Delaware Valley Veteran's Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 2701 Southampton Rd, Philadelphia, Pennsylvania 19154
- CMS Provider Number
- 39A436
- Inspections on file
- 19
- Latest survey
- December 12, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Delaware Valley Veteran's Home during CMS and state inspections, most recent first.
A resident with a history of seizures, opioid use disorder, hypertension, and depression was given an incorrect, higher dose of Suboxone due to pharmacy and nursing staff failing to verify the medication label and dosage as required by facility policy. The error was not detected until after administration, despite protocols for narcotic counts and verification.
A resident with dementia, mood disturbance, and hearing loss was observed propelling himself in a wheelchair beyond the designated outdoor safe zone and into areas with vehicle traffic, without staff supervision. The resident was not wearing hearing aids and regularly completed laps around the facility's oval road. Staff confirmed that this lack of supervision was unsafe.
A resident with a documented DNR order had resuscitation efforts initiated after being found unresponsive due to staff miscommunication regarding the resident's code status. The facility failed to follow the resident's advance directive as outlined in the POLST form, resulting in care that was not consistent with the resident's documented wishes.
A resident with hemiplegia and hemiparesis was found to be restrained by having their wheelchair locked, preventing independent mobility. The resident was unable to unlock the brakes due to physical limitations and depended on staff for assistance. Staff confirmed that the wheelchair was being locked outside of transfers, contrary to facility policy, resulting in the resident being unable to move freely.
A resident with an indwelling urinary catheter and multiple medical conditions was observed twice with their catheter bag dragging on the floor, once in the hallway and once in the dining room. An LPN confirmed the catheter should have been properly secured, indicating a failure in appropriate catheter care.
A resident was served a lunch consisting of pierogies, kielbasa, and wax beans that were difficult to cut, dry, and visually unappealing. The resident was unable to cut the kielbasa or pierogies and expressed dissatisfaction with the meal, which was confirmed by a test tray conducted by the Dietary Director.
Multiple residents reported that only cold food options, such as salads and sandwiches, were available for dinner, with no hot meals offered despite expressed preferences and a previous grievance. The Dietary Director confirmed that the facility's menus for several days included only cold items for dinner.
The facility did not develop or implement a water management program to prevent, detect, and control waterborne contaminants such as Legionella. Staff confirmed that water testing and compliance with a water management plan were not ensured, and no documentation of water testing was available, resulting in noncompliance with federal and state requirements.
A resident with dementia and a history of elopement risk was inadequately supervised during an outing to a theater, resulting in the resident leaving the premises and being unaccounted for nearly two hours. The facility lacked a protocol for assessing residents' elopement risks before outings, contributing to the incident.
The facility failed to provide trauma-informed care for four residents with PTSD, as their care plans did not address their diagnoses or identify triggers for re-traumatization. Despite the facility's policy requiring a comprehensive approach to trauma care, the care plans lacked specific interventions, which was confirmed by the DON.
A facility failed to administer Methadone according to prescribed instructions for a resident with opioid dependence. The resident's physician order required the Methadone bottle to be refilled with water and consumed to ensure all medication was taken. However, a nurse used orange juice instead, and the bottle was not refilled with water as instructed. Staff interviews revealed a misunderstanding of the administration protocol, confirmed by the DON.
The facility failed to store insulin in a locked compartment, as required by policy. During a medication pass, a container with sixteen vials of insulin was left on top of a medication cart, accessible to anyone. Staff interviews revealed inconsistencies in understanding and adherence to proper medication storage protocols. The DON confirmed that insulin should be stored inside the medication cart and locked.
The facility failed to properly dispose of garbage, as the dumpster containing kitchen and resident care area waste was found without a lid, exposing its contents and attracting flies. The administrator confirmed the dumpster was overfilled, preventing proper closure.
A resident at risk for elopement due to cognitive impairment and exit-seeking behaviors eloped during a theater outing. The resident was added to the outing roster last minute, and the facility lacked a protocol for screening residents for elopement risk during out-of-facility events. The resident was seated out of sight, leading to inadequate supervision and eventual elopement. The incident was identified as Immediate Jeopardy due to management failures by the NHA and DON.
A resident with diabetes and quadriplegia was sent to an appointment without an escort, leading to a hypoglycemic episode. The resident missed lunch and had a light breakfast, resulting in a blood sugar drop to 59 and an ER visit. The facility failed to provide a snack or check blood sugar upon return, despite being informed of the incident.
A resident with quadriplegia and diabetes was sent to a medical appointment without staff assistance due to insufficient staffing. The resident, who required help with mobility and other tasks, experienced a hypoglycemic episode and needed emergency care. Facility staff confirmed the need for an escort, but staffing shortages prevented this.
A resident with quadriplegia and diabetes was sent to an appointment without an escort or adequate food provisions, resulting in a hypoglycemic episode. The resident left after a light breakfast and was not given a snack or lunch, leading to a drop in blood sugar and an ER visit. Upon returning, the facility failed to provide a meal or recheck the resident's blood sugar, despite the resident reporting the incident.
A facility failed to provide a written transport agreement for a resident's medical appointment. The resident, who is quadriplegic and diabetic, was sent without an escort, leading to a medical emergency due to low blood sugar. The facility lacked a transport agreement with the company used, as confirmed by the DON.
Failure to Ensure Accurate Medication Dosage Verification
Penalty
Summary
A deficiency occurred when a resident with a history of unspecified seizures, opioid use disorder in remission, hypertension, and major depressive disorder was administered an incorrect dosage of Suboxone following re-admission from the hospital. The facility's pharmacy staff generated a label for Suboxone 2mg as ordered, but the technician mistakenly labeled an 8mg package instead. This error was not detected during the pharmacist's verification process, nor was it identified by the receiving nurse who signed off on the medication. The resident was on hospital leave at the time the medication was received, and the incorrect medication was stored until the resident's return, at which point the incorrect dose was administered. Multiple staff, including the pharmacist and nurses, failed to verify the correct dosage before administration, resulting in the resident receiving a higher dose than prescribed. The facility's policies required narcotic counts and verification at shift changes, as well as proper pharmacy verification procedures, but these were not followed. The error was discovered only after the resident had already received the increased dose, prompting further evaluation. The report confirms that the resident did not experience adverse effects from the increased dose.
Failure to Provide Adequate Supervision During Outdoor Activities
Penalty
Summary
The facility failed to provide adequate supervision for a resident with multiple diagnoses, including unspecified dementia, psychotic disturbance, mood disturbance, anxiety, sensorineural hearing loss, and major depressive disorder, during outdoor relaxation time. Facility policy allowed residents not at risk for elopement or wandering to use outdoor areas within designated boundaries during daylight hours. However, observations on two separate days showed that three to four residents were outside without staff supervision. Specifically, one resident was seen propelling himself in a wheelchair beyond the designated safe zone, around an oval road where vehicles were present, without staff oversight. During one observation, the resident, who was not wearing his hearing aids, was seen moving toward the curb and into areas with oncoming traffic. The resident reported that he regularly completed multiple laps around the oval road daily and suggested that increased visibility, such as a flag or safety vest, would improve his safety. Staff interviews confirmed that it was unsafe for the resident to be unsupervised in these circumstances, especially given his medical conditions and the presence of vehicular traffic.
Failure to Honor Advance Directive Due to Miscommunication of DNR Status
Penalty
Summary
The facility failed to follow and/or clarify a physician's order regarding advance directives for one resident. According to the facility's policy, residents' wishes concerning life-sustaining treatment, such as Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders, are to be clearly documented and honored, typically through a POLST form. In this case, the resident had a POLST form signed by their power of attorney, indicating a DNR status. However, when the resident was found unresponsive, staff initiated resuscitation efforts, including chest compressions and oxygen administration, before the nurse supervisor questioned the resident's code status and it was confirmed that the resident was DNR. This incident was confirmed through review of the clinical record, facility policy, and staff interviews. The miscommunication regarding the resident's code status led to actions that were not in accordance with the documented advance directive. The deficiency was identified for one of eight residents reviewed, and the facility's failure to honor the resident's documented wishes was substantiated by the evidence collected during the survey.
Resident Restrained by Locked Wheelchair
Penalty
Summary
A deficiency was identified when a resident with hemiplegia and hemiparesis following a cerebral infarction was found to be restrained by having their wheelchair locked, preventing independent mobility. The resident's left hand was contracted and the right hand was nonfunctional, making it impossible for the resident to unlock the wheelchair brakes independently. During an observation, the resident requested assistance to unlock the wheelchair so they could move closer to the dining table and propel themselves with their feet. Staff confirmed that the resident depended on them to lock and unlock the wheelchair, and the resident reported that staff locked the wheelchair from the back too often, restricting their movement. A review of the facility's restraint management policy indicated that physical restraints should not be used for discipline or convenience and only for medical treatment. However, the resident's inability to unlock the wheelchair brakes was not assessed during a prior evaluation for a specialized wheelchair, and staff practice did not align with the policy. Staff interviews confirmed that the wheelchair should only be locked during transfers, but in practice, it was being locked at other times, resulting in the resident being restrained and unable to move freely.
Failure to Properly Secure Urinary Catheter Bag
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter, admitted with diagnoses including hemiplegia, hemiparesis, obstructive and reflux uropathy, and edema, was observed on two separate occasions with their urinary catheter bag dragging on the floor. The first observation occurred while the resident was in a wheelchair in the hallway, and the second while the resident was in the dining room. During an interview, an LPN confirmed that the urinary catheter should be properly secured and not be on the floor. These findings were based on clinical record review, direct observation, and staff interview, demonstrating a failure to ensure proper catheter care for the resident.
Unpalatable and Unattractive Meal Served to Resident
Penalty
Summary
During a lunch meal observation, a resident was served three pierogies with kielbasa and wax beans. The resident was unable to cut through the skin of the kielbasa and reported that the pierogies appeared dry and were difficult to cut. The resident only managed to scoop out the soft potatoes from one pierogi and appeared visibly upset. A test tray conducted by the Dietary Director confirmed that the kielbasa was too hard to cut and the pierogies were dry and difficult to cut through. Additionally, the meal was not visually appealing, as all items on the plate were a similar beige color, making the meal look bland and unappetizing.
Failure to Provide Hot Meal Options for Dinner
Penalty
Summary
The facility failed to provide food that accommodated residents' preferences for hot meal options at dinner, as evidenced by interviews and menu reviews for three residents. One resident reported that only salads were available for dinner on multiple occasions, with no hot food options. Another resident confirmed that the dinner menu only included cold items and expressed a preference for a hot meal. A third resident filed a grievance regarding the lack of hot dinner options, and although the resolution was to ensure a hot entrée would be available, subsequent menu reviews showed that only cold options continued to be offered. The Dietary Director confirmed that the current and previous menus for certain days only included cold items such as egg salad sandwiches, chicken salad, ham and Swiss sandwiches, and seafood salad, with no hot dinner meals provided.
Failure to Implement Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to develop and implement a water management program aimed at the prevention, detection, and control of waterborne contaminants such as Legionella. This deficiency was identified through observation, policy review, and staff interviews, which revealed that the facility did not have a water management plan in place as required by CDC guidelines and CMS policy memoranda. Specifically, the facility did not conduct a facility risk assessment to identify potential areas where Legionella and other waterborne pathogens could grow and spread within the water system. Further, the facility was unable to provide documented evidence that water testing had been completed, and staff confirmed that water testing and compliance with a water management plan were not ensured. The absence of a documented water management program and lack of water testing protocols meant that the facility did not meet federal, state, and local requirements for inhibiting microbial growth in the building water system.
Inadequate Supervision During Outing Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision during an out-of-facility activity, resulting in a resident identified as at risk for elopement, exiting a theater and being unaccounted for one hour and 45 minutes. The resident, who had a history of dementia and was moderately cognitively impaired, was added to the outing roster on the morning of the event. Despite being identified as an elopement risk, the resident was not adequately supervised, leading to their unsupervised departure from the theater. The facility's policy on wandering and elopement required staff to maintain heightened awareness of residents at risk. However, during the outing, the resident was seated out of sight of the supervising staff, which contributed to the inability to monitor and redirect the resident effectively. The activities aides present were not aware of the specific elopement risks associated with the residents on the outing, and there was no protocol in place to screen residents for such risks before attending off-premise activities. The incident was identified as an Immediate Jeopardy due to the lack of supervision, which placed the resident at high risk for injury. The facility's failure to implement a protocol for assessing and addressing the care needs of residents during outings, particularly those at risk for elopement, directly led to the deficiency. The resident was eventually located at a nearby building and returned to the facility without injury.
Removal Plan
- A full assessment was completed of [Resident R138] by Registered Nurse Supervisor. No adverse effects or injuries noted. Increased supervision initiated with 15-minute checks upon return to the building and continued. [Resident R138] placed on purposeful rounding every hour and rounds continue.
- All residents with wander guards were verified to ensure electronic wander guards in place and functioning. Audit completed by Registered Nurse Supervisor including verification of orders, placement and function of wander guard; review of care plans updated and noted in clinical record. Wander guard master list updated, reviewed and provided to Interdisciplinary team.
- Facility off premise policy was created pertaining to off premises activities. New procedure developed to include staff education and evaluation of residents prior to attending an outing to ensure each resident's appropriate supervision and needs are met to include review of elopement risk, mobility needs, hygiene, toileting, meal and hydration intake, as well as other ADL needs related to staffing and/or volunteer support. Activity trip form is reviewed and approved by activities supervisor and clinical service manager for all residents prior to attending an outside activity; any deviations from the roster are reviewed by activities supervisor prior to leaving the premises. Nursing and security staff are updated regarding residents who are participating in event off premises. Resident profile binder in place with instruction for every off premises outing which is provided to staff prior to leaving for the activity that includes elopement risk, safety needs and medical needs. During the off premises outing all residents will be required to stay within the facility group under the supervision of a responsible party as per policy.
- Activities staff involved in the incident received immediate education on escorting residents to outside activities and the requirement that residents will not be left unattended at any time. All activities staff education completed on outings protocol. No additional off-site activities were held.
- Facility activity form updated to reflect a review by nursing and activities to ensure sufficient staff and supplies are available for the outings including a review of elopement risk, dietary needs, personal care needs and medical needs. Audits of forms completed with final review by activities supervisor and clinical service manager. All outings forms will continue to be reviewed and approved by activities supervisor and clinical service manager prior to any outings.
- QAPI meeting held and education, audits and policy reviewed by IDT. Next QAPI meeting scheduled.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for four residents, all of whom had a diagnosis of PTSD and a history of military service. The facility's policy required a multi-pronged approach to identify a resident's history of trauma and cultural preferences, including the use of screening tools and assessments. However, the care plans for these residents did not address their actual diagnoses or conditions of PTSD, nor did they identify past experiences and possible triggers that could cause re-traumatization. Resident R128, R24, R74, and R106 were all admitted with PTSD among other diagnoses, and their care plans were initiated between February and May 2023. Despite the facility's policy, the care plans lacked specific interventions to address the residents' PTSD, such as identifying past traumatic experiences and potential triggers. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the care plans did not include necessary details to mitigate re-traumatization. The facility's policy also included provisions for involving mental health professionals and family members in the care planning process, as well as evaluating the care plan quarterly. However, the report does not indicate that these steps were taken for the residents in question. The deficiency highlights a failure to adhere to the facility's own policy and professional standards of practice, potentially impacting the quality of care provided to these residents.
Failure to Follow Methadone Administration Instructions
Penalty
Summary
The facility failed to ensure that medications were dispensed and administered according to professional standards of practice for one resident, identified as Resident R125. The facility's policy on medication administration requires that every medication have a physician's order, including the route and dose, and be transcribed into the medication administration record (MAR). Resident R125 had a physician's order for Methadone 20 mg in a unit dose bottle to be taken once a day for opioid dependence. The special instructions specified that the resident should drink the entire bottle, refill it with water, and drink again to rinse out any remaining drug. However, during an observation of medication administration, a licensed nurse, identified as Employee E5, deviated from these instructions by pouring orange juice into the bottle instead of water, and the resident consumed the liquid without refilling the bottle with water as prescribed. Interviews with facility staff revealed a lack of adherence to the prescribed medication administration instructions. Employee E4, a unit manager, incorrectly stated that the bottle did not need to be refilled with water, and the resident could use orange juice instead. This was confirmed as incorrect by the Director of Nursing, Employee E2, who acknowledged that the orders required the bottle to be refilled with water and consumed as per the physician's instructions. This failure to follow the prescribed method of administration for Methadone, a highly regulated medication, constitutes a deficiency in the facility's pharmaceutical services.
Improper Storage of Insulin on Medication Cart
Penalty
Summary
The facility failed to store drugs and biologicals in a locked compartment as required by policy and regulations. During an observation of medication administration, it was noted that a container with sixteen vials of insulin was placed on top of a medication cart, making it accessible to anyone. This was contrary to the facility's policy, which mandates that medications and biologicals be stored in secured locations accessible only to designated staff. The insulin was originally stored in the medication room refrigerator and was intended to be returned there after the medication pass. Interviews with staff revealed a lack of understanding and adherence to proper medication storage protocols. Employee E5, a licensed nurse, stated that the container was supplied by a supervisor and intended to be returned after the medication pass. Employee E4, a unit manager, incorrectly believed it was acceptable to leave the insulin on top of the cart. Another licensed nurse, Employee E6, followed the correct procedure by storing insulin in a locked drawer during the medication pass. The Director of Nursing confirmed that insulin should be stored inside the medication cart and locked, highlighting a discrepancy in staff practices and understanding of the facility's medication storage policy.
Improper Garbage Disposal
Penalty
Summary
The facility failed to ensure proper disposal of garbage, as observed in the receiving and garbage disposal areas. The dumpster, which contained kitchen waste and general trash from the resident care area, was found without a lid, exposing its contents. This included open or untied garbage, and flies were observed around the dumpster's opening. The facility's administrator confirmed that the dumpster was designed to allow trash to be pushed inside without exposing the contents, but it was overfilled, preventing proper closure. This deficiency was identified during an observation with the Food Service Manager.
Resident Elopement During Theater Outing
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility, leading to a resident eloping during a planned out-of-facility activity. The resident, identified as being at risk for elopement due to ambulation status, cognitive impairment, and history of exit-seeking behaviors, was added to a theater outing roster on the morning of the event. Despite having an elopement care plan in place, the facility did not have a protocol for screening residents for out-of-facility events to identify their care needs, such as elopement risk. During the outing, the resident was seated in a location that was out of sight of the staff, which contributed to the staff's inability to supervise and redirect the resident effectively. The activities aides accompanying the residents were unaware of which residents were at risk for elopement. As a result, the resident was able to leave the theater unnoticed and was later found at a river toll bridge commission building. The facility's documentation and interviews with staff revealed that the root cause of the elopement was the seating arrangement at the theater, which prevented staff from maintaining proper supervision. This incident was identified as an Immediate Jeopardy of past non-compliance, highlighting the failure of the NHA and DON to fulfill their essential duties and responsibilities, as outlined in their job descriptions.
Failure to Provide Adequate Care for Diabetic Resident
Penalty
Summary
The facility failed to provide adequate care and services for a resident with diabetes and quadriplegia, leading to a hypoglycemic episode. The resident, who requires assistance due to quadriplegia, was sent to an outside appointment without an escort, despite expressing the need for one. During the appointment, the resident experienced a drop in blood sugar to 59, resulting in a visit to the emergency room. The resident had been out of the facility from 8 a.m. to 1:30 p.m., missing lunch and having only a light breakfast, which contributed to the hypoglycemic event. The facility did not provide the resident with a snack or lunch for the appointment, nor did they check the resident's blood sugar upon return, despite being informed of the low blood sugar incident. The Director of Nursing confirmed that the resident's blood sugar should have been checked and lunch offered upon return. The facility's failure to adhere to the care plan, which included monitoring for adequate meal consumption and holding insulin for skipped meals, contributed to the resident's hypoglycemic episode.
Failure to Provide Staff Escort for Resident with Quadriplegia
Penalty
Summary
The facility failed to provide sufficient staff to accompany a resident with quadriplegia and type 2 diabetes mellitus to a medical appointment. The resident, who was dependent on staff for various activities and controlled his motorized wheelchair with his chin, was sent to an appointment without an aide. This left him unable to manage tasks such as fastening and unfastening his seatbelt and operating the elevator, which he needed to access the doctor's office on the second floor. The resident's grievance highlighted that he felt insecure and required assistance during the appointment, which was not provided due to staffing shortages. As a result, he experienced a hypoglycemic episode, with his blood sugar dropping to 59, necessitating emergency room intervention. Interviews with facility staff confirmed that the resident should have been accompanied by a staff member, but due to insufficient staffing, this did not occur.
Failure to Meet Nutritional Needs for Diabetic Resident
Penalty
Summary
The facility failed to meet the daily nutritional and special dietary needs of a resident with quadriplegia and type 2 diabetes mellitus. The resident was sent to an appointment without an escort, despite being unable to perform many tasks independently. The resident left the facility after a light breakfast and was not provided with a snack or lunch for the appointment, which lasted from 8:00 a.m. to 1:30 p.m. During the appointment, the resident experienced a drop in blood sugar to 59 and was taken to the emergency room, where they were given a snack and drink to stabilize their condition. Upon returning to the facility, the resident reported the low blood sugar episode to the staff, but there was no evidence that the facility provided food or rechecked the resident's blood sugar. The meal intake documentation indicated that the resident was not provided lunch, even though they were back at the facility by 1:30 p.m. The Director of Nursing acknowledged that the resident should have been given packed food for the appointment and offered a meal upon their return before 2:00 p.m.
Failure to Provide Adequate Transportation and Escort for Resident
Penalty
Summary
The facility failed to ensure that necessary services not offered by the facility were provided under a written arrangement, specifically for the transportation of a resident to a medical appointment. The facility policy dated May 12, 2024, stated that there should be a contract with non-emergency transport services for use when the facility is unable to provide transportation. However, it was found that the facility did not have a transport agreement with the company used for a resident's appointment on September 3, 2024. The resident, who is quadriplegic and diabetic, was sent to an appointment without an escort, despite needing assistance with his wheelchair and elevator use. During the appointment, the resident experienced a drop in blood sugar, resulting in a visit to the emergency room. The resident expressed that having an escort would have prevented this situation and requested that a staff member accompany him to future appointments, along with a snack and drink due to his diabetic condition. The Director of Nursing confirmed the absence of a transport agreement for the service used.
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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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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