Embassy Of Scranton
Inspection history, citations, penalties and survey trends for this long-term care facility in Scranton, Pennsylvania.
- Location
- 824 Adams Avenue, Scranton, Pennsylvania 18510
- CMS Provider Number
- 395273
- Inspections on file
- 27
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 37 (1 serious)
Citation history
Health deficiencies cited at Embassy Of Scranton during CMS and state inspections, most recent first.
A resident with bilateral lower extremity amputations and intact cognition did not have reasonable access to a call bell needed to obtain staff assistance. During observation, the call bell cord was wrapped around the bed frame and positioned behind the resident’s head, with additional restriction from bags stored behind the bed, forcing the resident to reach backward to access it. The facility’s policy requires staff to ensure call light accessibility and response, yet clutter in the room had been discussed without resolution. Resident council minutes and a grievance documented broader concerns about delayed call bell responses and difficulty obtaining toileting assistance during the night shift.
A resident with anxiety, major depressive disorder, a history of suicide attempts, and prior psychiatric hospitalizations exhibited escalating anxiety, restlessness, pacing, self-harm behaviors, and worsening depression over time, while sharing a room with a spouse who was known to be a trigger and part of prior joint suicide attempts. The care plan for depression and anxiety did not include the resident’s suicide attempt history until after a serious incident, and there is no indication that enhanced supervision or suicide precautions were implemented despite persistent high-risk symptoms and staff reports of frequent falls and worsening mood. On one shift, an RN supervisor assessed the resident for nausea and urinary complaints, left the room after the resident became verbally abusive and returned to bed, and shortly thereafter the resident, alone with the spouse, opened an unsecured second-floor window that lacked any limiting device and jumped out. Facility investigation and maintenance interviews showed that windows were not routinely inspected, that some windows had rubber stoppers limiting opening while others had none, and that the resident’s window and other windows accessible to residents could open fully without restriction, demonstrating a systemic failure to control environmental hazards and prevent accidents or self-harm.
A resident admitted from a hospital with anxiety and depression did not receive the hospital-recommended psychotropic medication regimen. Despite documentation that Fluoxetine had been increased to 60 mg daily during a recent psychiatric stay, the facility’s CRNP ordered only 20 mg daily at admission, later increased it to 40 mg, and did not implement the 60 mg dose for several weeks. Lorazepam 0.5 mg twice daily was continued and then discontinued without a documented gradual dose reduction, contrary to hospital psychiatric recommendations. Facility policies required timely chart review and appropriate psychotropic management, but the DON could not provide justification for the deviations from the prescribed regimen.
Facility leadership, including the NHA and DON, did not effectively manage operations to ensure resident safety, failing to maintain an environment free of accident hazards, to provide adequate supervision, and to consistently implement safety policies. Windows were not secured to reduce environmental hazards, and additional unsecured windows remained in the facility. For a resident with psychiatric conditions, including suicidal ideation and worsening depression, the facility did not ensure appropriate oversight of psychiatric treatment and medication management, including correct dosing, timing, and monitoring for effectiveness and side effects. These failures allowed the resident to exit through a second-floor window and land on a porch in the snow, resulting in an Immediate Jeopardy citation under F689.
Several residents did not consistently receive fresh ice water due to a broken ice machine and inconsistent staff practices, leading to residents making their own ice and storing water in freezers. Staff confirmed the lack of fresh water provision during some shifts, and unsanitary conditions were observed in ice chests, with stagnant water and debris present.
Surveyors identified unsanitary conditions in the dietary department and resident pantries, including dirty dishwashing areas, soiled food containers, stagnant water with insects in ice chests, and unlabeled or expired food items. Staff interviews revealed a lack of awareness about proper food storage, and multiple food items were found without required labeling or dating, with strong odors and visible contamination present.
Multiple residents experienced excessive call bell wait times and were not provided with timely updates or written resolutions regarding their grievances. Staff interviews and observations confirmed a lack of consistent grievance tracking and follow-up, with some residents left in soiled conditions due to unaddressed care needs.
Two residents were discharged—one to the hospital after an episode of altered mental status and another home at their request—without completion of required discharge summaries or recapitulation of their stays, as confirmed by staff interviews and clinical record review.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed environmental risks and insufficient oversight, resulting in unsafe conditions for residents.
A resident with depressive disorder and weakness was prescribed Sertraline 25mg, and the consulting pharmacist recommended a gradual dose reduction. The attending physician did not document a response or rationale for continuing the medication, despite facility policy requiring such documentation. The DON confirmed the physician was notified but had not responded.
A resident was administered an antibiotic for a suspected UTI without meeting established clinical criteria, and the prescribed medication was later found to be ineffective against the identified bacteria. Documentation did not support the initiation of antibiotic therapy, and the DON was unable to provide further justification.
The facility did not ensure its essential ice machine was maintained in safe working order, resulting in residents not consistently receiving fresh ice water for approximately two weeks. Multiple residents reported having to purchase their own ice due to the broken machine, and a nurse aide confirmed the lack of consistent fresh water during shifts.
A resident receiving enteral tube feeding was found to have dried nutritional formula residue on the tube feeding pole, fall mat, and bedside table in their room. Multiple observations confirmed the presence of these residues, and the Nursing Home Administrator acknowledged that these areas should be kept clean and free from tube feeding spills.
A resident with bilateral leg amputations and a need for two-person assist was transferred by a single staff member who failed to lock the wheelchair, resulting in a fall onto the amputation site. The facility's investigation was incomplete, lacking key documentation and accountability, and no new interventions were implemented after repeated falls.
A resident with bilateral leg amputations and a care plan requiring two-person transfers was moved by a single staff member using a sliding board, resulting in a fall. The facility did not conduct a thorough investigation, failed to identify the staff involved, and did not implement corrective actions or analyze the incident as required by policy.
A resident with MS and dysphagia experienced significant weight loss over several weeks, but staff did not notify the physician or responsible party, nor did they conduct a timely nutritional assessment or revise the care plan. The RD confirmed that the nutritional regimen was not reviewed or changed until weeks after the weight loss, and there was no documented interdisciplinary reassessment or intervention during the decline.
A resident with PTSD, metabolic encephalopathy, and major depressive disorder did not have an individualized care plan addressing PTSD triggers or interventions to minimize re-traumatization. The facility did not demonstrate provision of trauma-informed, culturally competent care in accordance with professional standards.
A resident admitted with weakness and requiring personal assistance did not receive the required SNF-ABN notice about the end of Medicare Part A coverage until the day coverage ended. The DON confirmed the notice was not provided in advance, as required.
The facility failed to serve meals at safe and appetizing temperatures, affecting six residents. A breakfast cart was left unattended, leading to food being served within the 'Danger Zone' temperature range. Residents reported that food was often cold and unpalatable. The Nursing Home Administrator and dietary manager confirmed the deficiency.
Embassy of Scranton was found non-compliant with regulations for maintaining a safe and homelike environment. The kitchen and laundry room entrance doors were broken, unable to be properly closed or locked, posing safety and security issues. Despite receiving a repair quote in August 2024, the facility had not acted on it. The Dietary Manager and Nursing Home Administrator confirmed the disrepair during interviews.
The facility did not meet the required nurse aide to resident ratios on five shifts, with insufficient staffing on both day and night shifts. No additional higher-level staff were available to compensate for these deficiencies, as confirmed by the Nursing Home Administrator.
The facility did not meet the required LPN to resident ratios on two occasions. On the night shifts, the facility had fewer LPNs than required for the resident census, with no additional higher-level staff available to compensate. The Nursing Home Administrator confirmed the staffing shortfall.
The facility did not meet the required nurse aide to resident ratios on two occasions. On one evening shift, there were 6 nurse aides for 76 residents, below the required 6.91. On a day shift, there were 7.30 nurse aides for 75 residents, below the required 7.50. No additional staff were available to compensate for these deficiencies.
The facility did not meet the required LPN to resident ratios on one night shift, having only 1.50 LPNs instead of the required 1.88 for a census of 75 residents. This deficiency was confirmed through staffing records and an interview with the Nursing Home Administrator. No additional higher-level staff were available to address the shortfall.
The facility failed to provide timely treatment and medication administration for two residents. One resident experienced an 18-hour delay in receiving STAT intravenous fluids due to a lack of prompt notification to the physician. Another resident received multiple medications, including Apixaban and Carbidopa-Levodopa, over 60 minutes past the scheduled time, potentially compromising their effectiveness. Interviews confirmed the facility's responsibility in these deficiencies.
The facility did not meet the required nurse aide to resident ratios on two shifts. On one day shift, 8.00 NAs were provided instead of the required 8.20 for 82 residents, and on the night shift, 4.25 NAs were provided instead of the required 5.47. No additional higher-level staff were available to compensate for this deficiency, as confirmed by the DON.
The facility failed to resolve resident complaints about untimely call bell responses and inconsistent snack distribution, as repeatedly expressed during Resident Council meetings. Despite having a grievance policy, the facility did not provide evidence of addressing these issues or informing residents of resolution efforts, as confirmed by interviews with the NHA and DON.
The facility did not have a comprehensive grievance policy, failing to support residents' rights to file grievances anonymously and lacking necessary procedural information. Observations showed missing details on grievance forms' locations, anonymous filing procedures, and contact information for the grievance official. The Nursing Home Administrator and DON acknowledged these deficiencies.
A facility failed to meet professional standards of quality by improperly administering IV medication via a PICC line for a resident with sepsis and bilateral lower extremity wounds. Multiple LPNs signed the MAR for administering the medication, despite not being permitted or trained to do so. The DON confirmed a lack of ongoing education and supervision for LPNs regarding IV administration, contributing to the deficiency.
The facility failed to provide effective pain management for four residents by not attempting non-pharmacological interventions before administering opioid medications. Residents with chronic pain and other conditions received medications outside of prescribed orders, and the facility did not document any alternative pain management strategies. The DON confirmed these deficiencies.
The facility failed to date opened medications on two medication carts, including Humalog and Novolog insulin, and Simbrinza and Latanoprost eye drops. An LPN confirmed that these medications should be dated when opened, and the DON confirmed the requirement to date medications to determine expiration or use-by dates.
The facility failed to provide meals that were palatable, attractive, and at safe temperatures for residents. Observations and interviews revealed that meals were often served cold and unappealing, with food temperatures falling within the danger zone. Additionally, there were issues with meal service timing and equipment, leading to resident dissatisfaction.
The facility failed to provide therapeutic diets as prescribed for two residents with diabetes. Despite orders for a Consistent Carbohydrate Diet, meals served were high in carbohydrates and did not meet dietary needs. The RD consultant and food service manager confirmed the regular menu was used instead of a specific diabetic diet.
The facility's QA/QAPI committee failed to meet the required quarterly attendance for one quarter, as the Medical Director did not attend the July meeting. The committee, including the NHA, DON, Medical Director, and department heads, was supposed to meet quarterly, but records showed a lack of consistent participation by the Medical Director.
The facility failed to maintain a comprehensive water management program to prevent Legionella, lacking specific testing protocols and acceptable control measures. The program did not include a log for chlorine concentration levels, essential for monitoring water safety. This deficiency was confirmed by the DON, indicating a lapse in infection prevention over a twelve-month period.
The facility did not comply with regulations requiring a designated Infection Preventionist (IP) to oversee the Infection Prevention and Control Program. The previous IP left in early August, and no replacement was designated. Although two new RNs were hired, neither completed the required IP training, leaving the facility without a credentialed IP.
The facility failed to respect residents' rights by discontinuing a resident-run snack cart without prior discussion or explanation. This decision affected four residents who used the cart to fund activities and socialize. The NHA and DON confirmed the removal was due to auditing concerns but did not communicate this to the residents or discuss alternatives.
A resident admitted with complex medical conditions, including abscesses and a PICC line, did not have a comprehensive baseline care plan developed within 48 hours. The facility's policy required documentation of vital signs and skin condition, but the care plan failed to address the resident's specific needs, as confirmed by the DON.
A resident with anoxic brain damage experienced a 14.7% weight loss over 180 days, but the facility failed to update the care plan since May. Despite interventions by a dietitian, the care plan did not reflect current needs or interventions. The NHA confirmed the oversight during a survey.
A resident with COPD reported right hand pain after an unwitnessed fall. Despite the complaint and redness noted by an LPN, no timely follow-up assessment was conducted until a survey highlighted the issue. The resident received Tylenol for mild pain, and an X-ray later showed no injury. The facility's administration confirmed the lapse in timely assessment.
A resident's medications were left unattended on an overbed table, creating a potential accident hazard. The LPN confirmed leaving the medications for the resident to take during breakfast, intending to observe from the hallway, which is against facility policy. The DON acknowledged the risk of accidental ingestion by others.
A facility failed to assess and address a resident's bowel incontinence adequately. Despite the resident's frequent incontinence and a significant change in their MDS assessment, the facility did not conduct a necessary three-day bowel activity assessment. The care plan lacked an individualized toileting plan, and the facility did not identify the resident's incontinence patterns, as confirmed by the DON.
The facility failed to provide timely pharmaceutical services for a resident with HIV, resulting in missed doses of prescribed medication due to pharmacy approval delays. Additionally, the facility did not maintain accurate narcotic administration records for another resident, leading to discrepancies in the accounting and administration of opioid pain medications. The DON confirmed these issues, although no evidence of theft was found.
A facility failed to develop and implement an effective quality assurance plan for a resident's bowel and bladder program. The resident, diagnosed with dementia and atrial fibrillation, experienced a decline in bowel function, being mostly incontinent over an 18-day period. The facility did not conduct a necessary bowel activity assessment to establish an individualized toileting plan, and the QAPI committee did not ensure the corrective action plan met regulatory guidelines.
The facility did not correctly post nurse staffing information as required. On observation, the posted nursing hours were outdated and incomplete, failing to meet daily posting requirements.
A resident with a history of aggressive behavior was involved in multiple incidents of physical abuse against two other residents. Despite existing interventions, the facility failed to prevent these altercations, resulting in harm to one resident. The facility's leadership confirmed the failure to protect residents from abuse.
A facility failed to implement its bed hold policy, affecting a resident's return after hospitalization. The resident, under Medicaid, was transferred for a psychiatric evaluation due to behavioral issues. The facility did not provide necessary documentation or collaborate with the hospital to ensure the resident's needs could be met, leading to a deficiency.
A resident experienced a decline in bowel function, becoming frequently incontinent after hospitalization. The facility failed to conduct a necessary bowel assessment to determine incontinence patterns and did not develop an individualized toileting plan. The DON confirmed the lack of thorough assessment to address the resident's toileting needs.
The facility failed to provide abuse prevention training to four agency staff members, including an LPN, an RN, and two nurse aides, who had been working at the facility for varying periods. None of these employees received training on the facility's abuse prohibition policy before assuming their duties, and the DON confirmed the absence of training records. This deficiency violates the facility's obligation to educate all staff on abuse prevention.
A resident with diabetes and dementia experienced pain and swelling in the upper extremity, leading to a Doppler study and findings of a hematoma. Despite ongoing symptoms and eventual hospital admission for compartment syndrome, the facility failed to timely notify the resident's representative of these changes.
Failure to Ensure Accessible Call Bell and Timely Staff Assistance
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s need to obtain staff assistance by ensuring access to a call bell. The facility’s own policy on call lights, last reviewed January 22, 2026, states that staff must ensure residents have access to the call light and that all staff who see or hear an activated call light are responsible for responding. Resident 1, who was admitted with bilateral lower extremity amputations (left leg above knee and right leg below knee) and was cognitively intact with a BIMS score of 15, required staff assistance for basic needs. During an observation, the resident’s room contained multiple bags of personal items and clothing, and the resident asked the surveyor to hand him the call bell. The call bell cord was found wrapped twice around the undercarriage of the bed frame and positioned behind the resident’s head, out of reach. When the surveyor attempted to provide the call bell, the cord was caught under bags located behind the bed, limiting its length and requiring the resident to bend his arm backward to reach it. The resident could not explain how the call bell came to be placed on the bottom part of the bed behind his head and out of reach. The Nursing Home Administrator acknowledged that the facility had previously discussed clutter in the resident’s room with the resident but that the matter had not been resolved. Resident Council minutes documented concerns from residents, including this resident, about call bell response times and difficulty receiving toileting assistance during the night shift, and a grievance related to call bell response was filed, with audits initiated but no documented resolution at the time of survey. These findings were reviewed with the Nursing Home Administrator and the Director of Nursing, and the deficiency was cited under 28 Pa. Code 201.29(a) Resident rights.
Failure to Secure Windows and Address Suicide Risk Leading to Resident Jumping from Second-Floor Window
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision and environmental safety for a resident with significant mental health needs. The resident was admitted with anxiety, major depressive disorder, a documented history of suicide attempts, and prior inpatient psychiatric hospitalizations. The admission MDS showed the resident was cognitively intact, and the PASRR identified a Level II status for serious mental illness. Clinical notes over the ensuing weeks documented persistent and worsening depression, anxiety, pacing, restlessness, and episodes of self-harm behavior such as repeatedly striking his head against the wall. Psychology and psychiatric notes described high anxiety, guarded behavior, feelings of being trapped, visual hallucinations, and major depressive disorder with psychotic disturbance. The resident and spouse, who shared the same room, were known to have had numerous attempted joint suicides with psychiatric hospitalizations. Despite this history and ongoing symptoms, the resident’s care plan for depression and anxiety, initiated shortly after admission, did not include the resident’s documented history of suicide attempts until after the incident. Staff notes repeatedly described escalating anxiety, restlessness, frequent pacing in the room and hallways, and staff difficulty redirecting the resident. Staff and psychiatric providers reported frequent falls likely related to increased restlessness and worsening mood disturbances. The resident expressed a desire to go home, reported feeling dizzy and trapped, and was described as extremely anxious, with his wife identified as a trigger for his distress. Although separation from his wife and psychiatric follow-up were discussed, there is no indication in the report that increased supervision or specific suicide-risk precautions were implemented before the event. On the day of the incident, the RN supervisor assessed the resident for vomiting and difficulty urinating, noted no abdominal distension, and then left the room after the resident became verbally abusive, laid himself on the floor, and then returned to bed independently. Approximately 15 minutes later, the resident’s wife alerted staff that he had jumped out of the second-floor window. The resident had been alone in the room with his wife at the time. Facility investigation and interviews revealed that the window from which the resident exited could be opened fully without restriction, and the screen had been knocked out. The Maintenance Director stated that windows were not routinely inspected and had last been checked a year prior. Observations showed that while some windows in the facility had rubber stoppers limiting opening to a few inches, other windows, including the one in this resident’s room, did not have such devices. The facility’s investigative documentation initially claimed the resident had removed safety screws, but interviews and observations established that no such screws were in place on that window prior to the incident, and that screws were first installed after the event. Additional observations found other windows in resident-accessible areas that could open widely without restriction, demonstrating a broader failure to ensure window security and environmental safety.
Removal Plan
- Resident 1 was transported from the facility to the hospital emergency room and admitted; a safety device was placed in all windows in the facility that would not allow them to open past 4 inches.
- An audit was completed of all windows in residents' rooms and common areas to ensure that window safety devices are in place.
- Residents with a history of suicide attempts will be reviewed to ensure they have psychiatric services in place, psych medications are reviewed, care plans are updated if needed, and a suicide risk assessment is completed; if they trigger for suicide risk, appropriate actions will be taken per the facility Suicide Threats policy.
- Newly admitted residents will have their antidepressant medications reviewed and compared to their hospital discharge instructions to ensure that they are ordered correctly.
- Maintenance will ensure that all windows have been addressed so that they cannot open past 4 inches.
- Maintenance or a designee will perform random window safety audits.
- The DON/designee will audit all new admissions during morning meetings to check for a diagnosis or history of suicide attempts and ensure clinical recommendations are implemented if positive for suicidal ideations.
- The DON/designee will compare hospital discharge summaries for antidepressant medication orders to ensure they match the physician's orders.
- Results of audits will be presented to risk meetings and to the QAPI/QUAPI committee for further review and recommendations.
- All facility staff will be educated on suicide prevention, suicide threats, the six steps to identifying and addressing behavioral symptoms, and window safety.
- Maintenance or the designee will continue to monitor safety window checks.
- The DON/designee will continue to audit all new admissions during morning meetings for suicide-attempt history/diagnosis and implementation of clinical recommendations.
- The DON/designee will continue to compare hospital discharge summaries for antidepressant medication orders to ensure they match the physician's orders.
Failure to Follow Hospital Psychiatric Medication Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to implement procedures to ensure accurate administration of prescribed medications for one sampled resident. Facility policies required a complete admission/readmission chart review within 24 hours to ensure follow-through of physician orders, and specified that psychotropic medications be used only when necessary and managed under the attending physician’s leadership in collaboration with the interdisciplinary team. Despite these policies, the facility did not follow the hospital discharge summary and psychiatric recommendations for the resident’s psychotropic medication regimen. The resident was admitted from an acute care hospital with diagnoses including cerebral palsy, anxiety, and depression, and was documented as cognitively intact with a BIMS score of 15. The hospital discharge summary and psychiatric recommendations indicated that, during a recent inpatient psychiatric stay, the resident’s Fluoxetine dose had been increased from 40 mg to 60 mg daily to address anxiety, panic, and depression, and that Trazodone 25 mg three times daily was to be given as needed for anxiety or sleep. The summary also stated that Lorazepam 0.5 mg twice daily was to be continued, with a recommendation that it be gradually decreased and eventually discontinued due to the resident’s age and documented memory deficits. Upon admission, the facility’s CRNP ordered Fluoxetine 20 mg once daily, later increasing it to 40 mg daily and changing the administration time, but the hospital-recommended 60 mg daily dose was not implemented until nearly two months after admission. Facility records showed that the resident did not receive the recommended 60 mg Fluoxetine dose for several weeks despite the documented need for this dose to manage psychiatric symptoms. Additionally, Lorazepam 0.5 mg twice daily was administered from admission until it was discontinued on a single date without any documented gradual dose reduction as recommended in the hospital discharge summary. During an interview, the DON was unable to provide documented justification for not implementing the recommended medication regimen to meet the resident’s psychiatric needs.
Administrative and Clinical Oversight Failures Leading to Resident Exit Through Second-Floor Window
Penalty
Summary
Facility administration, including the NHA and DON, failed to effectively manage operations to ensure resident safety and maintain residents’ highest practicable physical and mental well-being. The NHA’s job description required directing day-to-day facility functions in accordance with federal, state, and local regulations to ensure quality care, and the DON’s job description required organizing and directing nursing services and resident care. Despite these responsibilities, the facility did not ensure the environment was maintained as free of accident hazards as possible, did not ensure adequate supervision and environmental safety, and did not ensure consistent implementation of facility policies related to resident safety. The facility also failed to ensure that windows were secured to reduce environmental hazards, leaving additional windows unsecured and placing residents at risk for falls and self-harm. The facility further failed to ensure appropriate management and oversight of a resident’s psychiatric care and medication regimen. For one sampled resident with known psychiatric conditions, including suicidal ideation and worsening depression, the facility did not maintain an effective system to identify and mitigate risks. This included failure to ensure appropriate oversight of psychiatric treatment and medication management, such as ensuring that prescribed drugs were given in the correct dose, at the correct time, and monitored for effectiveness and side effects. As a result of these failures, the resident was able to exit the facility through a second-floor window and land on a porch into the snow. These deficiencies were cited as Immediate Jeopardy under F689 (Accidents, 42 CFR §483.25(d)) and related Pennsylvania regulations, based on the lack of effective administrative oversight, monitoring, and enforcement of policies by facility leadership.
Failure to Provide Consistent Access to Fresh Drinking Water
Penalty
Summary
The facility failed to consistently provide fresh drinking water to residents, as required by its own hydration policy, which states that fresh water should be supplied to residents each shift and upon request. During an environmental tour, surveyors observed that the ice chest on the third floor contained stagnant water with visible hair and dead insects, and residents were storing frozen cups of water in the freezer due to the broken ice machine. Staff confirmed that the ice machine had been out of service for two weeks and that residents did not receive fresh water during the shift because of the lack of ice. Additionally, the second-floor pantry's ice chest contained standing water with small flies floating in it. During a group interview, several alert and oriented residents reported that fresh ice water was not consistently provided, despite the facility purchasing bags of ice. Residents stated that staff did not always refill the unit's ice chest, and some residents resorted to making their own ice using plastic cups in the freezer. Residents expressed a preference for ice water, especially in hot weather, and reported that they were sometimes told by staff that no ice was available due to the broken machine. The Nursing Home Administrator confirmed the ice machine was not working and that ice was being purchased, but could not explain why residents' requests for fresh water were not consistently met.
Unsanitary Food Storage and Service Practices Identified
Penalty
Summary
The facility failed to maintain proper food storage and sanitary conditions in both the dietary department and resident pantry areas, as observed during facility tours. In the dishwashing area, there was visible brown and white splatter on ceiling tiles and light fixtures above the dish machine, and a dirty mop was left soaking in a bucket alongside a broom in the janitor's closet. In the kitchen, a bulk container of flour had an unsecured, soiled lid with debris inside. The second-floor resident pantry contained a utility cart with a dirty ice chest and breakfast trays, standing water with flies in the ice chest, and a sticky, black-coated floor. The third-floor pantry had visible dirt, dried food, paper, and plastic debris on the floor, stained baseboards and walls, a missing metal threshold with accumulated dirt, soiled cabinets, a dusty air vent, and a ceiling tile with a red substance. The ice chest in this pantry contained stagnant water with hair and dead insects, and the freezer and refrigerator held unlabeled, undated, and expired food items, as well as containers emitting a strong odor. Employee interviews confirmed a lack of awareness regarding food storage practices, such as residents filling cups with water and storing them in the freezer due to a broken ice machine. The pantries contained multiple food items without proper labeling, dating, or resident identification, including open containers of juice, potato salad, takeout food, cold cuts, cheese, and mayonnaise. The presence of dead insects, offensive odors, and visibly unclean surfaces throughout the dietary and pantry areas demonstrated a failure to follow facility policy and professional standards for food safety and sanitation.
Failure to Resolve and Communicate Grievance Outcomes Related to Call Bell Response
Penalty
Summary
The facility failed to make ongoing efforts to resolve grievances and provide timely follow-up with residents regarding the status of their complaints, specifically related to call bell response times. Facility policy requires the grievance official to track all grievances through to their conclusion and to issue written grievance decisions to residents. However, interviews with residents and staff, as well as a review of grievance forms, revealed that multiple residents experienced excessive call bell wait times, sometimes exceeding one hour, and did not receive confirmation or updates regarding the resolution of their grievances. In one instance, a resident reported waiting over an hour for a call bell response, and another grievance indicated residents were left in urine-soaked beds for extended periods due to staff being unaware of their incontinent status. Despite these grievances being filed, there was no evidence that written resolutions were provided to the residents involved. Staff interviews confirmed that there was no consistent process for meeting with residents to review grievance resolutions, and the grievance official did not have a system in place to track filed and resolved grievances as required by policy. Observations further supported these findings, with a call bell going unanswered for 47 minutes and a foul odor of feces present in a resident's room, indicating a lack of timely response. The facility was unable to provide documentation that resolutions to the call bell response time issues were communicated to residents, despite multiple grievances being filed about the ongoing problem.
Failure to Complete Discharge Summaries for Discharged Residents
Penalty
Summary
The facility failed to ensure that discharge summaries, including a recapitulation of the residents' stays, were completed for two discharged residents. For one resident with a history of metabolic encephalopathy and transient cerebral ischemic attacks, clinical records showed that after an episode of altered mental status, the resident was transferred to the emergency room and subsequently admitted to the hospital. The Director of Nursing later informed the Area Agency on Aging that the resident would not be returning to the facility, but there was no documented evidence that a discharge summary or a recapitulation of the resident's stay was completed. Similarly, another resident with diagnoses of spinal stenosis and anxiety disorder requested discharge home with their spouse. The Director of Nursing and physician were notified, and the resident was discharged home after gathering belongings. However, as with the previous case, there was no documented evidence that a discharge summary, including a recapitulation of the resident's stay, was completed. Staff interviews confirmed that no additional documentation was provided to demonstrate that the attending physician had completed the required discharge summaries for either resident.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment posed risks for accidents, and there was insufficient oversight to mitigate these hazards. The report specifically notes the lack of preventive measures and supervision necessary to maintain resident safety in the affected area.
Physician Failed to Document Response to Pharmacist's Medication Recommendation
Penalty
Summary
A deficiency was identified when the attending physician failed to act upon a pharmacist's recommendation regarding a resident's medication regimen. The facility's policy requires that the attending physician document in the medical record whether a pharmacist's recommendation has been reviewed and what action, if any, has been taken. If no change is made to the medication, the physician must provide a rationale for this decision in the resident's record. In this case, the consultant pharmacist recommended a gradual dose reduction for Sertraline 25mg, an antidepressant prescribed to a resident with depressive disorder and weakness. Despite the pharmacist's recommendation, there was no documentation from the attending physician in the resident's clinical record explaining the rationale for continuing Sertraline or for rejecting the dose reduction. The DON confirmed that the physician had been notified of the recommendation via fax but had not responded as of the survey date. This failure to document and address the pharmacist's recommendation was found during a review of clinical records and staff interviews.
Failure to Ensure Drug Regimen Free from Unnecessary Antibiotics
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary antibiotics. A review of the clinical record for a resident admitted with diagnoses including atrial fibrillation and generalized weakness showed that the resident complained of penile discomfort and slightly cloudy urine on one occasion. Two days later, the resident had no urinary complaints and urine was clear and yellow. Despite the absence of consistent clinical signs or symptoms that met McGeer or Loeb criteria for infection, a physician ordered ceftriaxone sodium to treat a urinary tract infection, and the resident received one dose before laboratory results were available. Further review of the laboratory report revealed that the urine culture grew Klebsiella pneumoniae, and the prescribed antibiotic, ceftriaxone, was resistant to this bacterium. The facility’s documentation did not show that the required criteria for initiating antibiotic therapy were met, nor was there justification for the antibiotic order. During an interview, the DON confirmed that no additional documentation or justification could be provided to support the clinical decision to start antibiotic therapy.
Failure to Maintain Safe Operation of Essential Ice Machine Equipment
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, specifically the ice machine used for mechanical preparation of ice. Six alert and oriented residents reported during a group interview that fresh ice water was not consistently provided on all shifts because the facility's only ice machine had been broken for approximately two weeks. These residents stated they had to purchase their own bags of ice and have them delivered to the facility. A nurse aide confirmed that the lack of a functioning ice machine resulted in residents not consistently receiving fresh water during their shift. The Nursing Home Administrator acknowledged that the ice machine had been inoperable for about two weeks and that the facility was awaiting an estimate for repairs, during which time staff were purchasing bags of ice to fill unit ice chests and provide ice water passes to residents.
Failure to Maintain Cleanliness Around Enteral Feeding Equipment
Penalty
Summary
Facility staff failed to maintain a clean and sanitary environment for a resident receiving enteral tube feeding. Observations conducted in the resident's room on multiple occasions revealed dried tube feeding residue present on the base of the tube feeding pole, the fall mat on the floor beside the bed, and the surface of the bedside table. These findings were confirmed during an interview with the Nursing Home Administrator, who acknowledged that the tube feeding pole and surrounding areas should be free from liquid tube feed. The resident involved was receiving enteral tube feeding at the time of the observations, and the deficiency was specifically related to the lack of adequate housekeeping services necessary to ensure cleanliness and sanitation of both the resident care equipment and the immediate environment.
Failure to Protect Resident from Neglect During Transfer
Penalty
Summary
A resident with bilateral below-the-knee amputations, generalized weakness, and a need for personal assistance was admitted to the facility and assessed as cognitively intact. The resident's care plan and Kardex specified that all transfers required the assistance of two staff members and the use of a sliding board. Despite this, the resident experienced multiple falls, including an incident where a nurse aide, whose identity was not determined, transferred the resident alone using a sliding board and failed to lock the wheelchair, resulting in the resident falling onto the site of his right leg amputation. There was no evidence that new interventions were implemented after previous falls to prevent recurrence. The facility's internal investigation into the March 15 incident was incomplete, lacking witness statements, staff interviews, and a full written account of the event. The facility was unable to identify or hold accountable the staff member responsible for the unauthorized solo transfer. Additionally, the resident experienced three more falls after this incident, and the facility could not provide further documentation or details related to the March 15 event. These actions and inactions resulted in a failure to protect the resident from neglect as defined by facility policy.
Failure to Investigate and Address Improper Transfer Leading to Resident Fall
Penalty
Summary
The facility failed to promptly and thoroughly investigate an incident of potential neglect involving a resident with bilateral below-the-knee amputations and a documented need for two-person assistance during transfers. Despite care plan instructions specifying the use of a sliding board and two staff members for all transfers, the resident was transferred by a single staff member, and the wheelchair was not locked, resulting in a fall onto the resident's right amputated leg. Previous falls had occurred without new interventions being implemented, and the resident was noted to be cognitively intact at the time of the incident. Following the fall, the facility did not conduct a comprehensive investigation as required by its abuse, neglect, and exploitation policy. There was no documentation of witness statements, staff or resident interviews, or identification of the staff member involved in the transfer. The Director of Nursing confirmed that no investigation consistent with facility policy was completed, and no analysis or corrective actions were documented to address the incident or prevent recurrence. The lack of timely and complete investigation and failure to implement corrective measures constituted a deficiency in responding to alleged violations.
Failure to Provide Timely Nutritional Support and Assessment
Penalty
Summary
A resident with multiple sclerosis and dysphagia was admitted with a care plan identifying them as at risk for nutritional and hydration imbalances due to a history of significant weight loss. Physician orders specified a pureed diet with thickened liquids, fortified foods, and a frozen nutritional treat twice daily, with intake percentages to be recorded. Facility policy required significant weight changes to be reported to the physician and responsible party, and for the interdisciplinary team to assess and document interventions. The resident experienced a significant weight loss over several weeks, as documented in weight records and meal intake logs. Despite the documented weight loss meeting the facility's definition of significant loss, there was no evidence that the physician or responsible party were notified, nor was there documentation of a timely nutritional assessment, new interventions, or care plan revisions in response to the decline. The registered dietitian confirmed that she had not evaluated the resident following the weight loss and that the nutritional regimen was not reviewed or revised until several weeks after the initial decline. There was no documented evidence of timely interdisciplinary reassessment or intervention to address the resident's nutritional status during the period of weight loss.
Failure to Provide Trauma-Informed, Person-Centered Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident, who was admitted with diagnoses including metabolic encephalopathy, major depressive disorder, and PTSD, did not have their PTSD triggers identified in the care plan. Additionally, there were no resident-specific interventions documented to minimize triggers or prevent re-traumatization related to the PTSD diagnosis. A review of the resident's clinical record and staff interviews confirmed that the care plan in effect at the time of review did not address the resident's PTSD needs according to professional standards of practice. The Nursing Home Administrator was unable to demonstrate that culturally competent, trauma-informed care was provided, or that the resident's experiences and preferences were considered to eliminate or mitigate potential triggers for re-traumatization.
Failure to Timely Notify Resident of Medicare Coverage Termination
Penalty
Summary
The facility failed to provide timely notification to a resident regarding the end of Medicare Part A coverage for skilled nursing services. Clinical record review showed that the resident was admitted with diagnoses including weakness and a need for personal assistance. Documentation indicated that Medicare Part A coverage ended on February 18, 2025, but the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) was not issued until the same day coverage ended. An interview with the director of nursing confirmed that the SNF-ABN was not provided prior to the termination of coverage, as required. This deficiency was identified through review of records and staff interviews.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve meals that were palatable and maintained at a safe and appetizing temperature for six of ten residents sampled. Observations revealed that a breakfast cart was left unattended on the second floor for an extended period, resulting in food being served at temperatures within the 'Danger Zone,' which is defined as above 41°F and below 135°F. A test tray evaluation showed that the waffles, ham, and hot cereal were served below the required 135°F minimum, making them unpalatable and potentially unsafe. Interviews with six cognitively intact residents confirmed that the food was often served cold and not palatable. Residents reported that delays in tray passing contributed to the issue, with carts frequently left in hallways. The Nursing Home Administrator and the dietary manager acknowledged that the test tray results did not meet regulatory or facility standards, confirming the deficiency in maintaining appropriate food temperatures.
Plan Of Correction
The facility cannot retroactively r the cited deficiency. Meals that are being served are palatable, attractive, and at a safe and appetizing temperature. The Dietary Manager/Designee will re-educate the dietary staff on the facility's Test Tray and Point of Service Food Temperatures policy. The ADON/designee will re-educate nursing staff on timely pass of resident meal trays to help to ensure safe temperature of meals. The Dietary Manager/designee will audit all three meals weekly x 4, then monthly x 3 to ensure acceptable temperatures are served and that they are palatable and attractive on the tray line. Any variations will be corrected immediately and/or offered as training to staff to ensure compliance. The Dietary Manager/designee will audit all three meals weekly x 4, then monthly x 3 on the units to ensure that trays are being served timely and what is being served is palatable, attractive, and that the temperatures are in an acceptable range. Any variations will be corrected immediately and/or offered as training to staff to ensure compliance. The results of these audits will be discussed at the facility QAPI meeting monthly for further review and recommendations.
Facility Fails to Maintain Safe and Secure Environment
Penalty
Summary
Embassy of Scranton was found to be non-compliant with the requirements for maintaining a safe, clean, and homelike environment as per 42 CFR Part 483 Subpart B and the 28 PA Code. During a state revisit and abbreviated complaint survey, it was observed that the facility failed to maintain the kitchen and laundry room entrance doors in proper working condition. The kitchen's dishwasher entrance doors were broken, unable to be properly closed or locked, and swung off their hinges, posing a challenge for staff transporting tray carts. The Dietary Manager, who was hired in December 2024, confirmed the doors were already in disrepair at that time but could not specify the duration of the issue. Additionally, the laundry room entrance door was also found to be broken, unable to fully close or be secured with a lock. A review of documents revealed that a repair quote for the replacement and installation of both doors was received on August 21, 2024, but there was no evidence that the facility acted on this quote or made any repairs. The Nursing Home Administrator confirmed the broken condition of both doors during an interview, indicating a failure to address the maintenance issues in a timely manner.
Plan Of Correction
The replacement doors for the Kitchen and the Laundry Room entrances have been ordered and will take 6-8 weeks to be manufactured. Once they are received, they will be replaced. The Maintenance Director/designee will conduct an initial audit of existing doors in the facility to ensure that they are in good working order. The Administrator/designee will ensure identified concerns are rectified in a timely manner. The Maintenance Director/designee will educate staff to notify the maintenance department of any safety concerns or repair needs. Any identified needs will be entered into the preventive maintenance program (TELS) by issuing a work order for repair. The Maintenance department will repair the identified concern and/or involve the Administrator to gain approval for purchase of a timely replacement if necessary. The Maintenance Director/designee will audit existing doors in the facility on a weekly basis as part of the preventative maintenance program to ensure that they are in good repair. The Administrator/designee will ensure identified concerns are rectified in a timely manner. The results of these audits will be discussed at the facility QAPI meeting monthly for further review and recommendations.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on five out of twenty-one reviewed shifts. Specifically, on March 27, 2025, the day shift had 8.2 nurse aides instead of the required 8.5 for a census of 85 residents. On March 28, 2025, the night shift had 5.5 nurse aides instead of the required 5.6 for a census of 84 residents. On March 30, 2025, the night shift had 4.75 nurse aides instead of the required 5.67 for a census of 85 residents. On March 31, 2025, the day shift had 7.7 nurse aides instead of the required 8.6 for a census of 86 residents, and the evening shift had 7.36 nurse aides instead of the required 7.82 for a census of 86 residents. No additional higher-level staff were available to compensate for these deficiencies. The Nursing Home Administrator confirmed the facility's failure to meet the required staffing ratios during an interview on April 1, 2025.
Plan Of Correction
The facility will provide a staffing ratio based on July 1, 2024, regulations of one nurse aide per 10 residents on the day shift, one nurse aide per 11 residents during the evening shift, and one nurse aide per 15 residents during the night shift. All facility residents have the potential to be affected by this practice. The facility has implemented staff incentives for current and new staff as well as reinforcing the facility call off policy to deter unnecessary call offs. We are also hiring PRN CNAs to assist in covering shifts with call offs or openings in the schedule. We will be using Indeed for advertisements of open positions, participating in career fairs as they are available, and giving sign on bonuses and/or referral bonuses to new hires and our staff. NHA or designee will educate staff on incentives and call off policy. Administrator/designee during weekday daily review of nursing schedules will audit to ensure Certified Nurse Aide ratios are maintained. The results of these audits will be discussed at the facility QAPI meeting monthly for further review and recommendations.
Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on two occasions, as evidenced by a review of nurse staffing records and staff interviews. On March 26, 2025, the night shift had only 2.0 LPNs instead of the required 2.10 for a census of 84 residents. Similarly, on March 29, 2025, the night shift had 2.0 LPNs instead of the required 2.13 for a census of 85 residents. No additional higher-level staff were available to compensate for this deficiency. The Nursing Home Administrator confirmed the failure to meet the required staffing ratios during an interview on April 1, 2025.
Plan Of Correction
The facility will provide a staffing ratio of one Licensed Practical Nurse per 25 residents on day shift, one Licensed Practical Nurse to 30 residents on evening shift, and one Licensed Practical Nurse per 40 residents on overnight shift. All facility residents have the potential to be affected by this practice. The facility has implemented staff incentives for current and new staff as well as reinforcing the facility call off policy to deter unnecessary call offs. We are also hiring additional PRN LPNs to help cover shifts when there are call offs or openings in the schedule. We will be using Indeed for advertisements of open positions, participating in career fairs as they are available, and giving sign on bonuses and/or referral bonuses to new hires and our staff. NHA or designee will educate staff on incentives and call off policy. Administrator/designee during weekday daily review of nursing schedules will audit to ensure License Practical Nurse ratios are maintained. The results of these audits will be discussed at the facility QAPI meeting monthly for further review and recommendations.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on two occasions, as evidenced by a review of staffing records and staff interviews. On January 3, 2025, during the evening shift, the facility had 6 nurse aides for a census of 76 residents, falling short of the required 6.91 nurse aides. Similarly, on January 5, 2025, during the day shift, the facility had 7.30 nurse aides for a census of 75 residents, which was below the required 7.50 nurse aides. On both dates, there were no additional higher-level staff available to compensate for the staffing deficiency, resulting in non-compliance with the regulation effective July 1, 2024, which mandates specific nurse aide to resident ratios for different shifts.
Plan Of Correction
The facility will provide staffing ratio based on July 1, 2024, regulation of one nurse aide per 10 residents on the day shift, one nurse aide per 11 residents during the evening shift, and one nurse aide per 15 residents during the night shift. The facility is focusing on retaining current nursing staff. We have only 1 CNA opening at this time, so call offs have been the ongoing issue. The facility has implemented staff incentives for current and new staff as well as reinforcing the facility call off policy to deter unnecessary call offs. NHA or designee will educate staff on incentives and call off policy. Administrator/designee during weekday daily review of nursing schedules will audit to ensure Certified Nurse Aide ratios are maintained. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.
LPN Staffing Deficiency on Night Shift
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on one shift out of 21 reviewed. Specifically, on January 4, 2025, during the night shift, the facility had only 1.50 LPNs available, whereas the required staffing level was 1.88 LPNs for a census of 75 residents. This deficiency was confirmed through a review of the facility's weekly staffing records and an interview with the Nursing Home Administrator on January 9, 2025. No additional higher-level staff were available to compensate for this staffing shortfall.
Plan Of Correction
The facility will provide staffing ratio of one Licensed Practical Nurse per 25 residents on day shift, one Licensed Practical Nurse to 30 residents on evening shift, and one Licensed Practical Nurse per 40 residents on overnight shift. All facility residents have the potential to be affected by this practice. The facility is focusing on retaining current nursing staff. We have zero LPN openings at this time, so call offs have been the ongoing issue. The facility has implemented staff incentives for current and new staff as well as reinforcing the facility call off policy to deter unnecessary call offs. NHA or designee will educate staff on incentives and call off policy. Administrator/designee during weekday daily review of nursing schedules will audit to ensure License Practical Nurse ratios are maintained. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.
Deficiencies in Timely Treatment and Medication Administration
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. For Resident 6, there was a failure to promptly notify the physician regarding changes in treatment. Resident 6, who was admitted with diagnoses including sepsis and acute kidney failure, experienced a delay in the administration of intravenous fluids. Despite a physician's order for STAT blood work and intravenous fluids, the facility did not notify the physician or CRNP of the delay in initiating the treatment, which was not administered until 18 hours after the order was given. Additionally, the facility did not adhere to the timely administration of medications for Resident 7, who was admitted with chronic kidney disease. Resident 7's medications, including Apixaban, Lidocan patches, Bromfenac Sodium Ophthalmic Solution, and Carbidopa-Levodopa, were administered over 60 minutes past the scheduled time on multiple occasions. This delay in medication administration resulted in doses being given closer together than prescribed, potentially compromising the effectiveness of the medications. Interviews with the CRNP and the Director of Nursing confirmed the facility's failure to notify the physician of changes in Resident 6's condition and the delay in treatment. Similarly, the Director of Nursing acknowledged the late administration of medications for Resident 7, confirming the facility's responsibility to ensure medications are administered in accordance with physician's orders.
Plan Of Correction
The facility is not able to retroactively correct the citations for residents 6 and 7. Medication administration times will be reviewed for current residents and adjusted to ensure medications can be delivered on time. If medications are not delivered on time, the physician or physician extender will be notified. Residents with new IV medications/treatments will be reviewed to ensure that the delivery of the ordered medication/treatment and the insertion of the intravenous line are in place to deliver the IV medication/treatment timely. If this cannot occur, the physician or physician extender will be notified. The ADON/designee will re-educate licensed nursing staff on the facility's Medication Administration policy and the Notification of Changes policy. The DON/designee will audit medication administration times weekly to ensure timely delivery of medication per physician's order, and if not delivered timely that the physician was notified. The DON/designee will also review new orders for IV medications/treatments to ensure they are initiated per the physician order, or if this cannot be delivered timely that the physician or physician extender is notified. These audits will be discussed at the monthly QAPI meeting for further review and recommendations.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on two shifts out of 21 reviewed. On December 8, 2024, during the day shift, the facility provided 8.00 nurse aides instead of the required 8.20 for a census of 82 residents, failing to meet the 1:10 ratio. Additionally, on the same date during the night shift, the facility provided 4.25 nurse aides instead of the required 5.47, failing to meet the 1:15 ratio. No additional higher-level staff were available to compensate for this deficiency. The Director of Nursing confirmed the failure to meet the required ratios during an interview on December 13, 2024.
Plan Of Correction
The facility will provide staffing ratio based on July 1, 2024, regulation of one nurse aide per 10 residents on the day shift, one nurse aide per 11 residents during the evening shift, and one nurse aide per 15 residents during the night shift. All facility residents could be affected by this practice. The administrator, the nurse management team, and the nursing scheduler will be re-educated concerning CNA minimal staffing ratios and the appropriate response to unplanned variations in ratios. Administrator/designee during weekday daily review of nursing schedules will audit to ensure Certified Nurse Aide ratios are maintained. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to adequately address and resolve resident complaints and grievances as expressed during Resident Council meetings and verbal grievances. The facility's Grievance Policy, last revised in June 2024, outlines a system to ensure prompt resolution of grievances. However, reviews of the Residents' Council meeting minutes from June, July, and August 2024 revealed ongoing complaints about untimely call bell responses and inconsistent distribution of evening snacks. These issues were repeatedly raised by residents, indicating a lack of effective action by the facility to resolve these concerns. During a group meeting on September 5, 2024, with five residents, it was reported that the facility had not addressed their complaints regarding snack distribution and call bell response times. The facility was unable to provide documented evidence that they had determined whether the residents felt their grievances were resolved. Interviews with the Nursing Home Administrator and Director of Nursing on September 6, 2024, confirmed the absence of documentation showing that resident grievances were addressed in a timely manner and that residents were informed of the facility's efforts to resolve their complaints.
Deficiency in Grievance Policy and Resident Information
Penalty
Summary
The facility failed to develop a comprehensive grievance policy and ensure that necessary information for filing a grievance was available to residents or their representatives. The facility's policy, last revised in June 2024, did not include procedures to support the resident's right to file a grievance anonymously and did not identify the current grievance official. Observations on the nursing units revealed that the posted grievance policy lacked procedural information, such as the location of grievance forms, how to file anonymously, contact information for the grievance official, and the right to obtain a written decision with a reasonable time frame for review. During an interview, the Nursing Home Administrator and Director of Nursing acknowledged the failure to provide residents with the necessary details of the grievance process, including the procedure for filing an anonymous grievance and the locations of boxes for anonymous grievances.
Deficiency in IV Medication Administration via PICC Line
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality as per the Pennsylvania Code Title 49, Professional and Vocational Standards. Specifically, the deficiency involved the improper administration of intravenous medication via a central venous catheter for a resident. The resident, identified as having bilateral lower extremity wounds and sepsis, was admitted with a PICC line. Physician orders required the administration of Cefepime HCL intravenously every 8 hours, but the facility did not have a policy or procedure in place for LPNs to administer or withdraw fluids via a PICC line. The clinical record review revealed that multiple LPNs signed the Medication Administration Record (MAR) as administering the IV antibiotic through the PICC line, despite the facility's Director of Nursing stating that LPNs were not permitted to perform such tasks. An interview with an LPN confirmed that he had not been educated on administering medications through a PICC line and would call an RN to perform the task, yet still signed the MAR as if he had administered the medication himself. This indicates a lack of proper training and supervision for LPNs regarding IV administration and PICC line usage. Furthermore, the Director of Nursing admitted that only a few LPNs had received education on administering medications through PICC lines in the past several years, and there was no evidence of ongoing or yearly education for LPNs on this matter. The facility failed to provide evidence of any current education or supervision regarding IV administration for LPNs, which is a requirement under the Pennsylvania Code. This lack of training and oversight contributed to the deficiency in meeting professional standards of quality in nursing services.
Failure in Pain Management Protocols
Penalty
Summary
The facility failed to provide timely and effective pain management for four residents, as identified in a survey. The facility's policy on pain management requires collaboration with healthcare professionals and the resident to develop and implement interventions to manage pain. However, the facility did not adhere to this policy, as evidenced by the lack of documented attempts at non-pharmacological interventions before administering opioid medications to the residents. Resident 17, who has chronic pain, panic disorder, and major depressive disorder, was administered Tramadol 38 times in both July and August without any documented evidence of non-pharmacological interventions being attempted first. Similarly, Resident 3, with chronic pressure ulcers and peripheral vascular disease, received Hydrocodone-Acetaminophen outside of the prescriber's orders on multiple occasions, with no attempts at non-pharmacological interventions documented. Resident 41, suffering from chronic pressure ulcers and paraplegia, was also given Oxycodone outside of the prescribed parameters, again without documented non-pharmacological interventions. Resident 18, with a history of diabetes, hypertension, and falls with fractures, had their Oxycodone prescription adjusted multiple times in August, yet the medication was administered 35 times without any documented non-pharmacological interventions. The Director of Nursing confirmed the facility's failure to provide non-pharmacological interventions and to follow physician's orders for pain medication administration, leading to the identified deficiencies.
Failure to Date Opened Medications on Medication Carts
Penalty
Summary
The facility failed to adhere to medication expiration and use-by dates on two of its medication carts located on the Second Floor, specifically the Long Hall and Short Hall carts. During an observation on September 5, 2024, a multidose vial of Humalog insulin was found opened but not dated on the Long Hall cart, and another vial was found unopened and undated but labeled for refrigeration. Employee 1, an LPN, confirmed that multidose vials of Humalog insulin should be discarded 28 days after being opened and should be dated when opened. Additionally, unopened multidose insulin should remain refrigerated until needed. Further observation of the Short Hall medication cart revealed an opened and undated Novolog insulin pen, as well as opened and undated bottles of Simbrinza and Latanoprost eye drops. According to manufacturer instructions, Simbrinza eye drops should not be used more than 125 days after opening, and Latanoprost eye drops should be discarded 6 weeks after being opened. Employee 1 confirmed that these medications should have been dated when opened. The Director of Nursing also confirmed that the multidose vials of insulin and eye drops should have been dated to determine their expiration or use-by dates.
Deficiency in Meal Service Quality and Temperature
Penalty
Summary
The facility failed to serve meals that were palatable, attractive, and at safe and appetizing temperatures for two of the 18 residents sampled, as well as for four residents during a group interview. Observations and interviews revealed that meals were often served cold and unappealing, with food temperatures falling within the danger zone, which is between 41 degrees Fahrenheit and 135 degrees Fahrenheit. For instance, a test tray performed on a resident's lunch tray showed that the popcorn chicken was at 98 degrees Fahrenheit, potato wedges at 108.5 degrees Fahrenheit, and other items like coleslaw and gelatin were also not at appropriate temperatures. Additionally, the food was described as sparse, bland, and visually unappealing. The report also highlighted issues with meal service timing and equipment. During a lunch meal observation, there was a delay in initiating the lunch tray service, and staff ran out of mugs for hot beverages and clear plastic cups for cold beverages, leading to the use of disposable cups. Interviews with residents confirmed dissatisfaction with the meal service, citing cold and bland food, insufficient portions, and the need to request additional food. The facility's policy on Nutrition Services was reviewed, which stated that meals should be timely, visually appealing, and served at safe temperatures, but these standards were not met according to the findings.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to provide therapeutic diets as prescribed by the attending physician for two residents. Resident 44, who has type two diabetes and a diabetic foot ulcer, was ordered a Consistent Carbohydrate Diet. However, during an interview, the resident reported that the facility did not offer a diabetic diet and that most meals served were high in carbohydrates. Observations during meal rounds confirmed that the meals provided did not align with the prescribed diet, as they consisted mainly of starchy, high-carbohydrate foods. The facility's Registered Dietitian (RD) consultant and food service manager confirmed that the regular menu was used for consistent carbohydrate diets and that the facility did not offer a specific consistent carbohydrate or diabetic diet. The RD consultant was unable to provide a nutrient analysis for the diet, and the therapeutic spreadsheet indicated that the planned meals did not accommodate the dietary needs of diabetic residents. This lack of adherence to prescribed therapeutic diets was a violation of the facility's policy and state regulations.
QA/QAPI Committee Attendance Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QA/QAPI) committee met the required quarterly attendance for one quarter out of the three reviewed. The committee, which includes the Nursing Home Administrator (NHA), Director of Nursing (DON), Medical Director, and department heads, was reported to meet at least quarterly. However, upon reviewing the facility's QA/QAPI meeting attendance records, it was found that the committee met in April 2024 and July 2024, but there was no documented evidence of the Medical Director's attendance at the July 2024 meeting. This was confirmed during an interview with the NHA, who acknowledged the lack of consistent participation by the Medical Director in the quarterly meetings.
Failure in Legionella Water Management Program
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program specifically related to water management for Legionella. A review of the facility's documentation and interviews with staff revealed that the facility did not have specific testing protocols or acceptable ranges for control measures in place. Additionally, the facility's water management information lacked a description of the water system using a flow diagram, which is essential for identifying potential areas where Legionella could grow and spread. The facility's Water Management Program Control Measures did not include a log for Point of Use Disinfectant, which is necessary to measure and record chlorine concentration levels in both hot and cold water. The absence of this log meant that the facility was not monitoring whether chlorine concentrations were within the recommended control limits of 0.5 ppm to 4.0 ppm. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the facility's failure to implement adequate control measures for Legionella over a twelve-month period.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to comply with the Centers for Medicare and Medicaid Services regulation S483.80(b)(3), which requires the designation of an Infection Preventionist (IP) responsible for the Infection Prevention and Control Program. The regulation mandates that the IP must work at least part-time onsite at the facility and cannot be an off-site consultant. During interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON), it was revealed that the previous IP vacated the position in early August 2024, and no replacement had been designated. Although the facility hired two new Registered Nurses, neither had completed the necessary IP training. The DON confirmed that the facility lacked credentialed infection preventionists, resulting in non-compliance with the regulation.
Discontinuation of Resident-Run Snack Cart Without Consultation
Penalty
Summary
The facility failed to honor the residents' rights to a dignified existence and self-determination by abruptly discontinuing a resident-run snack cart without prior discussion or explanation. This decision affected four cognitively intact residents who were part of a group meeting. The residents expressed their dissatisfaction, stating that the snack cart was not only a source of funds for additional activities like pizza parties and bingo prizes but also a means of socializing with other residents, particularly those who were less mobile and did not leave their rooms often. The review of resident council meeting minutes from the past three months showed no indication or explanation for the discontinuation of the snack cart. During an interview, the Nursing Home Administrator and Director of Nursing confirmed that the snack cart was removed due to concerns about auditing the money. However, they admitted that they did not communicate this decision to the residents or discuss any potential alternatives, thereby failing to accommodate the residents' preferences and rights.
Failure to Develop Comprehensive Baseline Care Plan for Resident
Penalty
Summary
The facility failed to adequately address the immediate needs of a resident within the required 48-hour timeframe following admission. The resident, who was admitted with complex medical conditions including a cutaneous abscess, colostomy, Fournier gangrene, diabetes, and a scrotal abscess, did not have a comprehensive baseline care plan developed. The facility's policy required the nurse to assess and document the resident's vital signs, skin condition, and any acute issues, and to notify relevant medical staff of the admission and any immediate concerns. However, the baseline care plan for this resident did not identify the multiple skin impairments or the presence of a PICC line for administering IV antibiotics, nor did it include any goals, objectives, or interventions to address the resident's specific medical needs. An interview with the Director of Nursing confirmed the oversight in the resident's baseline care plan. The nursing progress notes indicated that the resident was alert and oriented, with specific medical needs such as a scrotal wound and a sacral wound requiring irrigation, yet these were not reflected in the care plan. This deficiency highlights a failure to meet the minimum standards of care as outlined in the facility's admission procedure policy, which is crucial for ensuring the resident's immediate needs are met upon admission.
Failure to Update Care Plan for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to review and revise the care plan of a resident who experienced significant weight loss. Resident 66, who was admitted with diagnoses including anoxic brain damage, had a 14.7% weight loss over 180 days, weighing 81 pounds as of August 20, 2024. Despite a nutritional note from August 22, 2024, indicating that the dietitian had implemented interventions to address the weight loss, the resident's care plan had not been updated since May 30, 2024. The care plan still listed the resident as nutritionally at risk due to various health conditions but did not reflect the current interventions or the need to monitor the resident's weight. During the survey conducted from September 4-6, 2024, it was found that there were no updates or revisions to the care plan regarding the resident's nutritional risk and weight status. The Nursing Home Administrator confirmed on September 5, 2024, that the facility had not reviewed or revised the care plan to accurately reflect the resident's current status and needs. This oversight was a violation of the relevant Pennsylvania Code sections regarding resident care plans and nursing services.
Failure to Timely Assess Resident's Pain After Fall
Penalty
Summary
The facility failed to provide timely assessment and follow-up care for a resident who reported pain in their right hand following an unwitnessed fall. The resident, who had been admitted with a diagnosis of chronic obstructive pulmonary disease (COPD), informed an LPN of the pain, and the nurse noted the redness and intended to inform the nursing supervisor. However, there was no documented evidence of any further assessment or follow-up care until the issue was brought to the facility's attention during a survey. Between the time of the resident's complaint and the survey, the resident was administered Tylenol for mild pain on three occasions, but no further assessment was conducted. An X-ray was eventually performed, revealing no injury. The Nursing Home Administrator and the Director of Nursing confirmed the failure to timely assess the resident's condition after the fall and subsequent complaint of pain.
Medication Administration Deficiency
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards during medication administration on the second floor, affecting one of the two residents observed. During an observation on September 6, 2024, medications were found on an overbed table in a resident's room. Two white tablets were observed in a clear plastic medication cup on the table of Resident 32, who was scheduled to receive Amlodipine Besylate for hypertension and Meloxicam for spinal stenosis at 9:00 a.m. The resident stated that the nurse left the medications on the table for him to take during breakfast, but he did not want to take them. An interview with the LPN responsible for the medication administration confirmed that she left the medications at the resident's bedside and intended to observe the resident from the hallway to ensure consumption. However, she acknowledged that medications should not be left at the bedside and that the nurse is required to observe each resident taking their medications. The Director of Nursing confirmed that leaving medications at the bedside created a potential accident hazard, as they could be accidentally ingested by another resident.
Failure to Assess and Address Bowel Incontinence
Penalty
Summary
The facility failed to thoroughly assess and evaluate the bowel function of a resident, identified as Resident A2, who was frequently incontinent of bowel. Despite the facility's policy requiring assessment of continence status within two weeks of admission and upon significant change, the resident's continence status was not adequately evaluated. The resident was admitted with diagnoses including dementia and atrial fibrillation, and a significant change in their Minimum Data Set (MDS) assessment indicated frequent bowel incontinence. However, the facility did not conduct a three-day bowel activity assessment to determine the resident's incontinence pattern. The resident's care plan noted bowel incontinence but lacked an individualized toileting plan based on the resident's habits or patterns. The facility's failure to identify these patterns and develop a tailored plan to address the resident's toileting needs was confirmed by the Director of Nursing. This oversight resulted in the facility not implementing appropriate interventions to restore or improve the resident's bowel function, as required by their policy.
Pharmaceutical Service Deficiencies
Penalty
Summary
The facility failed to provide timely pharmaceutical services for Resident 180, who was admitted with diagnoses including HIV, Type 2 diabetes, and Alzheimer's disease. The resident had physician orders for several medications, including Symtuza for HIV, which was not available for administration on multiple occasions. Observations revealed that the medication was not administered on September 5, 2024, and was not available on September 6, 2024. The Director of Nursing confirmed that the medication had not been available since the resident's admission on September 3, 2024, due to a delay in pharmacy approval related to the resident's payer source. Additionally, there was no documentation that the resident's representative or physician was informed about the unavailability of the medication. For Resident 18, the facility failed to maintain accurate narcotic administration records. The resident, who had a history of type 2 diabetes, hypertension, and falls with fractures, expressed concerns about the administration of her prn narcotic pain medications, suspecting theft. A review of the controlled substance records showed discrepancies between the signed-out doses and the Medication Administration Record, indicating inconsistencies in the accounting and administration of the opioid pain medications. The Director of Nursing confirmed these inconsistencies, although there was no evidence to support the resident's claim of theft.
Failure to Implement Effective Bowel and Bladder Program
Penalty
Summary
The facility failed to develop and implement an effective quality assurance plan to address ongoing quality deficiencies related to the assessment and implementation of bowel and bladder programs for a resident. During a survey ending on August 9, 2024, it was identified that the facility did not adequately assess or implement a program to maintain or restore the bowel function of a resident diagnosed with dementia and atrial fibrillation. The resident's clinical records indicated a decline in bowel function, with the resident being incontinent of bowel on most days over an 18-day period. Despite the resident's care plan noting the need to assist with toileting and establish a toileting plan, the facility did not initiate a three-day bowel activity assessment to determine the resident's incontinence pattern. This lack of assessment prevented the development of an individualized toileting plan to potentially restore bowel function. The facility's Quality Assurance and Performance Improvement (QAPI) committee also failed to recognize that the corrective action plan was not developed or implemented in accordance with regulatory guidelines, which would ensure sustained solutions to the identified problem.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to correctly post nurse staffing information as required by regulations. During an observation on September 4, 2024, at approximately 8:15 AM, it was noted that the facility's posted nursing hours were outdated, showing a date of August 29, 2024. Additionally, the posted nursing time for August 29, 2024, was incomplete for each shift. This indicates that the facility did not post the daily nurse staffing data on a daily basis and did not include all the required information.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect three residents from physical abuse, as evidenced by incidents involving Resident 2, who has a history of aggressive behavior due to intermittent explosive disorder. Resident 2, who is moderately cognitively impaired, was involved in an altercation with Resident 3, who is cognitively intact. During this incident, Resident 2 attempted to block Resident 3's wheelchair, shook it, and kicked it, leading to a confrontation. Despite interventions in place to manage Resident 2's behavior, such as engaging in calm conversation and walking away if aggression occurs, these measures were not effective in preventing the altercation. Subsequently, Resident 2 was involved in another incident with Resident 4, where he verbally threatened and physically assaulted Resident 4, resulting in a nosebleed and the need for hospital evaluation. This incident occurred after Resident 2 had been separated from Resident 4 following a verbal altercation. The facility's failure to implement effective interventions after the initial incident with Resident 3 allowed for the subsequent altercation with Resident 4, indicating a lack of adequate measures to prevent further abuse. The Director of Nursing and the Nursing Home Administrator confirmed the facility's failure to protect residents from physical abuse by Resident 2. The facility's policy on abuse reporting and investigation was not effectively executed, as evidenced by the repeated incidents of abuse involving Resident 2. The lack of timely and effective interventions following the initial incident contributed to the continuation of abusive behavior, resulting in harm to Resident 4.
Failure to Implement Bed Hold Policy and Ensure Resident's Return
Penalty
Summary
The facility failed to implement procedures for Medicaid bed holds and did not provide notices of the bed hold policy in an understandable language, which affected a resident's ability to return to the facility after a hospital transfer. The facility's policy required that residents or their representatives be informed in writing about the bed hold and return policy before any transfer or therapeutic leave. However, there was no evidence that the resident or their responsible party received the necessary bed hold/transfer form. The resident in question, who was under managed care Medicaid insurance, was transferred to the hospital due to a change in clinical condition, specifically for a psychiatric evaluation. The facility's documentation indicated that the resident exhibited increased behavioral symptoms, including verbal and physical abuse towards staff and other residents. Despite the facility's policy allowing for a return after hospitalization, the Director of Nursing (DON) stated that the facility could not meet the resident's needs due to her refusal to accept psychoactive medications and her preference for certain staff members. The facility did not provide documented evidence of the resident's or the representative's decision regarding the bed hold. Additionally, there was no discharge plan for the resident at the time of her hospital admission, and the facility did not demonstrate efforts to collaborate with the hospital to ensure the resident's needs could be met upon return. This lack of documentation and communication led to the deficiency noted in the survey.
Failure to Assess and Address Bowel Incontinence
Penalty
Summary
The facility failed to thoroughly assess and evaluate the bowel function of a resident, leading to a deficiency in providing appropriate care. The resident, who was initially assessed as continent of bowel, experienced a decline in bowel function after being hospitalized and readmitted to the facility. Despite this change, the facility did not initiate a bowel assessment to determine the resident's pattern of incontinence. The resident's toileting records indicated frequent incontinence, yet the facility did not conduct a three-day bowel activity assessment to identify the resident's habits or patterns of incontinence. The facility's failure to assess the resident's bowel function resulted in the lack of an individualized toileting plan to restore bowel function to the extent possible. The resident's care plan noted incontinence at times, with interventions to assist with toileting and identify incontinence patterns. However, these interventions were not effectively implemented. The Director of Nursing confirmed that the facility did not adequately assess the resident's bowel and bladder function to meet their toileting needs and decrease incontinence.
Failure to Train Agency Staff on Abuse Prevention Policies
Penalty
Summary
The facility failed to provide abuse prevention training to four agency employees, as determined through staff interviews and a review of employee personnel records. Employees 1, 2, 3, and 4, who were agency staff including a Licensed Practical Nurse, a Registered Nurse, and two nurse aides, reported that they had not received training on the facility's abuse prohibition policy prior to assuming their duties. Employee 1 had been working at the facility on and off for four months, Employee 2 was on her fourth shift, Employee 3 had been working intermittently for six months, and Employee 4 for four months. None of these employees had documentation of having received the required training. The Director of Nursing confirmed that there were no written records to show that these agency employees were trained on the facility's abuse prohibition policies and procedures as part of their orientation. The DON further stated that agency employees are not inserviced on the facility's abuse policy before starting their work. This lack of training is a violation of the facility's obligation to ensure all staff are educated on abuse prevention, as required by 28 Pa. Code 201.20 (a)(b) Staff development and 28 Pa. Code 201.19 (6)(7) Personnel policies and procedures.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to timely notify the responsible representative of a resident's change in condition. The resident, who was admitted with diagnoses including diabetes mellitus and dementia, began experiencing right upper extremity pain and edema on June 24, 2024. Despite the resident's condition requiring a Doppler study and subsequent findings of a large hematoma, the facility did not inform the resident's representative of these developments. The resident continued to experience pain and swelling, and by June 27, 2024, was unable to use her left hand due to pain and edema. On June 28, 2024, the resident's condition worsened, leading to a new order for an X-ray and eventual transfer to the emergency room. The resident was admitted to the hospital with compartment syndrome. It was only at this point that the resident's representative was informed of the situation. The director of nursing confirmed that the facility did not notify the resident's representative in a timely manner regarding the changes in the resident's condition, which included swelling, pain, and numbness.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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