Eldercrest Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Munhall, Pennsylvania.
- Location
- 2600 West Run Road, Munhall, Pennsylvania 15120
- CMS Provider Number
- 395013
- Inspections on file
- 27
- Latest survey
- November 14, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Eldercrest Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Two residents with diabetes experienced significant medication errors due to delayed administration of both scheduled and sliding scale insulin doses, contrary to prescriber orders and facility policy. These delays were confirmed through record review and staff interviews, and one resident suffered a hypoglycemic event requiring emergency intervention.
The facility failed to meet required staffing levels for NAs on several shifts between January 2 and January 7, 2025. The daylight shift was notably understaffed, with fewer hours provided than required based on the resident census. This deficiency was confirmed by the Nursing Home Administrator.
The facility did not meet the required LPN staffing levels over a six-day period, failing to provide the mandated minimum of one LPN per 25 residents during the day shift on five days, one LPN per 30 residents during the evening shift on all six days, and one LPN per 40 residents during the night shift on all six days. This was confirmed through staffing documents and an interview with the Nursing Home Administrator.
Two residents, both cognitively intact, were neglected during a specific shift, with no documented care provided. A nurse reported that one resident was not attended to due to instructions from the DON and NHA. The DON confirmed the lack of investigation into these incidents.
The facility failed to investigate and report potential neglect for two residents, who were not provided care during a specific shift. Both residents, who were cognitively intact, lacked documented care, and the DON admitted to not investigating the allegations. This inaction violated the facility's policy and several Pennsylvania Code regulations.
The facility did not employ a qualified Director of Dining Services to oversee the Dietary Department. The Dietitian visits weekly, and the Head of Dietary, who is still in training, was absent. The Head of Dietary's personnel file lacked evidence of meeting the required qualifications for the position, as confirmed by the NHA.
A facility failed to follow infection control protocols during a dressing change for a resident with a leaking colostomy bag. The ADON did not perform proper handwashing, failed to don appropriate PPE, and did not maintain the resident's privacy. Contaminated items were improperly handled, violating several Pennsylvania Code regulations.
A resident's privacy was compromised during a dressing change conducted at the entrance of their room with the door open, allowing passersby to see. The Assistant Director of Nursing confirmed the breach of privacy, violating resident rights.
A facility failed to administer a scheduled medication for a resident with prostate cancer, as documented in the MAR. The resident did not receive the drug Erleada for eight days due to its unavailability, and the facility did not contact the provider for an alternative or order change. The DON confirmed the failure to provide the medication.
A resident with prostate cancer did not receive the prescribed cancer treatment drug Erleada for eight days due to unavailability, as documented in the MAR. The facility's policy requires medications to be administered as ordered, but this was not followed, which was confirmed by the DON.
An LPN in a facility misappropriated narcotic medication by documenting administrations to residents without their consent or knowledge. A cognitively intact resident reported not receiving the medication, while another resident, with a history of addiction, denied receiving narcotics despite documentation. The facility's policies prohibit such actions, yet the LPN's behavior suggests a pattern of drug diversion, highlighting a failure to protect residents' rights.
The facility failed to investigate the misappropriation of resident property for eight residents, involving suspicious medication administrations by an LPN. Despite policies defining misappropriation, the facility did not confirm with residents whether they received medications as documented, nor did they investigate additional doses signed out on paper but not in the electronic medical record. This oversight involved multiple residents and medications, indicating a systemic issue in managing potential misappropriation.
The facility failed to provide adequate nursing staff, resulting in residents experiencing long wait times for assistance and being left in soiled briefs. Multiple residents reported waiting hours for care, with one resident left soiled overnight. The Director of Nursing confirmed the staffing inadequacies, affecting the well-being of several residents.
A facility failed to report the misappropriation of resident property involving two residents. An LPN documented administering oxycodone to these residents, which they later denied receiving. The DON was informed of suspicious medication administration, and further investigation revealed patterns of drug diversion by the LPN. Despite these findings, the facility only reported the suspected drug diversion for one resident, failing to include the misappropriation involving the second resident.
The facility failed to maintain an infection prevention and control program, leading to a significant outbreak of GI illness among residents and staff. The facility did not document surveillance, allowed ill staff to work, and failed to educate staff on precautions, resulting in 26 residents contracting the illness and two being hospitalized.
A facility failed to notify a physician about a resident's low blood glucose levels, despite multiple readings below 70 mg/dL. The resident, with a history of diabetes, hypertension, and atrial fibrillation, had several low readings recorded, but there was no documentation of physician notification as required by facility policy. The DON confirmed these findings.
The facility failed to provide medically related social services and complete psycho-social based assessments upon admission for four residents. Despite being oriented and having no noted behaviors, the necessary psycho-social assessments were missing from their records. This deficiency was confirmed by the Director of Social Services and the Nursing Home Administrator.
The facility failed to involve two residents in the development of their discharge plans and did not document their approval, despite having policies that require such involvement. Both the Director of Social Services and the Nursing Home Administrator confirmed this deficiency.
Failure to Prevent Significant Medication Errors in Insulin Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin for two residents with diabetes. Facility policy required medications to be administered according to prescriber orders and within specified timeframes, but multiple instances were documented where insulin Lantus and Lispro were administered significantly later than ordered. For one resident, Lantus insulin scheduled for 9:00 a.m. was repeatedly given after noon, and Lispro insulin, which should be administered before meals based on blood glucose readings, was often delayed by several hours. Similar delays were observed for another resident, with both scheduled and sliding scale insulin doses administered well past the prescribed times. These delays in insulin administration were confirmed through review of medication administration records and staff interviews. One resident experienced a hypoglycemic event, with a blood glucose reading of 36, after delayed insulin administration, requiring intervention per hypoglycemic protocol and subsequent transfer to the hospital. Facility leadership acknowledged that insulin administration did not adhere to the facility's medication administration policy, resulting in significant medication errors for both residents.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on multiple occasions between January 2, 2025, and January 7, 2025. Specifically, the facility did not provide the mandated number of NAs per resident on the daylight shift for four out of six days, on the evening shift for two out of six days, and on the night shift for one out of six days. The daylight shift was particularly understaffed, with the facility providing significantly fewer hours than required based on the resident census. This deficiency was confirmed by the Nursing Home Administrator during an interview on January 8, 2025.
Plan Of Correction
Nursing Home Administrator will re-educate the Director of Nursing and Scheduler on CNA staffing ratios regulation effective July 1, 2024. Nursing Home Administrator/Designee will audit staffing sheets weekly for four weeks to identify CNA ratio is met during staffing meeting. Moving forward, the Nursing Home Administrator/Designee will monitor staffing sheets. Nursing Home Administrator/designee is reviewing all current staffing contracts to ensure most up to date rates are in place and has posted open positions on employment platform. Findings will be reported to QAPI.
LPN Staffing Deficiency Over Six-Day Period
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) on multiple shifts over a six-day period. Specifically, the facility did not provide the mandated minimum of one LPN per 25 residents during the day shift on five out of six days, one LPN per 30 residents during the evening shift on all six days, and one LPN per 40 residents during the night shift on all six days. This deficiency was confirmed through a review of the facility's staffing documents and an interview with the Nursing Home Administrator, who acknowledged the failure to provide the required LPN coverage on the specified shifts.
Plan Of Correction
Nursing Home Administrator will re-educate the Director of Nursing and Scheduler on LPN staffing ratios regulation effective July 1, 2024. Nursing Home Administrator/Designee will audit staffing sheets weekly for four weeks to identify LPN ratio is met during staffing meeting. Moving forward, the Nursing Home Administrator/designee will monitor staffing sheets. Nursing Home Administrator/Designee is reviewing all current staffing contracts to ensure the most up to date rates are in place and has posted open positions on the employment platform. Findings will be reported to QAPI.
Neglect of Two Cognitively Intact Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as R21 and R300, were free from neglect. Resident R21, who was admitted with a stroke resulting in left-sided paralysis and glaucoma, was reported by a Registered Nurse to have not received care from 7:30 p.m. to 11:00 p.m. on a specific date. The Nurse Aide on duty claimed she was not allowed in the resident's room per instructions from the DON and NHA. The Documentation Survey Report for Resident R21 did not show any documented care during the 3-11 shift on that date. Similarly, Resident R300, who had stage IV kidney disease and Guillain-Barre Syndrome, also did not have documented care for the same shift on the same date. The DON confirmed the lack of investigation into these incidents and identified the Nurse Aide involved. Both residents were cognitively intact, as indicated by their BIMS scores of 14, suggesting they were aware of their surroundings and capable of reporting neglect.
Failure to Investigate and Report Alleged Neglect
Penalty
Summary
The facility failed to investigate and report potential neglect for two residents, R21 and R300, as required by their Abuse Prevention Program policy. Resident R21, who was admitted with a stroke and left-sided paralysis, was allegedly not provided care during a specific shift, as reported by a registered nurse. The documentation for that shift did not include any recorded care for R21. Similarly, Resident R300, who had stage IV kidney disease and Guillain-Barre Syndrome, also lacked documented care during the same shift. Both residents were cognitively intact, as indicated by their Minimum Data Set assessments. The Director of Nursing (DON) admitted to not investigating the allegations of neglect for these residents. During interviews, the DON could not recall why the nurse aide claimed they were not allowed to care for the residents, nor could they remember the name of the nurse aide involved. The facility's policy mandates that all reports of neglect be promptly reported and thoroughly investigated, which was not adhered to in this case. This failure to act is a violation of several Pennsylvania Code regulations related to the responsibility of the licensee, management, resident care policies, and nursing services.
Failure to Employ Qualified Director of Dining Services
Penalty
Summary
The facility failed to employ a qualified Director of Dining Services (DDS) to manage the daily operations of the Dietary Department. During an interview, it was revealed that the Dietitian visits the facility weekly, and the Head of Dietary, who is currently enrolled in classes to become a Dietary Manager, was not present. A review of the personnel file for the Head of Dietary showed that they did not meet the educational, experiential, and certification requirements for the DDS position. The Nursing Home Administrator confirmed the lack of documented evidence that the Head of Dietary met the necessary qualifications for the role.
Infection Control Deficiency During Dressing Change
Penalty
Summary
The facility failed to adhere to proper infection control techniques during a dressing change for a resident identified as R143. The Assistant Director of Nursing (ADON) did not perform thorough handwashing before beginning the procedure. Additionally, the ADON and a Licensed Practical Nurse (LPN) did not wear gowns despite the potential for contamination from blood and body fluids. The overbed table was not adequately cleared of personal items, risking contamination. The resident had a leaking colostomy bag, and the wound was adjacent to the leak, which contained stool. The ADON removed the ostomy bag and cleansed both the stoma and the wound without changing gloves or washing hands between procedures. Further, the ADON placed a box of gloves, Dakin's solution, and hand sanitizer on the overbed table, which was not properly sanitized. The resident's door was left open during the procedure, compromising privacy. The ADON acknowledged that the resident was under enhanced precautions, yet there was no sign or PPE available in the room. After the procedure, contaminated items were not disposed of properly, as the ADON returned them to the treatment cart. These actions violated several Pennsylvania Code regulations related to infection control, staff development, and resident care policies.
Resident Privacy Breach During Dressing Change
Penalty
Summary
The facility failed to maintain the personal privacy of a resident during a medical procedure. On November 26, 2024, from 11:15 a.m. to 11:44 a.m., a resident had a dressing change to the abdomen at the entrance of their room with the door open. This allowed any passerby to see the procedure, compromising the resident's privacy. The Assistant Director of Nursing confirmed during an interview that the resident's personal privacy was not maintained, which is a violation of resident rights as per 28 Pa. Code: 201.29(j).
Failure to Administer Scheduled Medication
Penalty
Summary
The facility failed to provide a scheduled medication for Resident R147, who was admitted with diagnoses including prostate cancer, a pacemaker/defibrillator, and a left femur fracture. The resident's clinical record indicated the use of the drug Erleada for prostate cancer treatment. However, the Medication Administration Record (MAR) showed that from November 18, 2024, through November 25, 2024, the medication was documented as unavailable and not administered. During an interview, the Director of Nursing confirmed that the facility did not provide the medication and failed to contact the provider for an alternative drug or order change. As a result, Resident R147 did not receive the prescribed cancer treatment drug for eight days.
Failure to Administer Cancer Medication as Ordered
Penalty
Summary
The facility failed to ensure that significant medications were administered as ordered by the physician for a resident. The facility's policy on Medication Administration, dated 2024, requires that all medications be administered in accordance with prescriber orders and within the required time frame. However, a review of the clinical record for a resident admitted with diagnoses including prostate cancer, a pacemaker/defibrillator, and a left femur fracture, revealed that the cancer treatment drug Erleada was not administered for eight consecutive days due to unavailability. This lapse was confirmed during an interview with the Director of Nursing, who acknowledged the failure to administer the medication as ordered. The resident's Medication Administration Record (MAR) indicated that from November 18 to November 25, the drug was documented as unavailable and not given. This oversight was identified as a deficiency under the regulations governing the responsibility of the licensee, pharmacy services, and resident care policies.
Misappropriation of Narcotic Medication by LPN
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property, specifically involving the wrongful administration of narcotic pain medication. The investigation revealed that an LPN, identified as Employee E1, documented the administration of oxycodone to several residents without their consent or knowledge. Resident R1, who was cognitively intact with a BIMS score of 15, reported not receiving the medication at the times documented by the LPN. Similarly, Resident R2, who also had a BIMS score of 15, denied receiving narcotics, preferring Tylenol due to a history of addiction. Despite this, the LPN recorded multiple administrations of oxycodone to Resident R2. Further investigation into Resident R3, who was also cognitively intact, showed a single administration of oxycodone by the same LPN, which was inconsistent with the resident's reported pain levels. Resident R4, who had a BIMS score of 4 due to dementia, was documented to have received oxycodone by the LPN, despite not exhibiting behaviors typically associated with severe pain. The facility's Director of Nursing confirmed the discrepancies in medication administration and the failure to protect these residents from misappropriation. The facility's policies on abuse, neglect, and misappropriation clearly prohibit such actions, yet the LPN's documentation and actions suggest a pattern of drug diversion. The investigation highlighted the facility's inability to ensure the safety and rights of its residents, as outlined in the Pennsylvania Code regarding nursing services and resident rights. The report underscores the need for stringent monitoring and adherence to policies to prevent such occurrences.
Failure to Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to implement policies and procedures to investigate the misappropriation of resident property for eight out of nine residents. The facility's policy on abuse, neglect, and misappropriation defines misappropriation as the wrongful use of a resident's belongings or money without consent. Despite this, the facility did not adequately investigate suspicious medication administrations documented by an LPN, which were not received by the residents as claimed. This issue was identified through a review of clinical records, facility policies, and staff interviews. Several residents, including those with cognitive impairments and those who were alert and oriented, were involved in the incidents. For instance, one resident with a BIMS score indicating cognitive intactness reported not receiving pain medication that was documented as administered by an LPN. Another resident, who had a history of addiction, stated she did not receive narcotics despite documentation indicating otherwise. The facility's investigation documents failed to show any attempt to confirm with the residents whether they received the medications, nor did they investigate additional doses signed out on paper but not documented in the electronic medical record. The facility's failure to investigate these discrepancies in medication administration records and controlled drug records indicates a lack of adherence to their own policies. The Director of Nursing confirmed that the facility did not implement the necessary procedures to investigate these incidents, which involved multiple residents and medications such as oxycodone and tramadol. This oversight suggests a systemic issue in managing and investigating potential misappropriation of resident property, particularly concerning controlled substances.
Insufficient Nursing Staff Leads to Resident Care Deficiencies
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident interviews and observations. Residents reported extended wait times for assistance, with some waiting up to 2.5 hours for care. Several residents were left in soiled briefs and clothing, indicating a lack of timely incontinence care. One resident reported being left soiled overnight and not receiving care until the following afternoon, despite having diarrhea for several days. The facility's records corroborated the lack of incontinence care provided during this period. The Director of Nursing confirmed the facility's failure to maintain adequate staffing levels to ensure the highest practicable physical, mental, and psychosocial well-being of the residents. The deficiency was identified in five out of eight residents reviewed, highlighting a systemic issue with staffing levels and the ability to provide necessary care. The facility's policy on Activities of Daily Living, which mandates services to maintain good nutrition, grooming, and hygiene, was not adhered to, resulting in compromised resident care.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report a misappropriation of resident property involving two residents, identified as Resident R1 and Resident R2. The issue arose when a Licensed Practical Nurse (LPN), identified as Employee E1, documented the administration of narcotic pain medication, oxycodone, to these residents, which they later denied receiving. The Director of Nursing (DON) was informed of a suspicious medication administration involving Resident R1, who was alert and oriented, and denied receiving the medication at the reported time. Further investigation revealed that Resident R2, who also had a history of avoiding narcotics due to past addiction, similarly denied receiving the medication that was documented as administered by the same LPN. The clinical records and Medication Administration Records (MAR) for both residents showed multiple instances where oxycodone was documented as administered by LPN Employee E1. Resident R1's MAR indicated several administrations of oxycodone, particularly between the evening and early morning hours, which the resident denied receiving. Similarly, Resident R2's MAR showed documented administrations of oxycodone by the same LPN, despite the resident's preference for Tylenol and denial of receiving narcotics. The Controlled Drug Record further indicated discrepancies, as no further medication was available for Resident R2 until a new order was received, contradicting the documented administrations. The facility's investigation revealed patterns of drug diversion by LPN Employee E1, affecting both residents. Despite these findings, the facility only reported the suspected drug diversion for Resident R1 to the State Survey Agency, failing to include the misappropriation involving Resident R2. This oversight in reporting the full extent of the drug diversion constitutes a deficiency in the facility's responsibility to report suspected abuse, neglect, or theft, as required by their policy and state regulations.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an infection prevention and control program, resulting in a significant outbreak of gastrointestinal (GI) illness among residents and staff. The facility did not document surveillance of residents and staff with GI illness, failed to preclude ill staff from working, and did not provide adequate education to staff on appropriate precautions related to GI illness. This led to 26 out of 43 residents contracting GI illness, with two residents requiring hospitalization due to severe symptoms and complications such as dehydration and pneumonia. The report details multiple instances where staff members continued to work despite showing symptoms of GI illness, violating the recommended 48-hour symptom-free period before returning to work. For example, Employee E1 worked during their illness and returned to work without completing the required symptom-free period, subsequently falling ill again. Similar patterns were observed with other employees, contributing to the spread of the illness among residents. The facility's failure to enforce these guidelines directly impacted the health and safety of the residents. Additionally, the facility did not provide formal education to staff on GI illness precautions and hand hygiene audits, as confirmed by multiple staff interviews. This lack of education and adherence to infection control protocols further exacerbated the outbreak. Residents reported that staff did not consistently wear personal protective equipment (PPE) such as gowns when caring for those with GI illness, increasing the risk of transmission. The facility's inadequate response and lack of proper infection control measures led to widespread illness and hospitalizations among residents.
Failure to Notify Physician of Low Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician of changes in a resident's blood glucose levels, which is a deficiency in their care protocol. The clinical records and staff interviews revealed that the facility did not inform the physician about a resident's low blood glucose levels, which were recorded multiple times during the night. The resident, who was admitted with diagnoses including diabetes, hypertension, and atrial fibrillation, had blood glucose readings of 52, 59, 60, 56, and 61 mg/dL at various times. Despite the facility's policy requiring immediate notification of the physician for blood glucose levels below 70 mg/dL, there was no documentation of such notification. The Director of Nursing confirmed these findings during an interview.
Failure to Provide Medically Related Social Services and Psycho-Social Assessments
Penalty
Summary
The facility failed to provide medically related social services and complete psycho-social based assessments upon admission for four out of five closed resident records. The Social Services Coordinator's job description requires the assessment of each resident within seven days of admission. However, the clinical records for residents CR1, CR2, CR3, and CR4 did not include the required psycho-social assessments upon their respective admissions. These residents had various diagnoses, including diabetes, gastrointestinal hemorrhage, hypertension, hypothyroidism, pelvis fracture, anxiety disorder, chronic obstructive pulmonary disease, vascular dementia, hyperlipidemia, and chronic kidney disease. Despite being oriented and having no noted behaviors, the necessary psycho-social assessments were missing from their records. During interviews, the Director of Social Services and the Nursing Home Administrator confirmed the facility's failure to provide the required medically related social services and complete the psycho-social assessments for the mentioned residents. This deficiency was identified through a review of clinical records and staff interviews, highlighting a significant lapse in the facility's adherence to its own policies and regulatory requirements. The deficiency was cited under 28 Pa. Code 211.16 (a) Social Services and 28 Pa. Code 211.5 (h) Clinical records.
Failure to Involve Residents in Discharge Planning
Penalty
Summary
The facility failed to involve two residents in the development of their discharge plans, as required by their policies. For Closed Resident Record CR1, the clinical record indicated that the resident was discharged to personal care with his belongings, but there was no documentation showing that the discharge plan was reviewed with him or that he had provided input or approval. CR1 had diagnoses including diabetes, gastrointestinal hemorrhage, hypertension, and hypothyroidism. Despite the care plan and physician orders indicating the discharge plan, the necessary review and approval by the resident were not documented prior to discharge. Similarly, for Closed Resident Record CR4, the clinical record showed that the resident was discharged home with occupational therapy, physical therapy, and nursing services, but again, there was no documentation indicating that the discharge plan was reviewed with her or that she had provided input or approval. CR4 had diagnoses including hyperlipidemia, diabetes, and chronic kidney disease. Both the Director of Social Services and the Nursing Home Administrator confirmed that the facility failed to involve the residents in the development of their discharge plans and did not document their approval as required by the facility's policies.
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.
