Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fair Acres Geriatric Center during CMS and state inspections, most recent first.
Misappropriation of resident funds occurred when a resident with vascular dementia and moderate cognitive impairment signed a POA that staff later confirmed should not have been executed due to lack of decision-making capacity. Financial records showed large withdrawals, ATM activity, and Venmo transfers to a nonresident individual, resulting in a loss of approximately $77,611.51. The DON, NHA, SSD, and LPN all confirmed the resident lacked capacity when the POA was signed, and the resident stated being unaware of the fund transfers.
A resident with severe vascular dementia and agitation was ordered risperidone and lorazepam, including scheduled and PRN doses, but the record showed no evidence that the resident or the resident's representative was informed in advance of the risks, benefits, options, and alternatives for either medication. The DON confirmed the resident or representative was not made aware before the medications were used.
A resident’s quarterly MDS incorrectly indicated use of physical restraints less than daily even though there was no physician order for restraints. An LPN confirmed the assessment was marked incorrectly during interview, and the deficiency was cited as an inaccurate resident assessment.
A resident with severe vascular dementia and agitation had orders for risperidone and lorazepam, including scheduled and PRN dosing, but the clinical record contained no care plan addressing the use of these psychotropic meds. LPN staff confirmed that no care plan had been developed for the resident’s psychotropic medication use.
A resident with respiratory failure had a physician order for an 1800 ml daily fluid restriction, with amounts assigned across nursing shifts and meals. Review of the clinical record showed no evidence that daily fluid intake was being monitored to ensure the resident did not exceed the ordered limit, and the DON confirmed the facility was not tracking the resident's daily fluid consumption.
Failure to Monitor Resident Weight Loss: A resident had documented wt loss of 6.3 lbs, or 6.94%, in one month, but the record showed no re-weigh and no dietary recommendations to address the loss. Facility policy required follow-up and a re-weigh when wt changed by 4% within one month, and an E5 interview confirmed further dietary interventions should have been implemented.
Surveyors found that residents were not educated on filing grievances and that grievance forms or boxes were not available or accessible on five nursing units. Staff interviews confirmed the absence of standardized grievance materials, and the DON stated there was no formal grievance policy. Resident council minutes showed no education on the grievance process.
The facility failed to maintain and inspect its emergency generator, lacking documentation for a 3-year, 4-hour load test, an annual 90-minute load bank test, and an annual fuel quality test. This deficiency was confirmed during an exit interview with the Maintenance Director.
The facility failed to maintain and inspect the fire alarm system, as the annual inspection report noted that the kitchen's duct detector was missing and untested. The facility lacked documentation of remediation, confirmed by the Maintenance Director.
The facility failed to maintain and inspect its sprinkler system, as it could not provide documentation of a dry sprinkler full flow test within the past three years and had a missing sprinkler escutcheon above the ice machine on the fifth floor. These issues were confirmed during an exit interview with the Maintenance Director.
The facility failed to maintain the door to a hazardous area on the first floor, as observed when the Clean Utility Room entry door was missing a strike plate. This deficiency was confirmed by the Maintenance Director.
The facility failed to maintain smoke barrier doors in compliance with NFPA 101 standards. Observations revealed that doors on the first floor did not close smoke tight and had missing hardware, while a door on the second floor was obstructed by a bariatric chair. These deficiencies were confirmed during an exit interview with the Maintenance Director.
The facility failed to prevent the unauthorized use of electrical devices, as observed in a designated smoking room and Resident Room 118. A fan was powered by a surge protector in the smoking room, and a light duty extension cord was used for resident electronics in Room 118. Additionally, an oscillating fan was plugged into a power outlet multiplier in the same room. These actions were confirmed by the Maintenance Director, indicating non-compliance with NFPA 101 standards.
The facility failed to maintain proper oxygen storage and cylinder identification. On one floor, the Clean Utility Room lacked required precautionary signage for oxygen storage. Additionally, on another floor, full and empty oxygen cylinders were mixed, and on the ground floor, cylinders were not labeled. These deficiencies were confirmed during an exit interview with the Maintenance Director.
The facility failed to maintain portable fire extinguishers on two floors. A fire extinguisher was blocked by a laundry cart, and others were improperly mounted, affecting access. These issues were confirmed by the Maintenance Director.
The facility did not maintain the fire resistance rating of vertical openings on the tenth floor. An observation revealed that the rated access ceiling door in the Electrical Closet next to room 1020 failed to self-close and latch, as confirmed by the Maintenance Director.
A facility failed to maintain corridor doors to resist smoke passage and positively latch, as observed in resident room 211. The door did not latch properly, compromising safety standards. This was confirmed by the Maintenance Director during an exit interview.
The facility failed to maintain smoke barrier walls free of unsealed penetrations, as observed on the eleventh floor above the smoke doors by room 1108. An unsealed penetration around electrical conduits was noted, which was confirmed by the Maintenance Director.
The facility did not maintain its HVAC system properly on one floor, as three portable air conditioning units were vented above the drop ceiling into the interstitial space, creating a plenum. This was confirmed by the Maintenance Director.
The facility failed to maintain the fire protection rating for linen chutes, with deficiencies observed on multiple floors. Chute doors in soiled utility rooms on the second, third, fourth, seventh, eighth, and tenth floors were found to be non-compliant, either failing to latch or being propped open. These issues were confirmed by the Maintenance Director, affecting six out of fifteen levels in the facility.
The facility failed to maintain electrical wiring protection on the tenth floor, where a junction box above the smoke doors at a resident's room was missing its cover plate, exposing the wiring. This was confirmed by the Maintenance Director.
A resident's drug regimen review at Fair Acres Geriatric Center revealed that the attending physician did not address several medication recommendations made by a pharmacist. These included discontinuing certain supplements and adjusting medication timing. The facility's Director of Nursing confirmed the absence of documented physician responses, indicating non-compliance with drug regimen review requirements.
Misappropriation of Resident Funds
Penalty
Summary
The facility failed to protect one resident from financial exploitation through misappropriation of resident funds, resulting in actual harm. Resident R186 had diagnoses of vascular dementia with agitation, altered mental status, and major depressive disorder, and a MDS dated January 8, 2025 showed a BIMS score of 8 out of 15, indicating moderate cognitive impairment. The facility policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Review of the resident's financial records showed that a brokerage account was opened by the resident's DPOA to manage the resident's funds, and the bank later identified multiple transactions including a large deposit, a withdrawal, an authorized purchase, several ATM withdrawals, and four Venmo transactions to an individual confirmed as not the resident. The account balance had decreased to $53,687.05. Facility documentation stated the facility became aware of the allegation when contacted by the Department, and the facility referred the matter to local police, though the current status was unknown. The resident signed a Pennsylvania Durable Power of Attorney form on January 10, 2025, witnessed by facility staff. During interviews, Licensed Employee E2 and the SSD stated the resident had a BIMS score of 8 and lacked decision-making capacity at the time the POA was signed, and should not have been permitted to sign it. The resident stated being unaware that the DPOA intended to transfer funds to another banking institution. The DON and NHA later confirmed the resident should not have signed the POA form, and the report states the resident suffered financial loss of approximately $77,611.51 after the POA was signed to a friend while the resident had vascular dementia and cognitive impairment.
Failure to Inform Resident or Representative Before Use of Psychotropic Medications
Penalty
Summary
The facility failed to inform a resident or the resident's representative in advance of the risks, benefits, options, and alternatives for the use of risperidone and lorazepam for Resident 332. The clinical record showed an order for risperidone 0.25 mg at bedtime for severe vascular dementia with agitation, followed by an order for lorazepam 0.5 mg at bedtime for palliative care and another order for lorazepam 0.5 mg every six hours as needed for severe vascular dementia with agitation. Review of the record found no evidence that the resident or the resident's representative was notified in advance about the risks, benefits, options, and alternatives for either medication. The DON confirmed in interview that the resident or representative was not made aware of these matters before the medications were used.
Inaccurate MDS restraint assessment
Penalty
Summary
Resident 12’s quarterly MDS dated December 31, 2025, was found to be inaccurate in Section P0100, Physical Restraints, because the resident was marked as using restraints less than daily even though review of the physician’s orders showed there was no order for any restraints. During interview on February 13, 2026, at 1:40 p.m., licensed staff member E6 confirmed that the MDS assessment was marked incorrectly. The deficiency was cited as failure to ensure resident assessments accurately reflected the resident’s status for one of 35 residents reviewed.
Missing Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address the use of psychotropic medications for one resident. The resident had an order for risperidone 0.25 mg at bedtime for vascular dementia, severe, with agitation, followed by an order for lorazepam 0.5 mg at bedtime for palliative care and another order for lorazepam 0.5 mg every six hours as needed for vascular dementia, severe, with agitation. Review of the clinical record found no care plan addressing the use of risperidone or lorazepam, and interviews with licensed staff confirmed that no care plan had been developed for these psychotropic medications.
Failure to Monitor Ordered Fluid Restriction
Penalty
Summary
The facility failed to follow a physician order for fluid restriction for Resident 388, whose diagnoses included respiratory failure. The resident had an order for 1800 ml of fluid daily, with specific amounts assigned for each nursing shift and each meal: 300 ml on 7-3, 180 ml on 3-11, 120 ml on 11-7, 480 ml at breakfast, 360 ml at lunch, and 380 ml at dinner. Review of the clinical record did not reveal evidence that the resident's fluid restriction was being monitored on a daily basis to ensure the resident did not exceed the ordered 1800 ml per day. The DON confirmed that the facility was not monitoring the resident's daily fluid consumption.
Failure to Monitor Resident Weight Loss
Penalty
Summary
The facility failed to obtain and monitor weights for one resident reviewed for nutrition. Facility policy required a follow-up and re-weigh when a resident had a weight gain or loss of 4% within one month. The resident’s record showed weights of 91.8 pounds on August 29, 2025, 90.8 pounds on September 9, 2025, and 84.5 pounds on October 31, 2025, reflecting a loss of 6.3 pounds, or 6.94%, in one month. There was no evidence that a re-weigh was completed to address the weight loss, and the clinical record also did not show recommendations to address it. An interview with Employee E5 confirmed that further dietary interventions should have been implemented in response to the resident’s weight loss.
Failure to Provide Grievance Education and Accessible Grievance Materials
Penalty
Summary
The facility failed to provide evidence that residents were educated on the process of filing grievances and did not ensure that grievance forms or boxes were available and accessible on the nursing units across five floors. Observations on multiple floors revealed the absence of grievance forms and drop boxes, and staff interviews confirmed that these resources were not present. Instead, staff reported that residents could either call a posted phone number, write complaints on plain paper, or use blank envelopes to submit grievances, but no standardized forms or accessible boxes were available on the units. In the main lobby, a complaint box was observed, but no grievance forms were available for residents to use. Review of facility documentation, including resident council minutes, showed no evidence of education or discussion regarding the grievance process. Additionally, the Director of Nursing confirmed that the facility did not have a formal grievance policy in place. The facility's policy on resident rights referenced staff training but did not address resident education or the availability of grievance materials. These findings demonstrate a lack of compliance with requirements to honor residents' rights to voice grievances without discrimination or reprisal.
Failure to Maintain and Inspect Emergency Generator
Penalty
Summary
The facility failed to maintain and inspect its emergency generator as required by NFPA standards. During a document review on February 3, 2025, it was discovered that the facility could not provide documentation of a 3-year, 4-hour load test of the emergency generator. This test is crucial to ensure the generator's capability to supply service within 10 seconds, as stipulated by NFPA 101 and NFPA 110. Further investigation revealed additional deficiencies in the facility's maintenance and testing procedures. The facility was unable to provide documentation for an annual 90-minute load bank test and an annual fuel quality test. These tests are essential to verify the reliability and efficiency of the emergency power system, which is critical for the safety and well-being of the residents. An exit interview with the Maintenance Director on February 4, 2025, confirmed the lack of documentation for these required tests and inspections. The absence of these records indicates a failure to adhere to the necessary maintenance protocols, potentially compromising the facility's ability to provide essential power in emergencies.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. Documentation will be provided by outside contractor for 3-year, 4-hour load test of emergency generator. Submission of Load test paper documentation will be checked quarterly to ensure all proper documentation is maintained. Documentation provided by outside contractor for 3-year, 4-hour load test of emergency generator. Documentation provided by outside contractor for Annual load bank test of. Documentation provided by outside contractor, Ferguson & McCann for fuel quality test. All paperwork needed for these items will be reviewed monthly by maintenance designee to ensure this issue does not reoccur.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain and inspect the fire alarm system as required, affecting the entire component. During a document review on February 3, 2025, it was discovered that the annual fire alarm inspection report dated May 2, 2024, indicated that the duct detector for the kitchen could not be found and was not tested. The facility was unable to provide documentation showing that this deficiency had been addressed. This was confirmed during an exit interview with the Maintenance Director on February 4, 2025.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0345 Johnson Controls Fire Protection was contacted and will provide information on the functionality of the duct detector. Annual fire alarm report will be reviewed by Maintenance designee to ensure this issue does not reoccur.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain and inspect its sprinkler system as required, affecting the entire component. During a document review on February 3, 2025, it was found that the facility could not provide documentation that a dry sprinkler full flow test had been conducted within the past three years. Additionally, an observation on February 4, 2025, revealed a missing sprinkler escutcheon above the ice machine on the fifth floor. These deficiencies were confirmed during an exit interview with the Maintenance Director on February 4, 2025.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0353 - 1 Sprinkler Company will be contracted to perform inspection. Area will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0353 - 2 Escutcheon was replaced. Area will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated.
Deficiency in Door Maintenance to Hazardous Area
Penalty
Summary
The facility failed to maintain the integrity of doors to hazardous areas, specifically on the first floor. During an observation on February 3, 2025, at 10:35 a.m., it was noted that the entry door to the Clean Utility Room was missing a strike plate. This deficiency was confirmed during an exit interview with the Maintenance Director on February 4, 2025, at 1:00 p.m. The absence of the strike plate compromises the door's ability to function as a proper barrier in accordance with fire safety regulations.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal Law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any court proceedings. New strike plate was installed and will be monitored monthly for one quarter by a maintenance department designee to ensure condition is not replicated.
Failure to Maintain Smoke Barrier Doors
Penalty
Summary
The facility failed to maintain smoke doors in compliance with NFPA 101 standards, affecting multiple areas across different floors. On February 3, 2025, observations revealed that the double doors to the Day Room on the first floor, next to rooms 129 and 118, did not close smoke tight when tested. Additionally, on the same day, the double smoke barrier doors next to the elevator on the first floor were found to have missing hardware on the push bar. These deficiencies were confirmed during an exit interview with the Maintenance Director on February 4, 2025. Further observations on February 4, 2025, indicated that on the second floor, next to room 208, one of the double smoke doors was obstructed by a bariatric chair, preventing it from closing smoke tight. This condition was also confirmed during the exit interview with the Maintenance Director. These findings demonstrate a failure to ensure that smoke barrier doors were maintained to resist the passage of smoke, as required by the NFPA 101 standards.
Plan Of Correction
Plan of Correction: Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0374 A & B A. New door coordinator for double doors next to room 129 will be installed. Door will be monitored monthly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. B. New door coordinator for double doors next to room 118 will be installed. Door will be monitored monthly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0374 Missing Hardware on push bar was installed on door. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. 2/19/2025 Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. Chair was removed from area blocking fire doors. Door was checked to ensure smoke tight closure. Fire and Safety or designee will monitor area weekly for 1 quarter to ensure this issue does not reoccur.
Unauthorized Use of Electrical Devices in Facility
Penalty
Summary
The facility was found to have failed in prohibiting the improper and unauthorized use of electrical devices, as observed during a survey. On February 3, 2025, between 9:00 a.m. and 12:30 p.m., it was noted that a fan in the designated smoking room was powered using a surge protector, which is not compliant with the regulations. Additionally, in Resident Room 118, a brown light duty extension cord was used to power resident electronics, which is against the guidelines that prohibit the use of extension cords as a substitute for fixed wiring. Further observations on February 4, 2025, at 10:20 a.m., revealed another instance of non-compliance in Resident Room 118, where an oscillating fan was plugged into a power outlet multiplier. These findings were confirmed during an exit interview with the Maintenance Director on February 4, 2025, at 1:00 p.m. The use of these unauthorized electrical devices indicates a failure to adhere to the standards set by NFPA 101 and related codes, which are designed to ensure safety in the facility.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0920 a & b a. Fan power source was relocated to wall outlet. Smoking room will be monitored weekly for one quarter by maintenance designee to ensure this condition is not replicated. b. Extension cord was removed. Room 118 will be monitored weekly for one quarter by maintenance designee to ensure this condition is not replicated. Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0920 Fan was plugged into wall outlet. Fire and Safety or designee will monitor room weekly for 1 quarter.
Deficiencies in Oxygen Storage and Cylinder Identification
Penalty
Summary
The facility failed to maintain proper oxygen storage requirements, as evidenced by observations and interviews conducted during the survey. On the first level, the Clean Utility Room lacked the necessary precautionary signage for oxygen storage, which should include the wording: "CAUTION: OXIDIZING GAS(ES) STORED WITHIN, NO SMOKING." This deficiency was confirmed during an exit interview with the Maintenance Director. Additionally, the facility did not properly store and identify medical gas cylinders on one of the three floors. On the second floor, full and empty oxygen cylinders were mixed in both racks, and on the ground floor, the cylinders were not labeled to distinguish between full and empty. These issues were also confirmed during the exit interview with the Maintenance Director.
Plan Of Correction
Plan of Correction: Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. New signage was installed. First level clean utility room will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0923 a & b A. New signage will be installed on second floor inside oxygen storage to ensure there is no mixing of full versus empty cylinders. Area will be monitored weekly for 1 quarter by a maintenance department designee to ensure this condition is not replicated. B. New signage on ground floor will be installed to label/designate full versus empty cylinders. Area will be monitored weekly for 1 quarter by a maintenance department designee to ensure this condition is not replicated.
Deficiencies in Fire Extinguisher Maintenance
Penalty
Summary
The facility failed to maintain portable fire extinguishers in accordance with NFPA 10 standards on two of fifteen floors. On February 3, 2025, a fire extinguisher in a corridor was obstructed by an unattended soiled laundry cart, as observed at 10:25 a.m. This was confirmed during an exit interview with the Maintenance Director on February 4, 2025. Further deficiencies were noted on February 4, 2025, between 9:40 a.m. and 10:30 a.m. On the thirteenth floor, next to stair tower #2, a fire extinguisher was improperly hung by its hose due to a missing mounting bracket. Additionally, on the tenth floor, fire extinguishers were mounted directly below handrails, impeding direct access. These issues were also confirmed in an exit interview with the Maintenance Director.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0355 Laundry cart was moved. Staff was in-serviced on the importance of not blocking fire extinguishers with laundry cart. Area will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0355 a New extinguisher and bracket was installed. Area will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. b Extinguishers will be remounted above handrail. Area will be monitored weekly for one quarter and by Fire & Safety Supervisor or designee for 1 quarter to ensure this condition is not replicated.
Failure to Maintain Fire Resistance Rating on Tenth Floor
Penalty
Summary
The facility failed to maintain the fire resistance rating of vertical openings, specifically affecting the tenth floor. During an observation on February 4, 2025, at 10:40 a.m., it was noted that the rated access ceiling door in the Electrical Closet next to room 1020 did not self-close and latch as required. This deficiency was confirmed during an exit interview with the Maintenance Director at 1:00 p.m. on the same day.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. Spring will be reset on ceiling door to ensure latching and ability to close. Ceiling door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated.
Corridor Door Fails to Latch, Compromising Smoke Resistance
Penalty
Summary
The facility failed to ensure that corridor doors were maintained to resist the passage of smoke and positively latch, as required by regulations. During an observation on February 4, 2025, at 10:50 a.m., it was noted that the door to resident room 211 on the second floor did not positively latch in the frame. This deficiency was identified as one of over three hundred corridor doors within the facility. The issue was confirmed during an exit interview with the Maintenance Director on the same day at 1:00 p.m. The report highlights that the door's inability to latch properly compromises its function to resist smoke passage, which is a critical safety requirement in long-term care facilities. The deficiency was observed and documented by surveyors, indicating a lapse in the facility's maintenance of safety standards for corridor doors.
Plan Of Correction
Exit Date: 02/04/25 0363 Scope/ Severity: E NFPA 101 STANDARD Corridor - Doors: Name - BLDG. 8 Component - 05 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. Observations: Based on observation and interview, it was determined the facility failed to ensure that corridor doors were maintained to resist the passage of smoke and positively latch on one of over three hundred corridor doors within the facility. Findings include: Observation on February 4, 2025, at 10:50 a.m., revealed, on the second floor, resident room 211, failed to positively latch in the frame. Exit interview with the Maintenance Director on February 4, 2025, at 1:00 p.m., confirmed the door did not latch. Plan of Correction: Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0363 Door was repaired to latch in the frame. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated.
Unsealed Penetration in Smoke Barrier Wall
Penalty
Summary
The facility failed to maintain smoke barrier walls free of unsealed penetrations, which is a requirement for ensuring a 1/2-hour fire resistance rating. During an observation on February 4, 2025, at 10:00 a.m., it was noted that on the eleventh floor, above the smoke doors by room 1108, there was an unsealed penetration around electrical conduits. This deficiency was confirmed during an exit interview with the Maintenance Director on the same day at 1:00 p.m.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0372 Penetration will be sealed with UL Rated Fire Stop. Fire safety supervisor or designee will monitor area weekly for 1 Quarter to ensure this condition is not replicated.
HVAC System Deficiency Due to Improper Venting
Penalty
Summary
The facility failed to maintain the heating, ventilating, and air conditioning (HVAC) system on one of its fifteen floors. During an observation on the ground floor inside the office therapy department, it was found that three portable air conditioning units were vented above the drop ceiling into the interstitial space, creating a plenum. This observation was confirmed during an exit interview with the Maintenance Director.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0521 Temporary AC units were removed from the building. Maintenance Department or designee will monitor are weekly for one quarter to ensure this issue does not reoccur.
Fire Protection Deficiencies in Linen Chutes
Penalty
Summary
The facility failed to maintain the fire protection rating for linen chutes, as evidenced by several deficiencies observed during a survey. On multiple floors, including the second, third, fourth, seventh, eighth, and tenth, the rubbish and laundry chute doors in the soiled utility rooms were found to be non-compliant. Specifically, the chute doors on the second and third floors failed to positively latch, while the chute door on the fourth floor was propped open by a lining cart. Additionally, the chute doors on the seventh, eighth, and tenth floors failed to close and latch properly. These deficiencies were confirmed during an exit interview with the Maintenance Director, who acknowledged the issues with the chute doors. The failure to maintain the fire protection rating for these chutes affects six out of fifteen levels in the facility, indicating a significant lapse in maintaining fire safety standards as required by NFPA 101. The report does not mention any corrective actions or plans to address these deficiencies.
Plan Of Correction
Plan of Correction: Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0541-a Door was repaired to positive latch. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0541-b Door was repaired to positive latch. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0541-c Linen chute door was closed and Facility staff will be educated about the hazards of propping doors open. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0541-d Door will be repaired to positive latch. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0541-e Door will be repaired to positive latch. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0541-f Door will be repaired to positive latch. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated.
Electrical Wiring Protection Deficiency
Penalty
Summary
The facility failed to maintain the protection of electrical wiring, as observed on the tenth floor. Specifically, a junction box located above the double smoke doors at resident room 1008 was missing its cover plate, which exposed the inner wiring. This deficiency was identified during an observation conducted on February 4, 2025, at 10:15 a.m. The Maintenance Director confirmed the missing cover plate during an exit interview later that day at 1:00 p.m.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0911 Junction box cover was replaced. Facilities Director or designee will monitor weekly for 1 Quarter to ensure this issue does not reoccur.
Failure to Act on Pharmacist's Recommendations
Penalty
Summary
Fair Acres Geriatric Center was found to be non-compliant with the requirements for drug regimen review as per 42 CFR 483.45(c). The facility failed to ensure that medication irregularities identified by a licensed pharmacist were acted upon by a physician for one of the residents reviewed. Specifically, the pharmacist's recommendations to discontinue certain medications and adjust the timing of another were not addressed by the attending physician. These recommendations included discontinuing D-Mannose due to ongoing urinary tract infections and potential effects on blood sugar, Melatonin due to concurrent use with Trazadone for insomnia, Glucosamine-Chondroitin due to uncontrolled pain, and PreserVision AREDS 2 due to duplication with another multivitamin. Additionally, a recommendation was made to change the timing of Omeprazole to optimize its effectiveness. The clinical record of the resident in question did not contain any documentation from the attending physician acknowledging or addressing these recommendations. During an interview, the Director of Nursing confirmed the absence of documented evidence of a physician's response to the pharmacist's recommendations. This lack of action and documentation constitutes a failure to comply with the federal and state regulations regarding drug regimen reviews and the necessary follow-up actions by the attending physician.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court finding. All residents receiving a Drug Regimen Review have the potential to be affected. Resident R134 was seen by the physician following the pharmacy recommendation that was reviewed by the physician on 10/9/24 on 10/21/24, 11/21/24, 12/20/2024, and 1/22/25. Resident R134 had drug regimen reviews completed on 11/6/24, 12/6/24, and 1/8/24 which did not have any additional recommendations for the physician. Medication Regimen Review Policy and Procedure was reviewed. The physicians were re-educated on the Medication Regimen Review Policy and Procedure. DON, or designee, will audit for documented evidence of a response to Drug Regimen Reviews. Audits will occur monthly x3. If trends are identified, corrective action, including a Root Cause Analysis, will be reported to the QA Committee.
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willowbrooke Court Skd Care Center At Lima Estates | 0 mi | ★★★★★ | 0 | 0 |
| Willowbrooke Court-granite | 0.6 mi | ★★★★★ | 0 | 0 |
| Sterling Health Care And Rehab Center | 2.8 mi | ★★★★★ | 2 | 0 |
| Hcc At White Horse Village | 3.5 mi | ★★★★★ | 3 | 0 |
| Monticello House | 3.5 mi | ★★★★★ | 0 | 0 |
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