Edinboro Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Edinboro, Pennsylvania.
- Location
- 419 Waterford Street, Edinboro, Pennsylvania 16412
- CMS Provider Number
- 395645
- Inspections on file
- 21
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Edinboro Manor during CMS and state inspections, most recent first.
The facility's fire alarm system was found deficient due to unresolved issues where the DACT main and point did not receive signals from the fire system. Despite being identified in an inspection report, these deficiencies were not corrected by the time of the survey, as confirmed by the maintenance supervisor.
The facility was found non-compliant with smoking regulations due to an accumulation of cigarette butts outside the oxygen storage room and in the designated smoking area. This was confirmed by the maintenance supervisor, indicating a failure to prohibit smoking in areas where flammable materials are stored.
Edinboro Manor failed to document required emergency preparedness exercises, including an annual full-scale and tabletop exercise, as confirmed by a maintenance supervisor.
The facility failed to maintain the sprinkler system according to NFPA 101 standards, as observed in the beauty salon where a missing escutcheon plate created an opening in the ceiling. This issue, confirmed by the maintenance supervisor, could potentially affect sprinkler activation.
The facility failed to provide written summaries of baseline care plans and order summaries to two residents or their representatives upon admission. One resident had dementia and COPD, while the other had dementia, hypertension, and hyperlipidemia. The DON confirmed the absence of documentation in their clinical records.
A facility failed to develop a care plan for a resident requiring a left resting hand splint, despite physician orders specifying its use and care. The resident, with conditions including flaccid hemiplegia, diabetes, and hypertension, had no care plan addressing the splint, confirmed by the DON during an interview.
A facility failed to show evidence of conducting care plan meetings or inviting a resident with COPD, anxiety, and hypertension to these meetings. The resident and staff confirmed the absence of such meetings or invitations since the resident's admission.
A resident with flaccid hemiplegia and other conditions did not receive the physician-ordered left resting hand splint to prevent further decrease in range of motion. Observations showed the splint was not worn during waking hours as required, and the Director of Nursing confirmed the non-compliance with the treatment plan.
The facility failed to store controlled Schedule II-V medications in a permanently affixed compartment and did not label an opened vial of Tubersol PPD with an open date, making discard date determination impossible. Additionally, an expired Humalog insulin pen was found in the A-Wing medication cart. These issues were confirmed by LPNs during interviews.
The facility did not meet the required minimum NA staffing ratios during an overnight shift, with only 6.50 NAs on duty for 113 residents, falling short of the required 7.53 NAs. This deficiency was confirmed by the Nursing Home Administrator.
The facility failed to meet the required LPN staffing ratios on multiple occasions, with shortages occurring during day, evening, and overnight shifts. The Nursing Home Administrator confirmed the deficiency, which was identified through a review of staffing documents and staff interviews.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident per day. A review of staffing documents revealed that on one day, the facility provided only 3.17 hours of care per resident. This was confirmed by the Nursing Home Administrator.
Fire Alarm System Deficiency Due to Unresolved Signal Issues
Penalty
Summary
The facility failed to meet the fire alarm system requirements as evidenced by a document review and interview conducted on February 4, 2025. The fire alarm inspection report, completed on October 14, 2024, identified two deficiencies that were not addressed by the time of the survey. Specifically, the Digital Alarm Communicator Transmitter (DACT) main and DACT point did not receive signals from the fire system, indicating a failure in the communication link between the fire alarm system and the monitoring station. An interview with the maintenance supervisor confirmed that these deficiencies were not corrected at the time of the survey. This lack of corrective action suggests a lapse in the facility's maintenance and testing program for the fire alarm system, which is required to comply with NFPA 70 and NFPA 72 standards. The failure to address these deficiencies could potentially compromise the safety and emergency response capabilities of the facility.
Plan Of Correction
The facility was provided with incorrect documentation by the inspection company. The company has provided the correct documentation depicting that there were/are no deficiencies present. The above-mentioned documentation will be provided upon submission of this Plan of Correction. The Maintenance Director will be educated on the importance of ensuring that the facility receives correct/accurate reports regarding any inspections that occur. All inspections/reports will be audited by the administrator and reviewed with the inspection companies prior to them exiting the facility. Once the written reports are obtained, the administrator and/or Maintenance Director will again review to ensure accuracy of findings. The results of inspections will be reviewed at the facilities monthly Quality Assurance and Performance Improvement Meeting. The facility was provided with incorrect documentation by the inspection company. The company has provided the correct documentation depicting that there were/are no deficiencies present. The above-mentioned documentation will be provided upon submission of this Plan of Correction. The Maintenance Director will be educated on the importance of ensuring that the facility receives correct/accurate reports regarding any inspections that occur. All inspections/reports will be audited by the administrator and reviewed with the inspection companies prior to them exiting the facility. Once the written reports are obtained, the administrator and/or Maintenance Director will again review to ensure accuracy of findings. The results of inspections will be reviewed at the facilities monthly Quality Assurance and Performance Improvement Meeting.
Non-compliance with Smoking Regulations
Penalty
Summary
The facility failed to adhere to smoking regulations as evidenced by an accumulation of cigarette butts observed outside the oxygen storage room and in various spots around the designated smoking area. This observation was made on February 4, 2025, at 1:15 p.m. The maintenance supervisor confirmed the presence of cigarette butts in these areas, indicating a lack of compliance with the requirement to prohibit smoking in areas where flammable materials, such as oxygen, are stored. This deficiency highlights the facility's failure to maintain a safe environment by not ensuring that smoking regulations are strictly followed, particularly in hazardous locations.
Plan Of Correction
The cigarette butts have been removed from the ground by the exit. The facility will ensure that ashtrays are being utilized properly. The Administrator and/or designee will educate the Maintenance Director on the importance of smoking regulations. The Maintenance Director will educate the staff on the importance of adhering to smoking regulations. Audits will be conducted 3 times a week for 4 weeks to ensure that smoking regulations are being met.
Failure to Document Emergency Preparedness Exercises
Penalty
Summary
Edinboro Manor was found to be non-compliant with the emergency preparedness requirements as outlined in 42 CFR 483.73. The facility failed to conduct and document the necessary exercises to test its emergency preparedness plan. Specifically, the facility did not have documentation to verify that an annual tabletop exercise had been conducted. This deficiency was identified during a document review on February 4, 2025. The survey revealed that the facility also lacked documentation for an annual full-scale exercise. These exercises are crucial for testing and evaluating the facility's emergency preparedness plan, ensuring that staff and systems are ready to respond effectively in the event of an emergency. The absence of such documentation indicates that the facility did not meet the regulatory requirements for emergency preparedness testing. An interview with the maintenance supervisor confirmed the lack of documentation for both the full-scale and tabletop exercises. This confirmation further substantiates the finding that Edinboro Manor did not fulfill its obligations to conduct and document these critical emergency preparedness activities, as required by federal regulations.
Plan Of Correction
This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position. Edinboro Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding. Please accept this plan of correction as Edinboro Manor's credible allegation of compliance. The facility will ensure that there is at least one tabletop exercise, and one full-scale exercise completed annually. The facility recently had a change in Administrators effective 12/30/2024. During the Life Safety Survey, proof of an Emergency Preparedness Tabletop discussion could not be found during the inspection. After exit, the facility located documentation of an Emergency Preparedness Tabletop discussion that occurred on 03/21/2024 by past administration. Sign-in sheet and documentation will be provided with this Plan of Correction. The facility will conduct a "full-scale exercise" by 03/13/2025. The full-scale exercise will be reviewed at the monthly Quality Assurance and Performance improvement meeting.
Sprinkler System Deficiency in Beauty Salon
Penalty
Summary
The facility failed to maintain the sprinkler system in compliance with NFPA 101 standards, as evidenced by an observation on February 4, 2025. During the inspection, it was noted that the first floor beauty salon had a missing escutcheon plate, which resulted in an opening in the ceiling. This deficiency could potentially affect the activation of the sprinkler system in that area. The maintenance supervisor confirmed the absence of the escutcheon plate during an interview conducted at the same time as the observation.
Plan Of Correction
The missing escutcheon plate was ordered during the week of the inspection. The plate will be installed when it is received. The Maintenance Director will be educated on the importance of properly installed escutcheon plates. The facility will ensure that all sprinkler heads have proper escutcheon plates installed. Audits of all escutcheon plates will be conducted 3 times a week for 4 weeks. The results of the audits will be reviewed at the facility's monthly quality assurance performance improvement meeting.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to two residents, R110 and R112, or their representatives. Resident R110 was admitted on 9/6/24 with diagnoses including dementia and chronic obstructive pulmonary disease. The clinical record for R110 did not contain evidence that a written summary of the baseline care plan and order summary was provided to the resident or their representative. Similarly, Resident R112, admitted on 9/17/24 with diagnoses of dementia, hypertension, and hyperlipidemia, also lacked documentation in their clinical record indicating that a written summary of the baseline care plan and order summary was provided. The Director of Nursing confirmed during an interview that the clinical records for both residents did not include evidence of the required documentation being provided upon admission.
Plan Of Correction
This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position. Edinboro Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding. Please accept this plan of correction as Edinboro Manor's credible allegation of compliance. The facility will ensure that all new admissions are provided with baseline care plans and order summaries. R110's representatives were provided with a written summary of their current care plan and order summary. R112's representatives were provided with a written summary of their current care plan and order summary. The DON/Nursing designee will audit all admissions within the last 30 days to ensure residents receive a written summary of their baseline care plan and order summaries. The Administrator and/or designee will provide education to the Resident Services Coordinator regarding the importance of providing residents with a written summary of their baseline care plan and order summaries during care conferences. Audits of all new admissions will be conducted 3 times a week for 4 weeks. The results of the audits will be reviewed at the monthly Quality Assurance and Performance Improvement meeting.
Failure to Develop Care Plan for Splint Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident R27, who required a left resting hand splint. The deficiency was identified during a review of the facility's policy and clinical records, as well as through staff interviews. Resident R27 was admitted with diagnoses including flaccid hemiplegia affecting the left non-dominant side, diabetes, and hypertension. A physician's order dated December 26, 2024, specified the use of a left resting hand splint during waking hours, with instructions for frequent skin checks for irritation or breakdown and removal for hygiene purposes. Despite these orders, there was no evidence of a care plan addressing the use of the left resting hand splint in Resident R27's records. During an interview, the Director of Nursing confirmed the absence of a care plan for the splint and acknowledged that one should have been developed. This oversight indicates a failure to comply with the requirement to create a comprehensive, person-centered care plan that includes all necessary services to meet the resident's needs.
Plan Of Correction
R27 no longer needed the left-hand splint; therefore, the order has been discontinued. R27's care plan has been reviewed, and it has been determined to be personalized and appropriate. The Administrator will educate the Director of Nursing and Assistant Director of Nursing on the importance of the development and periodic review/revision of comprehensive person-centered care plans for each resident. The DON and/or the Assistant Director of Nursing will audit care plans of all residents with splints to ensure there's a comprehensive, personalized care plan that includes splint care. The DON and/or Assistant Director of Nursing will audit care plans for 5 random residents 3 times a week for 4 weeks to ensure that each one has a comprehensive, personalized care plan in place which appropriately reflects their specific needs. The results of the audits will be reviewed at the monthly Quality Assurance and Performance Improvement meeting.
Lack of Evidence for Resident Care Plan Meetings
Penalty
Summary
The facility failed to provide evidence of conducting resident care plan conference meetings or inviting residents to these meetings, as required by regulations. Specifically, for one resident, identified as Resident R106, there was no documentation indicating that the resident or their representative had been invited to or attended a care plan conference meeting. This deficiency was identified through a review of clinical records, facility policies, and staff interviews. Resident R106, who was admitted to the facility with diagnoses including chronic obstructive pulmonary disease, anxiety, and hypertension, reported not having attended or been invited to a care plan conference meeting. This was confirmed by interviews with the Social Services Coordinator and the Director of Nursing, who acknowledged the lack of evidence for such meetings or invitations in the resident's records since their admission.
Plan Of Correction
A care plan conference has been scheduled for R106. The facility will ensure that residents and/or resident representatives are invited to attend care plan conference meetings to discuss their goals and plan of care. Documentation of attendance/refusal will be noted in the clinical record. The Administrator will educate the Resident Services Coordinator regarding the importance of inviting and documenting attendance/refusal of residents and/or resident representatives to care plan conference meetings. The RSC will review documentation of resident care conferences held within the past 30 days to ensure appropriate individuals were invited to care conferences. The Assistant Director of Nursing will conduct a weekly audit of care conferences for 4 weeks to ensure that appropriate individuals were invited to care conferences with supportive documentation. The results of the audits will be reviewed at the monthly Quality Assurance and Performance Improvement meeting.
Failure to Provide Physician-Ordered Splint for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received the physician-ordered treatment and services necessary to prevent further decrease in range of motion. Resident R27, who was admitted with conditions including flaccid hemiplegia affecting the left non-dominant side, diabetes, and hypertension, had a physician's order for a left resting hand splint to be worn during waking hours. The order also required frequent skin checks for signs of irritation or breakdown and allowed removal of the splint for hygiene purposes. Observations over several days revealed that Resident R27 was not wearing the left resting hand splint as ordered. On multiple occasions, the splint was observed lying on the resident's bedside table while the resident was either in bed or sitting in a wheelchair in the lounge. During an interview, the Director of Nursing confirmed that the resident did not have the splint on as per the physician's orders, acknowledging the failure to comply with the prescribed treatment plan.
Plan Of Correction
R27 no longer needed the left-hand splint; therefore, the order has been discontinued. The facility has ensured that all current residents with physician-ordered treatments and services to prevent further decrease in range of motion are utilized as ordered. An initial audit was conducted by the Director of Nursing after the concern was brought to the facility's attention. The Director of Nursing and/or designee will educate the nursing staff on the importance of providing residents with a limited range of motion, the appropriate treatment and services to increase range of motion, and/or to prevent further decrease in range of motion. A nursing designee will conduct audits on 5 random residents 3 times a week for four weeks to ensure residents with physician-ordered treatments and services to prevent further decrease in range of motion are utilized as ordered. The results of the audits will be reviewed at the monthly Quality Assurance and Performance Improvement meeting.
Deficiencies in Drug Storage and Labeling
Penalty
Summary
The facility failed to comply with regulations regarding the storage and labeling of drugs and biologicals. Specifically, controlled Schedule II-V medications were not stored in a separately locked, permanently affixed compartment as required. Instead, these medications were found in two separately locked containers attached to a removable shelf in the main medication room refrigerator. Additionally, an opened vial of Tubersol PPD was found without an open date, making it impossible for staff to determine the appropriate discard date. Further deficiencies were observed in the A-Wing medication cart, where an open injector pen of Humalog insulin was found with an open date indicating it was expired. The pen had been opened on 12/25/24, and according to the manufacturer's guidelines, it should have been discarded after 28 days. These findings were confirmed by LPNs during interviews, highlighting lapses in the facility's adherence to proper medication storage and labeling protocols.
Plan Of Correction
The facility immediately disposed of the medication which was not dated upon notification of the concern. The facility immediately disposed of the expired Humalog insulin upon notification of the concern. The DON and ADON have audited all medication carts and the facility medication room to ensure that there were no expired or un-dated medications present. The facilities Maintenance Director permanently attached/affixed the removable shelf on the date that it was brought to the facilities' attention. The Director of Nursing and/or designee will educate the facilities nurses on the importance of properly dating medication, disposing of expired medication, and ensuring proper storage of controlled schedule II-V medications. An audit of all medication rooms and medication carts has been conducted to ensure that there are no undated or expired medications present, as well as ensuring that controlled substances are secured and stored properly. The Assistant Director of Nursing and/or designee will conduct a weekly audit of the med room refrigerator to ensure that controlled substances are secured/stored properly and one (1) med cart a week for 4 weeks to ensure that there are no undated and/or expired medications present and that the controlled substances are secured/stored properly within the medication cart(s). The results of the audits will be reviewed at the monthly Quality Assurance and Performance Improvement meeting.
Overnight Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing ratios during the overnight shift on January 1, 2025. Specifically, the facility had a census of 113 residents but only 6.50 NAs were on duty, whereas 7.53 NAs were required to meet the regulatory standard of one NA per 15 residents. This deficiency was confirmed by the Nursing Home Administrator during a telephone interview on January 8, 2025.
Plan Of Correction
The Administrator and/or designee will provide education to the staffing coordinator, administrative nurses, and charge nurses on the state required minimum staffing ratios regarding nursing assistants. The Administrator and/or designee will review staffing sheets 4 times a week for 2 weeks, 3 times weekly for 4 weeks to ensure that the state required minimum staffing ratios for nursing assistants are met per regulation. All audits will be reviewed through the Quality Assurance/Performance Improvement process. The Administrator/designee will utilize recruitment platforms and Indeed for job applicants, attend job fairs as able, corporate talent acquisition specialist, employee referral bonus program, and tuition reimbursement for recruitment efforts. Charge Nurses will be provided employee contact listings and will be responsible for calling staff when ratios are projected to be unmet. They will be able to offer our hourly call-in pay to help with incentive shift pick-ups. Call-offs are to be addressed by these charge nurses to ensure staffing requirements are met.
LPN Staffing Shortages in Facility
Penalty
Summary
The facility failed to meet the required staffing ratios for Licensed Practical Nurses (LPNs) on multiple occasions between December 31, 2024, and January 6, 2025. Specifically, the facility did not have the minimum number of LPNs per resident during the day, evening, and overnight shifts on several days. On January 2 and January 5, 2025, the day shift was understaffed with 4.06 and 4.25 LPNs working, respectively, when 4.52 and 4.64 were required based on the resident census. Similarly, the evening shift on January 3 and January 6, 2025, was short with 3.59 and 3.43 LPNs working, while 3.77 and 3.90 were needed. The overnight shift also experienced shortages on December 31, 2024, and January 2 and 3, 2025, with fewer LPNs than required. The Nursing Home Administrator confirmed during a telephone interview on January 8, 2025, that the facility did not meet the minimum LPN staffing ratios on the specified days and shifts. This deficiency was identified through a review of the facility's nursing staffing documents and staff interviews, highlighting a failure to comply with the regulation effective July 1, 2023, which mandates specific LPN-to-resident ratios for different shifts.
Plan Of Correction
The Administrator and/or designee will provide education to the staffing coordinator, charge nurses, and administrative nurses on the state required minimum staffing ratios for licensed practical nurse requirements. The Administrator and/or designee will review staffing sheets 4 times a week for 2 weeks, and 3 times weekly for 4 weeks to ensure that the state required minimum staffing ratios for licensed practical nurses are met per regulation. All audits will be reviewed through the Quality assurance/performance improvement process. The Administrator and/or designee will utilize recruitment platforms and Indeed for job applicants, attend job fairs as able, corporate talent acquisition specialist, employee referral bonus program, and tuition reimbursement for recruitment efforts. Charge Nurses will be provided with employee contact listings and will be responsible for calling staff when ratios are projecting to be unmet. They will be able to offer our hourly call-in pay to help with incentive shift pick-ups. Call offs are to be addressed by these charge nurses to ensure that the staffing requirements are met.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. This deficiency was identified during a review of the facility's nursing staffing documents for the period from December 31, 2024, to January 6, 2025. Specifically, on January 5, 2025, the facility provided only 3.17 hours of direct nursing care per resident, falling short of the mandated minimum. This shortfall was confirmed during a telephone interview with the Nursing Home Administrator on the same day.
Plan Of Correction
The Administrator and/or designee will provide education to the staffing coordinator, charge nurses, and administrative nurses on the state required minimum staffing of 3.2 hours of direct care per patient day requirements. A new staffing meeting will be conducted after the morning clinical meeting to review deployment sheets and the PA DOH staffing excel sheet. The current day and upcoming days will be reviewed at each meeting to ensure that the facility meets the required PPD at the projected census level. The Administrator will keep the admission team updated and informed. Attendees will be the Administrator, Scheduler, and Nursing Administration. The Administrator and/or designee will review staffing 4 times a week for 2 weeks, 3x weekly for 4 weeks to ensure that the state required minimum staffing minimum PPD requirement of 3.2. All audits will be reviewed through the Quality assurance/performance improvement process. The Administrator and/or designee will utilize recruitment platform and Indeed for job applicants, attend job fairs as able, corporate talent acquisition specialist, employee referral bonus program and tuition reimbursement for recruitment efforts. Charge Nurses will be provided with employee contact listings and will be responsible for calling staff when ratios are projected to be unmet. They will be able to offer our hourly call-in pay to help with incentive shift pick-ups. Call offs are to be addressed by these charge nurses to ensure staffing requirements are met.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
