Edgehill Nursing And Rehab Cen
Inspection history, citations, penalties and survey trends for this long-term care facility in Glenside, Pennsylvania.
- Location
- 146 Edgehill Road, Glenside, Pennsylvania 19038
- CMS Provider Number
- 395757
- Inspections on file
- 17
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Edgehill Nursing And Rehab Cen during CMS and state inspections, most recent first.
The facility failed to implement Enhanced Barrier Precautions (EBPs) for a resident with a Foley catheter and two residents with wounds, as required by their policy. Observations showed a lack of necessary supplies and signage to alert staff and visitors about the precautions, which was confirmed by the Regional Nurse.
The facility failed to maintain an effective antibiotic stewardship program, lacking protocols and a system to monitor antibiotic usage. Over ten months, infections were treated with antibiotics without proper documentation or review, as confirmed by a regional nurse. The facility did not adhere to CDC guidelines, contributing to the deficiency.
The facility failed to ensure nurse aides received the required 12 hours of continued education per year. Three nurse aides did not meet the training requirements for 2023-2024, with one completing only 7.5 hours and two others completing 10 hours each. This deficiency was confirmed by HR staff.
The facility failed to provide necessary treatment for pressure ulcers for two residents. Despite physician orders for heel suspension devices, observations revealed that residents' heels were in contact with surfaces without offloading measures. Staff confirmed the absence of required devices, indicating non-compliance with treatment plans.
The facility failed to monitor and address the nutritional needs of three residents, resulting in significant weight loss. One resident lost 9.02% of their weight without new dietary interventions, another lost 9.98% without weekly weight checks, and a third resident's nutritional needs were not reassessed after being taken off hospice care.
A facility failed to provide proper care and assessments for a resident's intravenous therapy. The resident, admitted with a urinary tract infection and receiving IV antibiotics through a PICC line, had no documented IV line care or maintenance, such as dressing changes or assessments. Additionally, the length of the external catheter was not measured upon admission, as required by facility policy. An interview confirmed the absence of orders for PICC line management.
The facility failed to notify a physician and complete assessments for significant weight loss in two residents, as required by care plans and policy. One resident lost 9.02% of their weight in less than a month, while another lost 9.98% in a similar timeframe. Despite care plans requiring physician notification, there was no documentation of such actions, confirmed by a Regional Nurse.
The facility did not complete required yearly performance reviews for two nurse aides, Employees E10 and E13. Employee E10, hired in 2022, missed a review in 2023, while Employee E13, hired in 2009, missed reviews in both 2023 and 2024. This issue was confirmed by HR, citing turnover in the DON position as a possible reason.
A facility failed to implement a consultant pharmacist's recommendation to increase a resident's Clindamycin dosage, despite physician approval. The resident continued to receive the original dosage as per the MAR, leading to a deficiency in pharmacy and nursing services.
The facility failed to employ a qualified director of food and nutrition services. Employee E6, the Food Service Director, lacked necessary qualifications such as a CDM, CFM, or relevant degree. Additionally, the Registered Dietitian worked only part-time, contributing to the deficiency in qualified staffing for the department.
The facility's QAPI program was found deficient due to a lack of systematic identification, reporting, and prevention of adverse events. Despite identifying falls as a concern, no action plan or performance tracking was documented. An interview confirmed poor documentation and absence of data collection, analysis, and monitoring.
The facility did not designate a qualified infection preventionist with the required specialized training in infection prevention and control. The infection preventionist was in the process of completing a CDC training program but had not yet finished it, leading to a deficiency in regulatory compliance.
A facility failed to develop a comprehensive care plan for a resident with a colostomy following hospital readmission and surgery. The resident, with multiple diagnoses including dementia and Parkinson's, was dependent on assistance for personal care. Despite these needs, the facility did not establish a care plan with goals and interventions for colostomy care, as confirmed by the DON.
A resident with multiple sclerosis, who was incontinent and dependent on staff for toileting and bathing, did not receive adequate incontinence care or showers as per her preference. Despite her care plan requiring checks every two hours, she was found with soaked pants, having not been changed for five hours. The facility's failure to adhere to the care plan and policy resulted in inadequate grooming and personal hygiene care.
A resident with dementia and Parkinson's Disease experienced severe abdominal pain and confusion, but there was a two-day gap in nursing documentation before the resident was sent to the ER for chest pain and shortness of breath. The DON confirmed the lack of assessment and documentation, leading to a deficiency in care.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically in the implementation of Enhanced Barrier Precautions (EBPs) for residents with indwelling medical devices and wounds. The facility's policy, dated March 2024, outlines the use of EBPs, including the use of gowns and gloves during high-contact resident care activities to prevent the spread of multidrug-resistant organisms (MDROs). However, observations revealed that for Resident R51, who had an indwelling Foley catheter, there were no enhanced barrier precaution supplies available, nor were there signs posted outside the room to alert staff and visitors about the necessary precautions. Similarly, for Resident R39, who had open wounds to the sacrum and heels, and Resident R32, who had a pressure injury on the right heel, there were no enhanced barrier precaution supplies or signage present. Interviews with the Regional Nurse confirmed that the facility did not implement the required EBPs for these residents, despite their conditions necessitating such precautions. This lack of implementation was in direct violation of the facility's own policy and state regulations, as noted in the report.
Deficient Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program over a period of ten months, as determined by a review of facility documentation, policies, and staff interviews. The program lacked a system to effectively monitor antibiotic usage and did not include antibiotic use protocols. The facility's surveillance tool was found to be inadequate, as it did not document symptoms, tests ordered, or reviews to determine the appropriateness of antibiotic orders for infections treated with antibiotics. Throughout the months of January to September 2024, the facility's documentation revealed multiple instances where infections were treated with antibiotics without proper documentation or review. For example, in February 2024, all 33 infections treated with antibiotics lacked documentation of symptoms, tests ordered, or appropriateness reviews. Similar deficiencies were noted in other months, with varying numbers of infections treated without adequate documentation. An interview with a regional nurse confirmed the absence of antibiotic use protocols and a system to monitor antibiotic usage effectively. The facility's failure to adhere to CDC guidelines and implement the core elements of an antibiotic stewardship program contributed to the deficiency. The lack of integration of pharmacists into the clinical care team and failure to track antibiotic use patterns further exacerbated the issue.
Deficiency in Nurse Aide Training Hours
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of continued education per year, as mandated by regulations. This deficiency was identified through a review of personnel files and staff interviews, which revealed that three out of four nurse aides did not meet the training requirements for the calendar year 2023-2024. Specifically, Employee E10, hired on November 7, 2022, completed only 10 hours of training, missing 2 hours. Employee E12, hired on October 8, 1999, also completed only 10 hours of training, missing 2 hours. Employee E13, hired on March 5, 2009, completed only 7.5 hours of training. An interview with Employee E9 from Human Resources confirmed these findings, indicating a failure in the facility's staff development and training processes.
Failure to Implement Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to provide necessary treatment and services to promote the healing of pressure ulcers for two residents, as observed and documented by surveyors. Resident R39, who was admitted with dementia and Parkinson's disease, had open wounds on the sacrum and heels due to pressure injuries. Despite physician orders for heel suspension devices to offload pressure from the heels, observations on multiple occasions revealed that the resident's heels were in contact with the mattress or footrest without any offloading measures. Interviews with staff confirmed the absence of heel suspension devices in the resident's room, indicating a failure to adhere to the prescribed treatment plan. Similarly, Resident R32, diagnosed with dementia and chronic obstructive pulmonary disease, had a pressure injury on the right heel. Physician orders required the use of a heel suspension device while in bed, but observations showed the resident's heels were touching the mattress without offloading measures. A heel boot was found next to the resident's dresser, unused, and staff confirmed the lack of proper offloading measures. These findings demonstrate the facility's failure to implement necessary interventions to prevent and treat pressure ulcers, as outlined in their policies and physician orders.
Failure to Monitor and Address Nutritional Needs
Penalty
Summary
The facility failed to adequately monitor and address the nutritional needs of three residents, leading to significant weight loss. Resident R12 experienced a weight loss of 9.02% between July and August 2024, without any new dietary interventions being initiated despite the resident's nutritional risk and the absence of a recent hospitalization. The facility did not notify the physician or revise the care plan appropriately, as confirmed by the Regional Nurse. Resident R39 also suffered a significant weight loss of 9.98% within a month, and the facility failed to complete the required weekly weight checks. Although the resident's care plan included nutritional interventions, such as providing lactose-free milk and requesting a multivitamin supplement, the facility did not follow through with the necessary monitoring and adjustments. Resident R2, who was taken off hospice care, did not have monthly weights documented for several months, and the Registered Dietitian did not reassess the resident's nutritional needs after the change in hospice status. Despite observations of poor eating habits, the facility did not adjust the care plan to reflect the resident's current needs, as confirmed by interviews with facility staff.
Failure in IV Therapy Care and Assessment
Penalty
Summary
The facility failed to provide care and assessments consistent with professional standards of practice related to intravenous therapy for Resident R54. The facility's policy on Central Vascular Access Device (CVAD) Dressing Change requires assessment of the vascular access site upon admission, during dressing changes, and at least once every shift when not in use. However, there was no documentation of any IV line care or maintenance, such as dressing changes or assessments, for Resident R54. Additionally, the length of the external catheter was not obtained upon admission, as required by the facility's policy. Resident R54 was admitted with a diagnosis of a urinary tract infection and was receiving intravenous antibiotic therapy through a peripherally inserted central catheter (PICC) line. Despite this, there were no orders or documentation for the care and management of the PICC line, and progress notes did not indicate that the IV line was assessed or monitored each shift and/or with each infusion. An interview with the Regional Nurse confirmed these deficiencies, highlighting the lack of proper orders and documentation for the PICC line care.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a physician assessment was completed for unplanned weight loss in two residents, R12 and R39, as required by their care plans and facility policy. Resident R12 experienced a significant weight loss of 9.02% between July 10, 2024, and August 1, 2024, with a BMI indicating underweight status. Despite the dietitian documenting the weight loss and revising the care plan, there was no evidence that the physician was notified or that an assessment was completed. Similarly, Resident R39 experienced a 9.98% weight loss from August 29, 2024, to September 11, 2024, and was identified as being at nutritional risk. The care plan required weekly weights and notification of the dietitian and physician for significant weight changes, but there was no documentation of physician notification or assessment. The facility's policy on weighing residents mandates that significant weight changes be communicated to the dietitian, physician, family, and RNAC, with documentation in the resident's medical record. However, interviews with the Regional Nurse confirmed the absence of evidence that the physician was notified of the weight loss for both residents, as required by the care plans and facility policy. This deficiency was identified under the Pennsylvania Code sections related to nursing services, physician services, and clinical records.
Failure to Conduct Yearly Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to conduct required yearly performance reviews for two out of four nurse aides reviewed, specifically Employees E10 and E13. Employee E10, hired on November 7, 2022, did not receive a performance review in 2023. Similarly, Employee E13, who was hired on March 5, 2009, did not have a performance review completed in either 2023 or 2024. This deficiency was confirmed during an interview with Employee E9 from Human Resources, who acknowledged the absence of these reviews and attributed it to the turnover of several Directors of Nursing, which may have contributed to the oversight.
Failure to Implement Pharmacy Review Recommendations
Penalty
Summary
The facility failed to implement identified pharmacy review irregularities for a resident. A consultant pharmacist recommended increasing the dosage of Clindamycin to 300 mg every 6 hours for a resident, and this recommendation was approved by the physician. However, the resident's medication administration record (MAR) showed that the resident continued to receive Clindamycin 300 mg three times daily, both on July 25, 2024, for 10 days, and again on August 8, 2024, for 21 days. The recommended dosage increase was not implemented, resulting in a deficiency in pharmacy services and nursing services as per the relevant Pennsylvania codes.
Deficiency in Qualified Food Service Director
Penalty
Summary
The facility failed to employ a qualified director of food and nutrition services, as evidenced by the findings related to Employee E6. During an interview, Employee E6, who held the position of Food Service Director, revealed responsibilities that included oversight of ordering, receiving, storing, preparation, and service of food. However, a review of Employee E6's personnel file indicated that they did not possess the necessary qualifications, such as being a certified dietary manager (CDM), a certified food manager (CFM), or holding a national certification for food service management and safety. Additionally, Employee E6 did not have an associate's or higher degree in food service management or hospitality from an accredited institution. The Registered Dietitian, Employee E7, confirmed that they only worked part-time at the facility, further highlighting the deficiency in qualified staffing for the food and nutrition services department.
Deficiency in Quality Improvement Program
Penalty
Summary
The facility failed to maintain an effective Quality Improvement Program as evidenced by the lack of systematic identification, reporting, investigation, analysis, and prevention of adverse events and performance indicators. The facility's QAPI plan, revised in May 2023, was supposed to include problem descriptions, specific goals, timelines, feedback, data monitoring, and systematic analysis and action. However, the review of the QAPI Committee Meeting Records for July 2024 showed that although the facility identified falls as an area of concern using the CASPER reports, there was no documented evidence of an action plan being implemented to address this issue or track performance improvements. In August 2024, the QAPI Committee Meeting Records again listed falls as a concern, but there was no evidence of monitoring or evaluation of falls, nor any tracking of medical errors and adverse events. The facility did not analyze the causes of these issues or implement preventive actions. An interview with the Regional Nurse Consultant confirmed the absence of documentation, tracking of events, data collection, analysis, performance indicators, goals, or monitoring of progress, indicating a significant deficiency in the facility's QAPI program.
Infection Preventionist Lacks Required Training
Penalty
Summary
The facility failed to designate a qualified infection preventionist responsible for the infection prevention and control program, as required by regulations. During an interview, the Regional Nurse, identified as Employee E3, stated that the infection preventionist had not completed the specialized training in infection prevention and control. A review of the educational records confirmed that the infection preventionist was in the process of obtaining the necessary training from the CDC but had not yet completed the program. This lack of completion of specialized training led to the deficiency in meeting the regulatory requirements for infection prevention and control.
Failure to Develop Comprehensive Colostomy Care Plan
Penalty
Summary
The facility failed to timely develop and implement a person-centered care plan for a resident who required the use of a colostomy. The resident, diagnosed with coronary heart disease, dementia, depression, anxiety, and Parkinson's Disease, was cognitively impaired and dependent on assistance for toileting, bathing, dressing, and personal hygiene. Following a hospital readmission for treatment of a perforated viscus, the resident underwent an exploratory laparotomy and low anterior resection with colostomy. Despite these significant medical interventions, the facility did not create a comprehensive care plan addressing the resident's colostomy care, including necessary goals and interventions. This deficiency was confirmed during an interview with the Director of Nursing.
Failure to Provide Adequate Incontinence and Hygiene Care
Penalty
Summary
The facility failed to provide adequate care to maintain grooming and personal hygiene for a resident diagnosed with multiple sclerosis, who was alert and oriented but had impairments in one side of the upper and both sides of the lower extremities. The resident was incontinent of urine and bowel and dependent on staff for toileting and bathing. Despite the resident's preference for showers, staff opted to give bed baths instead, citing the time it takes to use a Hoyer lift for showers. This resulted in the resident not receiving showers twice a week and going an unspecified duration without having her hair washed. On the day of the survey, the resident was observed with soaked pants, indicating she had not been changed since the previous shift, approximately five hours prior. The resident's care plan specified that she should be checked every two hours for incontinence and assisted with changing briefs. However, the Nursing Home Administrator confirmed that the resident had not received incontinence care since 6:00 a.m., which was a clear deviation from the established care plan and facility policy.
Failure to Document and Assess Resident's Change in Condition
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident who experienced a change in condition. The resident, diagnosed with dementia and Parkinson's Disease, required partial to moderate assistance with personal care and was incontinent. On February 25, 2024, the resident complained of severe abdominal pain, rated at 10.5/10, and was noted to be confused. Vital signs were taken, and Tylenol was administered with positive results. However, there was a significant gap in documentation, as the next nursing progress note was not recorded until almost two days later, when the resident was sent to the emergency room due to chest pain and shortness of breath. The Director of Nursing confirmed that the nursing notes lacked a timeline and assessments during this period, indicating a failure to assess and document the resident's status adequately. This lack of documentation and assessment during the two-day period contributed to the deficiency, as it was unclear what occurred leading to the resident's hospitalization. The facility did not maintain complete and accurate nursing progress notes, which is a requirement under professional standards of practice.
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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