Embassy Of Woodland Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Orbisonia, Pennsylvania.
- Location
- 18889 Croghan Pike, Orbisonia, Pennsylvania 17243
- CMS Provider Number
- 395697
- Inspections on file
- 34
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Embassy Of Woodland Park during CMS and state inspections, most recent first.
The facility did not serve hot food at the required temperature, as observed when seasoned broccoli was delivered to a resident at 111.0°F, below the policy standard of 120°F. The broccoli was lukewarm and unappetizing, and the Dietary Manager confirmed it should have been hotter.
A resident with a history of stroke and requiring maximum assistance was found on the floor after a fall, but the emergency contact was not notified until three days later. Documentation and staff interviews confirmed the delay in notification following the incident.
A resident with cognitive impairment and constipation was not administered senna-docusate sodium at the physician-ordered time. Instead, an LPN left the medication at the bedside in the afternoon, and the resident took it unsupervised, contrary to facility policy and the care plan. The DON confirmed that medications should be administered by licensed staff at the prescribed time.
A resident with cognitive impairment and dementia was left with a cup containing three tablets and water at bedside by an LPN, contrary to facility policy requiring staff to observe medication ingestion. The DON confirmed that staff must not leave medications at bedside and must ensure proper administration.
The facility failed to follow its planned menu and recipe instructions, leading to discrepancies in meals served. Residents reported that the kitchen did not always serve the listed menu items. On one occasion, Brussels sprouts were substituted with a vegetable mix without informing residents. Additionally, ground chicken breast was served with poultry gravy instead of the specified citrus glaze, as confirmed by a test tray and the Dietary Director.
The facility did not comply with food storage standards, as observed by surveyors who found coffee boxes on the floor and an unlabeled, undated, and unsealed chocolate cake in the freezer. The Dietary Director confirmed these storage violations.
The facility failed to maintain a clean and homelike environment for two residents. One resident's room had a black and worn carpet that remained dirty despite cleaning attempts. Another resident had a fan blowing on her with visible dirt and debris on the blade cover. Cleaning of resident fans was not part of scheduled duties, but staff would clean them if notified.
The facility failed to verify the nursing licenses of two nurses and the registry status of a nurse aide before their employment, contrary to its abuse prevention policy. The oversight was confirmed by the HR Director, violating state regulations.
A facility failed to develop a care plan for a resident who was cognitively intact and required assistance for daily care needs, including frequent bowel incontinence. Despite the facility's policy requiring a baseline care plan, there was no documented evidence of a care plan addressing the resident's bowel incontinence. The DON confirmed that a care plan should have been developed but was not.
The facility failed to update care plans for two residents, resulting in deficiencies in care management. One resident's care plan did not reflect multiple pain medications prescribed, while another's care plan was outdated, not reflecting a current urinary catheter order. The DON confirmed the need for updates.
A resident, identified as an elopement risk and cognitively intact, repeatedly removed her Wanderguard bracelet and exited the facility without triggering an alarm. Despite being aware of the resident's actions and dissatisfaction, the facility did not implement additional interventions beyond the Wanderguard to prevent her from leaving.
The facility did not verify the registry status of a newly hired nurse aide before she began working. The personnel file lacked evidence of a registry check until several months after her hire date, which was confirmed by the HR Director.
A resident with dementia exhibited behaviors such as hallucinations and anxiety, but the facility failed to document or implement interventions to address these issues. Despite the care plan noting these behaviors, staff did not take further steps to manage the resident's symptoms, and the physician deemed the behaviors as dementia-related without requiring additional psychological services.
A facility failed to document the administration of controlled medications for a resident with a Stage IV pressure ulcer receiving hospice care. Morphine was signed out but not recorded as administered on the MAR, as confirmed by the DON.
A resident's medications were improperly stored at their bedside, and insulin pens on a medication cart were not labeled with opening dates. An LPN left medications on a resident's table, and another confirmed insulin pens should have been dated.
The facility's QAPI committee failed to address recurring deficiencies effectively, leading to repeated citations for issues such as unsafe environments, inadequate abuse and neglect policies, and improper medication management. Despite plans of correction involving audits and committee reviews, the same deficiencies persisted across multiple surveys.
The facility did not provide the required notices to two residents regarding the end of their Medicare coverage. The SNF Beneficiary Protection Notification Review forms were not issued timely, and the Advanced Beneficiary Notices of Non-coverage were not provided. An interview with the Admissions Director revealed a lack of awareness about the requirement to issue these notices.
A resident sustained a head injury due to improper use of a mechanical wheelchair lift. The lift was not in the correct position, and the alarm system failed to alert the staff. The resident, who required assistance for transfers, fell and suffered a subdural hematoma, necessitating hospitalization.
A resident, who required two-person assistance for transfers, sustained a bruise after a nurse aide attempted a solo transfer, contrary to the care plan. The incident involved discrepancies in staff accounts, with the resident becoming weak during the transfer, leading to the use of a hoyer lift. The facility confirmed neglect due to the failure to adhere to the care plan, resulting in disciplinary action against the nurse aide.
A resident, who was care planned for a two-person transfer, was injured when a nurse aide attempted to transfer her alone, resulting in a large bruise. The resident's care plan required extensive assistance from two staff members, but this was not followed, leading to the incident. The nurse aide was terminated for failing to adhere to the care plan.
Failure to Serve Hot Food at Required Temperatures
Penalty
Summary
The facility failed to serve food items at appetizing temperatures as required by its policy, which states that hot food should be served at a temperature of at least 120 degrees Fahrenheit at the point of service. On August 19, 2025, during lunch service, the food cart left the main kitchen and arrived at the 100 unit within one minute, but the last resident was not served until 13 minutes later. At that time, the temperature of the seasoned broccoli was measured at 111.0 degrees Fahrenheit, which was below the required standard. The broccoli was observed to be lukewarm and unappetizing. The Dietary Manager confirmed during an interview that the broccoli should have been hotter. This deficiency was cited under 28 Pa. Code 211.6(b) Dietary Services.
Failure to Timely Notify Resident Representative After Fall
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in condition following a fall. A cognitively intact resident with a history of stroke, who required maximum assistance for daily care, was found on the floor in front of her wheelchair while attempting to get up. Although this incident was documented in the nursing notes, there was no evidence in the clinical record that the resident's emergency contact was informed of the fall until three days later. Staff interviews confirmed that the notification was delayed, despite the requirement for immediate notification of such events.
Failure to Administer Medication According to Physician's Orders
Penalty
Summary
The facility failed to ensure that care and treatment were provided in accordance with physician's orders and professional standards of practice for one resident. According to the facility's medication administration policy, licensed nurses are required to administer medications as ordered, verify medication details with the Medication Administration Record, and observe the resident consuming the medication. For a resident with cognitive impairment, constipation, and dementia, the care plan specified administration of medications as ordered to address constipation. Physician's orders directed that the resident receive three tablets of senna-docusate sodium by mouth once daily at 8:00 p.m. However, on the day of observation, a medication cup containing three red pills and a cup of water was left at the resident's bedside in the afternoon, and the resident took the pills at that time. An LPN confirmed leaving the medication at the bedside and identified it as senna-docusate, acknowledging it was to be administered in the evening. The DON confirmed that licensed staff are responsible for administering medications at the physician-ordered time.
Medication Administration Policy Not Followed for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a licensed nurse failed to properly administer medication to a resident with cognitive impairment, dementia, and constipation. According to the facility's policy, medications are to be administered by licensed nurses who must verify the medication against the Medication Administration Record (MAR) and observe the resident consuming the medication. However, during an observation, the nurse left a medication cup containing three red, round tablets and a cup of water at the bedside of the resident, who was lying in bed on the locked memory unit. The resident later sat up and took the pills without the nurse present. Interviews with both the LPN involved and the Director of Nursing confirmed that the nurse should not have left the medication at the bedside and was required to remain with the resident to observe ingestion. The failure to follow the facility's medication administration policy and professional standards resulted in the medication not being stored or administered appropriately for the resident.
Menu and Recipe Discrepancies in Dietary Services
Penalty
Summary
The facility failed to adhere to its planned menu, as evidenced by several discrepancies between the written menu and the meals served. According to the facility's policy, menus should be prepared in advance and followed, with any substitutions recorded only in emergency situations. However, an interview with residents revealed that the kitchen did not always serve the items listed on the menu. On September 30, 2024, the kitchen staff prepared and served a vegetable mix of green beans, wax beans, and carrots instead of the Brussels sprouts listed on the menu. The Dietary Manager admitted to forgetting to order Brussels sprouts and substituted them without informing the residents or the resident council president. Further discrepancies were observed on October 1, 2024, when the facility served ground chicken breast with poultry gravy instead of the citrus glaze specified in the recipe. A test tray confirmed that the ground chicken did not have the citrus glaze and tasted different from the regular texture chicken breast. The Dietary Director acknowledged that the ground chicken should have had the citrus glaze, indicating a failure to follow the planned menu and recipe instructions.
Non-compliance with Food Storage Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper food storage practices. During an initial tour of the main kitchen, surveyors observed two cardboard boxes of coffee stored directly on the floor, which is against the facility's policy requiring dry storage items to be at least six inches off the floor. Additionally, in the three-door freezer, a box containing approximately two-thirds of a chocolate cake was found without a date, label, or seal, contrary to the facility's policy that mandates all freezer items be labeled, dated, and sealed according to Hazardous Analysis Critical Control Point (HACCP) guidelines. The Dietary Director confirmed these observations, acknowledging the non-compliance with the established food storage protocols.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for two residents. For one resident, who was cognitively intact and used a wheelchair due to cerebral palsy, the carpet in his room was observed to be black and worn. Despite attempts to clean it, the condition of the carpet did not improve. The Director of Maintenance acknowledged the carpet's poor condition and mentioned plans to replace it with vinyl flooring, but no timeline or work schedule was established. Another resident, who was also cognitively intact and had diagnoses including COPD and a history of congestive heart failure, was observed with a fan blowing directly on her. The fan had a moderate amount of visible dirt and debris on the blade cover. The Director of Maintenance and the Director of Housekeeping both stated that cleaning resident fans was not part of their scheduled duties, but they would clean them if notified. The Director of Nursing confirmed that the fan cover should have been clean, but it was not.
Failure to Verify Nursing Licenses and Registry Status
Penalty
Summary
The facility failed to ensure that the status of nursing licenses was checked with the State Board of Nursing for two nurses and did not complete a Nurse Aide Registry verification for one nurse aide. The facility's policy on abuse prevention, dated March 15, 2024, mandates conducting background checks and not employing individuals with disciplinary actions against their professional licenses. However, the personnel files for a registered nurse and a licensed practical nurse showed no documented evidence of license verification with the State Board until October 2, 2024, despite their start dates being in April and July 2024, respectively. Additionally, the personnel file for a nurse aide revealed no documented evidence of registry verification until October 2, 2024, although the aide started working in July 2024. An interview with the Human Resources Director confirmed these findings, acknowledging the lack of timely verification of licenses and registry status for the involved staff members. This oversight is a violation of the facility's policy and state regulations, specifically 28 Pa. Code 201.14(a) and 28 Pa. Code 201.18(e)(1).
Failure to Develop Care Plan for Bowel Incontinence
Penalty
Summary
The facility failed to develop a care plan for a resident, identified as Resident 61, who was reviewed during a survey. According to the facility's policy dated March 15, 2024, a baseline care plan should be developed for each resident to provide effective person-centered care and meet professional standards. A significant change Minimum Data Set (MDS) assessment for Resident 61, dated September 6, 2024, indicated that the resident was cognitively intact, required assistance for daily care needs, and experienced frequent bowel incontinence. Task records for September 2024 confirmed that the resident had two or more episodes of bowel incontinence weekly. However, there was no documented evidence of a care plan addressing the resident's bowel incontinence needs. The Director of Nursing confirmed on October 3, 2024, that a care plan should have been developed for this issue but was not.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update care plans for two residents, leading to deficiencies in their care management. For one resident, the care plan was not revised to include multiple pain medications prescribed over several months, despite significant changes in the resident's medication regimen. This resident, who was cognitively intact and required assistance for daily care needs, had been prescribed morphine sulfate and a fentanyl transdermal patch for chronic pain. However, there was no documented evidence that the care plan was updated to reflect these changes in pain management. Another resident, also cognitively intact and requiring assistance for daily care needs, had a care plan that was outdated and did not reflect current medical orders. The resident had a physician's order for a urinary catheter due to urinary retention, but the care plan still included interventions for bladder incontinence and the use of pantiliners, which were no longer applicable. The Director of Nursing confirmed that the care plans for both residents should have been updated to reflect their current medical needs and interventions.
Failure to Prevent Elopement Risk for a Resident
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for Resident 55, who was identified as an elopement risk. The resident, who was cognitively intact, had a history of verbalizing a desire to leave the facility and had previously removed her Wanderguard bracelet, an electronic device intended to alert staff when she approached an exit. Despite this knowledge, the facility did not implement additional interventions beyond the Wanderguard to prevent her from leaving. On two occasions, the resident was able to exit the building without triggering an alarm, as she had removed the Wanderguard. The Director of Nursing confirmed awareness of the resident's actions and dissatisfaction with residing at the facility, yet no further measures were taken to address the risk of elopement.
Failure to Verify Nurse Aide Registry Status
Penalty
Summary
The facility failed to verify the registry status of a newly hired nurse aide before allowing her to work. Specifically, the personnel file for Nurse Aide 3 showed that she was hired on July 10, 2024, but there was no documented evidence of a registry check until October 2, 2024. This oversight was confirmed during an interview with the Human Resources Director on October 2, 2024, who acknowledged that the registry check should have been completed prior to the nurse aide's start date.
Failure to Address Dementia-Related Behaviors
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident diagnosed with dementia. The resident, who had a history of cerebrovascular accident/stroke and anxiety, exhibited behaviors such as screaming, yelling, refusal of care, and hallucinations, including seeing snakes and dinosaurs. Despite these behaviors being documented in the care plan, there was no evidence of interventions being implemented to address the resident's delusions or hallucinations. Observations revealed that the resident frequently called out, cried, and looked for her family, indicating a need for additional support and intervention. Staff interviews and record reviews indicated that the facility did not document any new interventions to manage the resident's anxiety, confusion, and hallucinations. The Nursing Home Administrator confirmed that the staff were following the existing care plan, but acknowledged the lack of documented interventions to assist the resident. The physician consulted believed the behaviors were related to dementia and did not require outside psychological services, yet the facility did not take further steps to address the resident's ongoing symptoms.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for one resident, identified as Resident 12. According to the facility's policy, when administering a controlled medication, both the controlled drug record form and the Medication Administration Record (MAR) must be signed. However, for Resident 12, there were instances where morphine was signed out on the controlled drug record but not signed as administered on the MAR. This discrepancy was noted on specific dates in September 2024. Resident 12 was moderately cognitively impaired, had a Stage IV pressure ulcer, and was receiving hospice care, including opioid medication for pain management. The resident's spouse confirmed that the resident received pain medication prior to dressing changes due to significant pain. Despite this, the Director of Nursing confirmed that there was no documented evidence in the clinical records to indicate that the signed-out doses of morphine were administered to the resident, highlighting a failure in the facility's medication administration process.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store medications for a resident and did not label multi-dose insulin pens with the date they were opened. During an observation, a resident was found sleeping with a medicine cup full of pills on his bedside table. The medications included various tablets and capsules, and the resident's clinical record did not indicate that he was cleared to self-administer his medications. An LPN admitted to pouring the medications earlier in the shift and leaving them on the table because the resident preferred to take them with lunch, acknowledging that this was not appropriate. Additionally, an inspection of a medication cart revealed that several insulin pens, including glargine, Basaglar, and Toujeo SoloStar, were opened but not dated. These insulin pens have specific discard timelines after being opened, which were not adhered to. An LPN confirmed that the insulin pens should have been dated, and the Nursing Home Administrator acknowledged both the improper storage of the resident's medications and the failure to date the insulin pens.
Repeated Deficiencies in Facility's Quality Assurance
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated citations in multiple surveys. The deficiencies identified include the failure to provide a safe, clean, and homelike environment, develop and implement abuse and neglect policies, and create comprehensive care plans. Additionally, the facility was cited for not being free from accident hazards, failing to maintain accurate accounts of controlled medications, and improper labeling and storage of drugs and biologicals. Further deficiencies were noted in the facility's failure to prepare and follow menus that meet residents' needs and to store, prepare, and serve food in a sanitary manner. These issues were consistently identified in surveys conducted over several months, indicating a pattern of non-compliance with nursing home regulations. The QAPI committee's role in reviewing audit results and ensuring compliance was ineffective, as the same issues persisted across multiple survey periods. The repeated citations suggest that the facility's plans of correction, which included conducting audits and reporting findings to the QAPI committee, were not successful in achieving compliance. The ongoing deficiencies highlight the committee's inability to implement effective quality assurance systems to maintain regulatory standards and improve the delivery of care and services.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to provide the required notice to residents or their representatives regarding the end of Medicare coverage for two residents who remained in the facility for long-term care. For Resident 62, Medicare coverage began on July 11, 2024, and ended on July 30, 2024. The facility did not issue the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form at least 48 hours in advance, and the Advanced Beneficiary Notice of Non-coverage (ABN) was not issued. Similarly, for Resident 95, Medicare coverage started on June 19, 2024, and ended on July 10, 2024, but the ABN was not issued. An interview with the Admissions Director revealed a lack of awareness regarding the requirement to issue the ABN when residents remain in the facility.
Failure to Ensure Safe Transfer on Wheelchair Lift
Penalty
Summary
The facility failed to ensure safe techniques were used during a transfer onto a mechanical wheelchair lift, resulting in a head injury for a resident. The manufacturer's directions for the lift indicated that the platform must be at floor level when loading and unloading. However, Nurse Aide/Transporter 1 did not verify that the lift was in the correct position before attempting to transfer the resident. The aide unhooked the safety mechanisms and attempted to maneuver the resident onto the lift, but due to the lift not being in the proper position, both the aide and the resident fell, causing the resident to sustain a head injury. The resident, who was cognitively intact and required extensive assistance for transfers, suffered a subdural hematoma and other injuries as a result of the fall. The incident report and interviews revealed that the alarm system on the lift did not activate to warn the aide that the lift was not in the correct position. The resident was subsequently hospitalized for evaluation and treatment of the head injury, which included reversing her blood thinner medication and starting antiseizure medication. The Director of Nursing confirmed that the failure to ensure the lift was in the correct position led to the fall and injury.
Neglect Due to Failure to Follow Transfer Care Plan
Penalty
Summary
The facility failed to protect a resident from neglect, as evidenced by an incident involving Resident 4, who was care planned to require extensive assistance from two staff members for transfers. On April 7, 2024, Resident 4, who was cognitively intact and required assistance with care needs, was involved in an incident where she sustained a large bruise on her lower back and buttocks. The bruise was discovered after therapy noted it, and upon assessment, it was found to be firm upon palpation, although the resident denied pain or discomfort. The resident reported that she may have bumped off the arm of her wheelchair when she became weak during a transfer from her wheelchair to her bed. The investigation revealed discrepancies in staff accounts regarding the transfer. Nurse Aide 1 was identified as attempting to transfer Resident 4 alone, despite the care plan requiring two-person assistance. Nurse Aide 1 claimed that she and Nurse Aide 2 attempted the transfer, but Resident 4 became weak, leading to the use of a hoyer lift. However, Nurse Aide 2's statement indicated that she was not present initially and only arrived after being called for help. Nurse Aide 3 corroborated that Nurse Aide 1 sought her assistance after the initial attempt failed, and they used the hoyer lift to complete the transfer. The facility's investigation confirmed that Nurse Aide 1 did not adhere to the care plan, resulting in the neglect of Resident 4. The Director of Nursing and the Nursing Home Administrator verified that the resident was indeed care planned for a two-person transfer at the time of the incident. The failure to follow the care plan led to the resident's injury, and the facility took disciplinary action against Nurse Aide 1, who was suspended and later terminated for her inability to follow the care plan despite previous education on the matter.
Failure to Implement Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that staff implemented care-planned interventions for a resident, resulting in injury. The comprehensive care plan policy required a person-centered care plan with measurable objectives and timeframes to meet the resident's needs. A quarterly Minimum Data Set (MDS) assessment indicated that the resident was cognitively intact, required assistance with care needs, and had no fall history. The care plan specified that the resident required extensive assistance from two staff members for transfers. However, an incident occurred where the resident was transferred by one nurse aide, contrary to the care plan, resulting in a large bruise on the resident's back. The resident reported that the nurse aide attempted to transfer her alone, despite the care plan requiring two-person assistance. The resident recalled the incident and stated that her leg gave out during the transfer, causing her to fall onto the wheelchair armrest. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that the resident was care planned for a two-person transfer at the time of the incident. The nurse aide involved was terminated for not following the care plan, despite previous education on the matter.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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