifically, the clinical records of these residents lacked evidence of acknowledgment that they had received the required notices upon being discharged from Medicare provided services. Resident R6, with diagnoses including broken vertebrae, colon cancer, repeated falls, and a bacterial skin infection, did not have documented acknowledgment of receiving the Notice of Medicare Non-Coverage or the SNFABN. Similarly, Resident R52, with diagnoses including pulmonary embolism, seizure disorder, general muscle weakness, and abnormal gait, also lacked documented acknowledgment of receiving these notices. Additionally, Resident CR190, who had diagnoses including urinary tract infection, dementia, history of falling, alcohol abuse, and long-term kidney disease, did not have documented acknowledgment of receiving the required notices upon discharge. The Director of Nursing and Clinical Consultant confirmed the absence of this documentation during an interview.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to eight residents and/or their representatives within 48 hours of admission. The facility policy, dated 2/12/24, mandates that residents and/or their representatives receive a written summary of the baseline care plan, including goals, medication summaries, dietary instructions, and services to be administered. However, clinical records for eight residents, each with various medical conditions such as heart failure, end-stage renal disease, diabetes, and chronic obstructive pulmonary disease, lacked evidence of this documentation. This deficiency was confirmed by the Assistant Director of Nursing during an interview on 5/2/24 at 2:35 p.m. The residents affected by this deficiency included those with serious health conditions requiring immediate and ongoing care. For instance, one resident had heart failure, another had end-stage renal disease, and others had conditions like major depressive disorder, pneumonia, diabetes, dysphagia, and muscle weakness. Despite the critical nature of their health issues, the facility did not provide the necessary written summaries of their baseline care plans and order summaries, as required by their policy. This lapse in protocol was identified through a review of clinical records and staff interviews, highlighting a significant oversight in the facility's admission process.
Failure to Review and Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to review and revise comprehensive care plans to reflect the current care and services for nine of 22 residents reviewed. The facility policy requires the interdisciplinary team to review and update care plans when there is a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted from a hospital stay, and at least quarterly. However, the care plans for residents with various diagnoses, including vitamin D deficiency, major depressive disorder, pneumonia, dysphagia, muscle weakness, heart failure, dementia, schizophrenia, Parkinsonism, end-stage renal disease, and urinary retention, were not reviewed and revised timely to reflect their current care and services. The target dates for these care plans were past due, indicating non-compliance with the facility's policy. During an interview, the Registered Nurse Assessment Coordinator confirmed that the care plans for the identified residents were not reviewed and revised in a timely manner. This deficiency was found to be in violation of the facility's resident care policies and nursing services regulations as outlined in 28 Pa. Code 211.10(c)(d) and 28 Pa. Code 211.12(d)(1)(5).
Failure to Provide Clinical Rationale and Non-Pharmacological Interventions for PRN Psychotropic Medication
Penalty
Summary
The facility failed to provide a clinical rationale for the continued use of PRN psychotropic medication beyond 14 days and did not attempt non-pharmacological interventions prior to administering the medication for four residents. Specifically, the facility's policy required non-pharmacological approaches to be used to minimize the need for medications and mandated a clinical rationale for extending PRN orders beyond 14 days. However, for Residents R81, R41, R43, and R2, the facility did not adhere to these requirements. Resident R81 had multiple administrations of Lorazepam without a stop date or clinical rationale, and no evidence of non-pharmacological interventions was found in the clinical records. Similarly, Resident R41's records showed multiple administrations of Lorazepam without the required documentation and lacked evidence of non-pharmacological interventions for some instances. Residents R43 and R2 also had Lorazepam orders without the necessary stop date or clinical rationale for continued use beyond 14 days. During an interview, the Assistant Director of Nursing confirmed the deficiencies, acknowledging that the residents' Lorazepam orders lacked the required stop date or clinical rationale and that non-pharmacological interventions were not documented for Residents R41 and R81. The facility's failure to comply with its policy on psychotropic medication use and non-pharmacological interventions led to these deficiencies, as identified by the surveyors.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to prevent unauthorized access to medications, properly label a multi-dose insulin pen, and securely store controlled substances. Specifically, a medication cart in the Primrose Lane memory care unit was found unlocked and unattended in the central hallway, which was confirmed by an LPN. Additionally, a multi-dose insulin pen in the Maple Lane medication cart was opened but not labeled with the date it was opened, contrary to the facility's policy requiring such labeling to ensure timely disposal. This was also confirmed by an LPN during an interview. Furthermore, controlled medications in the Blue Wing Medication Room were not stored in a permanently affixed compartment. Instead, they were kept in a locked clear plastic box that was affixed to removable wire shelving, which does not meet the facility's policy for securely storing controlled substances. This was confirmed by an LPN at the time of observation. These deficiencies were identified through a review of facility policies, observations, and staff interviews.
Failure to Hold QAPI Committee Meeting
Penalty
Summary
The facility failed to provide evidence of a Quality Assurance and Performance Improvement (QAPI) Committee meeting for the First Quarter of 2024. The facility policy, dated 2/27/2023, mandates that the QAPI Committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities. However, a review of the QAPI Committee Attendance Records revealed no evidence of such a meeting for the specified quarter. This deficiency was confirmed by the Nursing Home Administrator during an interview on 5/01/24 at 11:30 a.m.
Failure to Obtain Informed Consent for Treatment Changes
Penalty
Summary
The facility failed to fully inform and discuss the change of treatments for the medical management of a resident's clinical status and/or discuss alternate treatment options preferred by the resident's representative in advance of these changes. This deficiency was identified for a resident with multiple diagnoses, including secondary hyperaldosteronism, kidney disease, heart disease, Alzheimer's Disease, severe intellectual disabilities, and psychosis. The resident's clinical record included a pharmacy consultant note recommending monitoring potassium levels due to the combination of medications being taken. However, the record indicated that the family declined this recommendation, but there was no evidence of informed consent from the family or a physician's order to withhold bloodwork and/or diagnostic testing. Interviews with the resident's legal guardian and facility staff confirmed that the legal guardian did not decline the bloodwork and/or diagnostic testing, and there was no documentation to support the decision to withhold these tests. The facility's clinical consultant and Director of Nursing also confirmed the lack of evidence of informed consent or a physician's order in the resident's clinical record. This failure to obtain informed consent and properly document the decision-making process led to the identified deficiency.
Inaccurate MDS Completion for Two Residents
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) accurately for two residents. Resident R14, who was admitted with diagnoses including end-stage renal disease, hypokalemia, and hypertension, had dialysis ordered and received treatments on specific dates. However, the five-day MDS incorrectly indicated that the resident was not receiving dialysis treatments. Similarly, Resident R57, admitted with diagnoses including hypertension, anxiety, and type II diabetes, had a Trulicity injection ordered, which is not classified as insulin. The Quarterly MDS incorrectly indicated that the resident received insulin one time. These inaccuracies were confirmed by the Registered Nurse Assessment Coordinator during an interview.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents within the required timeframe. Resident R14, admitted with diagnoses including end-stage renal disease, hypokalemia, and hypertension, had a physician's order for dialysis twice a week but only had a care plan for nutrition. Similarly, Resident R64, admitted with diagnoses including a urinary tract infection, Parkinson's Disease, and hypertension, also had a care plan that only addressed nutrition. The Registered Nurse Assessment Coordinator confirmed that the comprehensive care plans for both residents were not completed within 21 days of admission, as required by facility policy.
Failure to Maintain Clean Respiratory Care Equipment
Penalty
Summary
The facility failed to promote cleanliness and prevent the spread of infection regarding respiratory care equipment for two residents. For Resident R43, who has diagnoses including dementia, COPD, and peripheral vascular disease, the facility did not follow physician orders to change the humidification water bottle every two days and the oxygen tubing weekly. Observations revealed that the humidification water bottle was dated 3/4/24, and the oxygen tubing lacked a date, despite the resident receiving oxygen on multiple occasions in March and April 2024. This indicates that the equipment was not changed as required by the physician's orders. Similarly, for Resident R69, who has diagnoses including COPD, heart failure, and hypertension, the facility did not adhere to physician orders to change the humidification water bottle every two days and the oxygen tubing weekly. Observations showed that the oxygen concentrator's filter was covered with a large amount of white substance, and both the oxygen tubing and humidification water bottle lacked dates. Interviews with an LPN confirmed that the equipment should have been dated and cleaned as per the physician's orders, but this was not done, leading to the deficiency.
Failure to Maintain Dialysis Communication Records
Penalty
Summary
The facility failed to maintain proper records of communication between the facility and the dialysis clinic for a resident requiring dialysis services. The review of the facility's dialysis contract and the resident's clinical record revealed that the necessary medical, social, administrative, and other information were not consistently communicated to the dialysis center. Specifically, the facility's dialysis communication form, which should include treatments, medications, and any changes in the resident's condition, was not completed and sent with the resident during transfers to the dialysis clinic. Resident R14, who was admitted with diagnoses including end-stage renal disease, hypokalemia, and hypertension, had physician orders for dialysis every Tuesday and Saturday. However, the clinical record lacked evidence of communication between the facility and the dialysis clinic. Interviews with staff, including a registered nurse and the Assistant Director of Nursing, confirmed that the communication forms were not completed and sent as required, leading to a deficiency in the coordination of care for the resident.
Failure to Submit Direct Care Staffing Information
Penalty
Summary
The facility failed to electronically submit direct care staffing information for one of the last four quarters (Quarter Four of 2023) as required by Section 6106 of the Affordable Care Act (ACA). The review of Payroll Based Journal (PBJ) Staffing Data Reports revealed that the facility did not meet the reporting requirement for the fourth quarter of 2023, which includes data from July 1st through September 30th and was due by November 14th. During an interview, the Nursing Home Administrator confirmed that the PBJ report for Quarter Four of 2023 indicated a failed submission status, thereby not meeting the reporting requirement.
Failure to Provide Nourishing and Well-Balanced Diet
Penalty
Summary
The facility failed to provide each resident with a nourishing, well-balanced diet that meets their daily nutritional needs. This deficiency was observed during the lunch meal on 4/01/24 and continued through the dinner meal on 4/01/24 and the breakfast meal on 4/02/24. The facility's policy on resident food preferences, which mandates that individual food preferences be assessed and communicated to the interdisciplinary team, was not followed. Observations revealed that the lunch meal served noodles instead of chicken pot pie with biscuits, and the alternate meal of hamburgers lacked buns and tomatoes. Additionally, the pantry and kitchen were inadequately stocked, with limited snacks, beverages, and essential meal components such as fresh fruit, vegetables, and milk. Residents reported that the food supply frequently runs out before the next delivery, and they were not notified of menu changes, leading to uncertainty about meal contents and dissatisfaction with the food provided. The Dietary Manager confirmed these issues, including the lack of coffee, peas, and biscuits, and acknowledged that the food supply truck was not expected until after 12:00 p.m. on 4/02/24. The facility's failure to manage the dietary department effectively resulted in an inability to meet residents' nutritional needs and provide a variety of foods at each scheduled meal. Interviews with residents indicated ongoing issues with food availability and quality, including a lack of coffee, fresh lettuce, hamburgers, buns, tomatoes, salad, fresh fruit, juice, and milk. The Dietary Manager confirmed the inadequacies in food supply and the lack of notification to residents about menu changes. The facility's census was 93 on 4/01/24, and the dietary department's mismanagement affected the residents' overall dining experience and nutritional intake.
Failure to Provide Scheduled Baths/Showers
Penalty
Summary
The facility failed to honor the residents' right to self-determination by not providing baths/showers according to their preferences. This deficiency was identified through observations, clinical record reviews, and interviews with residents and staff. Four residents (R1, R4, R5, R6) did not receive their scheduled baths/showers over a specified period. Resident R1, who has diagnoses including polyosteoarthritis and hypothyroidism, reported not receiving a bath/shower in the past 10 days and expressed a preference for day shift baths due to more reliable staff. Documentation confirmed missed baths/showers on multiple scheduled dates for Resident R1. Resident R4, with diagnoses including heart failure and chronic pulmonary obstructive disease, did not receive any baths/showers for the entire month of March 2024 despite being scheduled for twice-weekly baths/showers. Resident R5, with diagnoses including heart failure and anxiety, missed several scheduled baths/showers in March and April 2024. Resident R6, with diagnoses including cerebral infarction and heart failure, also missed multiple scheduled baths/showers in March 2024. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that baths/showers were not provided according to the residents' scheduled days and preferences during the specified period.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to follow physician orders for three residents, leading to deficiencies in medication administration. Resident R1, diagnosed with polyosteoarthritis, dysuria, hypothyroidism, and the presence of an artificial eye, did not receive their prescribed Levothyroxine Sodium on multiple occasions in March 2024. Resident R1 confirmed during an interview that they had not received their hypothyroidism medication as ordered by the physician. Resident R2, with diagnoses including urinary tract infection, muscle weakness, and unsteadiness on feet, did not receive their prescribed Nubega Oral Tablet for urinary tract infection on several occasions in March 2024. Similarly, Resident R3, diagnosed with hemiplegia, high blood pressure, gastro-esophageal reflux disease, and rheumatoid arthritis, did not receive their prescribed Norco Oral Tablet for pain management on multiple dates in March 2024. The Director of Nursing confirmed that the medications were not administered as per physician orders for all three residents during the month of March 2024.
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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