Delaware Valley Skilled Nursing & Rehabilitation C
Inspection history, citations, penalties and survey trends for this long-term care facility in Matamoras, Pennsylvania.
- Location
- 111 Rivers Edge Drive, Matamoras, Pennsylvania 18336
- CMS Provider Number
- 396148
- Inspections on file
- 26
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Delaware Valley Skilled Nursing & Rehabilitation C during CMS and state inspections, most recent first.
A resident with sepsis and a UTI did not receive all prescribed IV antibiotic doses due to medication unavailability, and the facility failed to notify the physician or representative as required. Additionally, staff did not consistently complete required shift count documentation for controlled substances, with missing signatures on the medication cart log.
A resident with dementia expressed suicidal ideation to staff, leading to an evaluation by social services and implementation of frequent safety checks. However, the facility did not update the resident's care plan to include interventions or measurable objectives addressing the risk of self-harm or psychosocial needs, as confirmed by the Nursing Home Administrator.
A resident with dementia and nutritional risk experienced significant weight loss over a 30-day period. Despite assessment by an RD and ongoing recommendations, the care plan was not reviewed or revised to address the change in nutritional status or weight trends, and no new interventions were documented.
The facility failed to follow physician orders for bowel protocols, therapeutic devices, and preventative measures for residents, leading to extended periods without bowel movements and improper application of devices. Additionally, inaccurate documentation of food and fluid intake for a resident with heart disease resulted in delayed identification of condition changes, leading to hospitalization.
A resident experienced significant weight loss and dehydration due to the facility's failure to consistently monitor weights and implement effective nutrition management interventions. Despite being cognitively intact and having a history of weight fluctuations, the resident's declining oral intake was not timely addressed, leading to hospitalization and the need for a feeding tube.
The facility failed to provide evening snacks to residents, as required by policy, when the interval between dinner and breakfast exceeded 14 hours. Residents reported not being offered snacks, and observations confirmed insufficient snack options. The Registered Dietitian could not explain the inconsistency in offering snacks.
A resident with multiple health conditions and at risk for pressure sores was not adequately monitored or cared for, leading to the development of a new wound. The facility failed to follow its Skin Impairment Protocol, and the wound was not properly evaluated. Despite the care plan including an air mattress and regular repositioning, these measures were not effectively implemented.
A facility failed to provide necessary emergency supplies for a resident receiving hemodialysis. Despite a physician's order for an emergency kit at bedside, the resident's care plan lacked interventions for emergency care, and no kit was observed at the bedside. Interviews with the resident and DON confirmed the absence of the emergency kit.
The facility failed to provide timely dental services for two residents, one with a broken dental bridge and another with poor dentition and a high-risk heart condition. Despite scheduled appointments and identified needs, there was no follow-up or evidence of dental care provided, leading to unresolved dental issues.
A resident with cognitive impairments and mobility assistance needs suffered a dislocated shoulder, but the facility failed to fully investigate the incident or identify the root cause. Despite signs of pain and an odd sound reported by a nurse aide, the facility's investigation was incomplete, and no specific concerns or corrective actions were identified. The facility's QAPI program did not effectively address the incident or ensure quality care.
Failure to Ensure Timely Medication Administration and Accurate Controlled Drug Documentation
Penalty
Summary
The facility failed to ensure the timely acquisition and administration of a prescribed intravenous antibiotic for one resident who was readmitted from the hospital with sepsis and a urinary tract infection, and who required IV medication via a PICC line. Despite a physician's order for Meropenem to be administered every 12 hours for five days, the medication was not available for administration on two separate occasions, resulting in missed doses. Facility policy required staff to check the automated medication dispensing system, contact the pharmacy for STAT delivery, notify the physician and resident representative if the medication was unavailable, and document these actions. However, the clinical record lacked documentation that the physician or resident representative was notified of the missed doses, and the resident did not receive the full course of prescribed antibiotic therapy. The Nursing Home Administrator confirmed that backup pharmacy resources were available but not utilized to prevent the missed doses. Additionally, the facility failed to maintain accurate controlled drug shift count documentation on one of two medication carts reviewed. Facility policy required Schedule II medications to be counted and verified at each shift change by both oncoming and outgoing nurses, with signatures required to verify accuracy. Review of the controlled medication shift change log revealed missing signatures on multiple occasions, and staff interviews confirmed that the required sign-offs were not completed. The Nursing Home Administrator acknowledged the facility's failure to consistently adhere to procedures for verifying and documenting controlled substance counts.
Failure to Update Care Plan for Resident Expressing Suicidal Ideation
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan with measurable objectives and timetables to address the needs of a resident who expressed suicidal ideation. Clinical record review showed that the resident, who had dementia, was admitted with multiple diagnoses and, on one occasion, communicated to staff a desire to harm herself. Although the social services department evaluated the resident and initiated every 15-minute checks, the resident's care plan was not updated to reflect her expressed suicidal ideation or to include interventions addressing her mental health risk. The care plan lacked documentation of strategies to monitor, support, and ensure the resident's safety regarding her psychosocial needs. The Nursing Home Administrator confirmed that the care plan had not been updated to address these concerns.
Failure to Update Care Plan After Significant Weight Loss
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident who experienced a significant change in condition related to weight loss. The resident, who had dementia and was at nutritional risk with a mechanically altered diet, lost 6.8% of body weight over a 30-day period. Although a registered dietitian assessed the resident and continued to recommend interventions following the weight loss, the care plan, originally developed months earlier, was not updated to reflect the resident's new nutritional status or to address ongoing weight trends. During the survey, it was found that there was no documented evidence that the care plan had been reviewed or revised after the significant weight loss was identified. No new interventions were added, nor were existing interventions updated to address the change in the resident's condition. The Nursing Home Administrator confirmed that the care plan should have been updated to reflect the resident's current needs following the weight loss.
Failure to Follow Physician Orders and Document Resident Care
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice by not following physician orders for a bowel protocol for a resident with Alzheimer's Disease and chronic kidney disease. The resident had physician orders for a bowel regimen that included Milk of Magnesia, Bisacodyl, and Fleet Enema to be administered sequentially if no bowel movement occurred. However, the Medication Administration Record showed no evidence that the prescribed bowel protocol was followed during periods of constipation, leading to extended periods without bowel movements. Additionally, the facility did not consistently apply prescribed therapeutic devices and preventative measures for three residents. One resident was observed without Geri-sleeves and TED stockings, which were ordered to protect skin integrity and manage edema. Another resident was not wearing TED stockings as ordered, and a third resident's heels were not offloaded, and hip precautions were not maintained as prescribed. These observations were confirmed by staff interviews, indicating a failure to adhere to physician orders and care plans. The facility also failed to accurately document food and fluid intake for a resident with a history of heart disease and chronic heart failure. The resident experienced significant weight loss and had poor oral intake, but meal intake records were incomplete, with nearly half of the entries missing. This lack of documentation contributed to a delay in identifying changes in the resident's condition, resulting in critical lab values and hospitalization. The Director of Nursing confirmed the inconsistencies in documentation and the failure to act on the resident's condition changes.
Failure to Monitor Resident Weight and Nutrition
Penalty
Summary
The facility failed to consistently and accurately monitor the weights of a resident, leading to significant weight loss and dehydration. The facility's policy required re-weighing residents whose weight fluctuated by a certain amount, but this was not adhered to for a resident who experienced a significant weight loss over a period of time. The resident, who was cognitively intact, had a history of weight fluctuations and was on a therapeutic diet due to conditions such as hypertension and diabetes. Despite these conditions, the facility did not timely obtain, assess, and monitor the resident's weights to develop effective nutrition management interventions. The resident's weight records showed a progressive decline from 127 lbs to 97.6 lbs over several months, indicating a 20.9% weight loss. The Registered Dietitian (RD) noted the need for re-weighing and identified significant weight loss, but the interventions, such as the use of appetite stimulants and nutritional supplements, were not effectively evaluated or adjusted. The resident's oral intake was inconsistent, and the discontinuation of an appetite stimulant was linked to decreased intake, yet alternative methods for nutrition and hydration were not adequately explored or discussed with the resident and the interdisciplinary team. Ultimately, the resident was admitted to the hospital with dehydration, acute kidney injury, and other complications, necessitating the insertion of a feeding tube. The facility's Director of Nursing confirmed that the facility did not timely address the resident's declining oral intake, which led to the significant weight loss and hospitalization. The report highlights the facility's failure to adhere to its own policies and procedures regarding weight monitoring and nutrition management, resulting in adverse health outcomes for the resident.
Failure to Provide Evening Snacks to Residents
Penalty
Summary
The facility failed to routinely offer evening snacks to residents, as required by their policy, which states that all residents should be provided a nourishing snack at bedtime unless medically contraindicated. During a group meeting with residents, four residents reported that they were not offered snacks in the evening as desired. One resident mentioned that they had not been offered snacks for several months, while another recalled that staff used to offer snacks after supper, but this practice had ceased. All residents in attendance agreed that they were not offered evening snacks. The review of meal delivery times showed that the interval between dinner and breakfast exceeded 14 hours, necessitating the provision of a nourishing snack. However, the available snacks in the nursing unit were insufficient to meet this requirement. Observations revealed limited snack options, including a single rice crispy treat and 15 peanut butter crackers, with minimal items in the refrigerator/freezer. The Registered Dietitian was unable to explain why residents were not consistently offered a nourishing snack at bedtime, despite the extended interval between meals.
Failure to Implement Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to consistently implement measures to promote healing and prevent the development of pressure sores for a resident identified as Resident 43. The resident, who was admitted with diagnoses including Parkinson's disease, heart disease, and diabetes, was moderately cognitively impaired and required substantial assistance for daily activities. Despite being at risk for pressure sore development, the facility did not adequately monitor or address the resident's significant weight loss, which was a risk factor for pressure ulcers. The care plan included interventions such as the use of an air mattress, regular repositioning, and skin assessments, but these measures were not effectively implemented. A new wound was discovered on the resident's sacrum, which was not identified by staff prior to its development. The facility's investigation revealed that the wound was not evaluated for size, drainage, or the condition of surrounding tissue, and the Skin Impairment Protocol was not followed. The resident was later sent to the emergency room due to a change in condition, and hospital documentation recommended consideration for an air mattress, which was supposedly already in place. The interim Director of Nursing confirmed the facility's failure to evaluate the pressure area and implement the necessary protocol.
Failure to Provide Emergency Dialysis Supplies
Penalty
Summary
The facility failed to ensure the availability of necessary emergency supplies for a resident receiving hemodialysis. Resident 218, who was admitted with end-stage renal disease and dependent on renal dialysis, had a physician order dated July 29, 2024, for an emergency kit at bedside for the dialysis access site. However, the resident's care plan did not include interventions for emergency care of the Ash Cath, and an observation on August 6, 2024, revealed no emergency kit or supplies at the resident's bedside. Interviews conducted with Resident 218 and the Director of Nursing (DON) confirmed the absence of the emergency kit. Resident 218 stated that he had never seen or been informed of an emergency kit since his admission. The DON acknowledged that each resident receiving dialysis should have emergency supplies at bedside and confirmed the facility's failure to provide the necessary emergency kit for Resident 218.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to promptly refer a resident with a broken dental bridge for necessary dental services and did not provide dental care for another resident with poor dentition and a high-risk heart condition. Resident 4, who was moderately cognitively impaired, had a broken upper bridge noted on July 1, 2024. Although a dental appointment was scheduled for July 17, 2024, there was no documentation of the appointment's outcome or any follow-up by the speech therapist. By the time of the survey ending on August 8, 2024, there was no evidence that the dental appliance had been repaired or replaced. Resident 24, who was cognitively intact and had a history of atherosclerotic heart disease with a xenogeneic heart valve, was identified with broken teeth and dentures upon admission. Despite these findings and a subsequent hospitalization for endocarditis, which highlighted poor dentition as a contributing factor, the facility did not arrange for dental services to address the resident's dental issues. The Director of Nursing confirmed that dental services were not provided to prevent the infection related to the resident's poor dental condition.
Failure to Implement Effective QAPI Program
Penalty
Summary
The facility failed to demonstrate the implementation of ongoing Quality Assurance and Performance Improvement (QAPI) programs, specifically in investigating and analyzing the root cause of adverse events. This deficiency was evidenced by the case of a resident who was admitted with diagnoses including hemiplegia, hemiparesis, aphasia, and dementia. The resident was moderately cognitively impaired and required extensive assistance for daily activities. An incident occurred where the resident was found to have a dislocated left proximal humerus, but the facility did not fully investigate the circumstances surrounding the injury. The resident's care plan indicated the need for assistance with mobility and toileting, and there were multiple instances where the resident showed signs of pain. On one occasion, a nurse aide reported hearing an odd sound while providing care, but there was no evidence that this was communicated to the nursing staff. The resident was later found to be guarding her left arm and shoulder, leading to an x-ray that confirmed the dislocation. Despite these events, the facility's investigation did not identify any specific concerns with the care provided or determine the root cause of the injury. The facility's QAPI plan outlined goals for infection control, creating a QAPI team, and staff training, but there was no evidence of corrective actions developed from the QAPI review of this incident. The investigation was incomplete, and the facility did not demonstrate an effective QAPI program to ensure quality of care and life by thoroughly investigating resident incidents and maintaining documentation to support their analysis and corrective actions.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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