Forest City Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Forest City, Pennsylvania.
- Location
- 915 Delaware Street, Forest City, Pennsylvania 18421
- CMS Provider Number
- 395554
- Inspections on file
- 20
- Latest survey
- August 7, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Forest City Nursing And Rehab Center during CMS and state inspections, most recent first.
A resident admitted with multiple diagnoses and a surgical wound did not have individualized wound care interventions included in the baseline care plan, despite physician orders and documented wound assessment. The baseline care plan only addressed pressure sore risk, and the omission was confirmed by the DON.
A resident with a recent vascular surgery and a surgical wound did not have physician-ordered wound care transcribed onto the TAR, resulting in unverified and inconsistent wound treatment. Nursing documentation showed gaps and changes in the wound's condition, and the DON confirmed the omission, which led to the resident requiring hospital admission for further wound management.
The facility failed to maintain proper food storage and service practices, leading to potential contamination and increased risk of foodborne illness. Observations revealed unsanitary practices, including uncovered bulk food storage containers, unlabeled thawed supplements, and food particles in storage areas. The second-floor pantry also had unlabeled food items and a dirty breakfast tray on the ice machine. The NHA confirmed these areas should be sanitary and properly labeled.
Forest City Nursing and Rehab Center was found non-compliant with MDS assessment accuracy requirements. The facility failed to ensure accurate weight data for three residents, using outdated or unsupported information. The RD admitted to using self-reported weights or hospital data instead of facility records, leading to errors in the assessments.
A facility failed to reassess a resident's pain status and the repeated use of PRN opioid medication, leading to a deficiency. The resident, with dementia and polyneuropathy, frequently experienced severe pain and received both daily and PRN pain medications. Despite a significant increase in PRN opioid use, no additional pain assessments were conducted, and the pain management plan was not modified. This failure did not align with professional standards or the facility's policy, resulting in potential unmanaged pain and unnecessary opioid exposure.
A facility failed to maintain accurate controlled medication records and ensure medication availability for a resident with severe pain. Doses of Morphine Sulfate Solution were signed out but not documented on the MAR, raising concerns about administration. The resident, with dementia and polyneuropathy, was unable to confirm their medication regimen due to cognitive impairment.
A resident with dementia and polyneuropathy was prescribed multiple opioid pain medications without documented justification for their concurrent use. The facility's Director of Nursing confirmed the absence of necessary documentation, highlighting a deficiency in the resident's care.
A resident with Alzheimer's disease was inaccurately diagnosed with delusional disorder without documented clinical evidence, leading to the prescription of Olanzapine. The facility failed to provide care in accordance with professional standards, as confirmed by the DON, with no practitioner verification or supporting clinical findings for the diagnosis.
A facility failed to properly label and store Morphine Sulfate Solution for a resident with dementia and polyneuropathy. The medication was used beyond the recommended 28-day period, with one bottle in use for 20 months and another for 18 months. Staff did not check expiration dates, and a new bottle from the emergency supply was unlabeled, leading to the administration of an unlabeled narcotic for nearly a month.
The facility did not meet the required nurse aide to resident ratios on six shifts. On specific dates, the evening and night shifts were understaffed, with fewer nurse aides than required for the resident census. No additional higher-level staff were available to compensate for these deficiencies, and the Nursing Home Administrator confirmed the failure to meet the required ratios.
The facility did not meet the required LPN to resident ratios on three shifts, with insufficient LPNs on the evening and night shifts for a census of 88 residents. No additional higher-level staff were available to compensate for this deficiency, as confirmed by the Nursing Home Administrator.
The facility did not meet the required 3.2 hours of direct resident care per resident, providing only 2.75, 2.82, and 2.87 hours on three consecutive days. This was confirmed by the Nursing Home Administrator.
The facility failed to implement effective fall prevention interventions and provide necessary supervision for a resident with a history of falls and unsafe behaviors. The resident experienced two falls, resulting in a head injury and a fractured wrist, due to inadequate supervision and failure to follow the care plan.
The facility failed to review and revise the care plan for a resident with diabetes who experienced significant weight loss in February and March 2024. Although nutritional progress notes addressed the weight loss, the care plan was not updated to reflect the resident's condition or include plans to monitor and prevent further decline. This deficiency was confirmed by the NHA.
The facility failed to implement a timed prompted toileting program for a resident with overactive bladder and Alzheimer's disease and did not evaluate the clinical necessity of an indwelling urinary catheter for another resident with dementia and chronic kidney disease. These deficiencies were confirmed by the Director of Nursing and other staff members during the survey.
The facility failed to document the prescriber’s clinical rationale for the use of psychotropic medication and the justification for duplicate drug therapy for a resident with dementia and psychosis. Despite changes in medication due to increased behavioral symptoms, there was no documented evidence justifying the concurrent use of Seroquel and Risperdal.
Failure to Include Surgical Wound Care in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered baseline care plan that included individualized interventions for wound management for one resident. Upon admission, the resident had diagnoses including heart failure, diabetes, and morbid obesity, and was noted to have a surgical wound on the left groin. The admission nursing assessment documented the wound's size and condition, and physician orders specified wound care procedures to be performed twice daily. However, the baseline care plan only addressed the risk for pressure sore development due to mobility deficits and did not include the surgical wound or the physician-ordered wound care interventions. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the baseline care plan did not reflect person-centered approaches specific to the resident's surgical wound. As a result, the physician-ordered wound care was not incorporated into the resident's care plan within the required timeframe after admission.
Failure to Transcribe and Administer Physician-Ordered Wound Care
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice and physician orders for a resident admitted with multiple diagnoses, including heart failure, diabetes, morbid obesity, and a recent vascular surgery to the left groin. Upon admission, the resident had a surgical wound with specific physician orders for wound care, including cleansing with normal saline, patting dry, and applying a dry dressing twice daily. However, the physician's order for wound care was not transcribed onto the Treatment Administration Record (TAR), making it impossible to verify that the ordered wound treatments were completed as prescribed. Nursing documentation showed inconsistent wound care entries, with gaps in documentation and changes in the wound's condition, including increased drainage and eventual signs of possible infection. Further review revealed that the wound worsened, with a contracted wound care nurse practitioner later documenting a deep, open, full-thickness wound with granulation and slough, and moderate seropurulent drainage. Diagnostic testing identified a fluid collection in the wound area, and the resident was subsequently sent to a vascular surgeon and admitted to the hospital for further treatment. The Director of Nursing confirmed that the failure to transcribe the physician's wound care order onto the TAR led to an inability to verify that the prescribed wound care was provided as ordered.
Improper Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food storage and service practices in the dietary department and second-floor resident pantry/nourishment room, leading to potential contamination and increased risk of foodborne illness. Observations revealed several unsanitary practices, including an unlidded garbage can in the cook's prep area, uncovered bulk food storage containers stored less than six inches from the floor, and Magic Cup frozen supplements in direct contact with the walk-in freezer floor. Additionally, thawed Mighty Shakes were not labeled with a thaw date, and there were unlabeled and undated items in the walk-in produce cooler. Further inspection of the dry-storage area and food preparation area uncovered more issues, such as food and supplies in direct contact with the floor, a hole in the ceiling tile, and food particles in a drawer storing cooking equipment. The second-floor resident pantry/nourishment room also had a dirty breakfast tray on top of the ice machine, food splatter inside the microwave, and multiple opened and unlabeled food items in the refrigerator/freezer. An interview with the Nursing Home Administrator confirmed that these areas should be maintained in a sanitary manner, and all supplements should be labeled and stored according to manufacturer instructions.
Plan Of Correction
The garbage can was emptied, a lid was placed on it and it was removed from the cooks area. The white bulk food storage containers were removed from the kitchen. The Magic Cups were relocated to a shelf. The thawed magic cups were discarded. The unlabeled/undated pitcher and milk were discarded. Stained/broken ceiling tiles are being replaced. Walls behind the stove, oven and griddle were cleaned. The knives will be covered. The red bucket was removed from the prep sink. Breakfast tray was removed from the nourishment room. The ice scoop was covered. The microwave will be replaced. The refrigerator and pantry were cleaned, and any improperly labeled items were discarded. The dietary staff will be educated regarding proper labeling, dating and kitchen sanitation. The housekeeping staff will be educated regarding cleaning of pantries. Kitchen and pantry sanitation audits will be completed 3x per week x 4 weeks and then monthly x 2 by the NHA/designee. Any discrepancies will be corrected. The results of the sanitation audits will be reviewed at monthly QAPI x 3 months.
Inaccurate MDS Assessments at Forest City Nursing and Rehab Center
Penalty
Summary
Forest City Nursing and Rehab Center was found to be non-compliant with the requirement for the accuracy of assessments as per 42 CFR Part 483, Subpart B. The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of three residents. For one resident, the weight used in the MDS assessment was outdated, having been recorded more than 30 days prior to the assessment reference date, contrary to the MDS instructions. The Registered Dietitian (RD) admitted to being unaware of the requirement to code a dash for missing data and mistakenly used the outdated weight. Another resident's MDS assessment inaccurately indicated a significant weight loss, despite the resident being admitted only two days before the assessment, with no supporting evidence of such weight loss in the clinical record. Similarly, a third resident's MDS assessment incorrectly reported a weight loss, although the resident had been newly admitted just four days before the assessment. The RD confirmed that errors were present in the MDS assessments, as she had been using self-reported weights or hospital data instead of documented facility weight records.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely because it is by the provisions of federal and state law. The plan of correction represents the facility's credible allegation of compliance. The facility cannot retroactively obtain a weight for Resident 7 for the required timeframe for MDS coding. A modification MDS will be completed. Resident 42's weight change reported on the 11/7/24 MDS was calculated by the 10/27/24 hospital weight of 125 pounds and upon admission weight 11/5/24 of 116.6 which results in a 6.7% weight loss which is more than 5% in the past 30 days as per the RAI manual instructions. Resident 17's weight change reported on December 30, 2024, MDS was calculated by the 12/15/24 hospital weight of 169 pounds compared to the 12/26/24 facility obtained weight of 159.4 pounds which results in a 5.5 % weight loss in 30 days as per the RAI manual instructions. The last 30-day lookback audit will be completed to ensure proper weights were entered on the MDS. The RD will be educated on proper and accurate coding of weights and weight changes on the MDS. The RD will be given the list of obtained weights on a monthly/weekly/daily basis as obtained. She will code the MDS as per the weights obtained. An audit will be completed of 5 random resident weights compared to MDS entry weekly x 1 month and then 10 resident's MDS monthly x 2. The results of the audits will be reviewed at monthly QAPI x 3 months.
Failure to Reassess Pain Management for a Resident
Penalty
Summary
The facility failed to reassess a resident's pain status and the repeated daily use of opioid pain medication prescribed on an as-needed (PRN) basis, which led to the deficiency. Resident 28, who was admitted with diagnoses including dementia and polyneuropathy, frequently experienced severe pain and was receiving both daily and PRN pain medications. Despite the significant increase in PRN opioid use, the facility did not conduct additional pain assessments to justify this increase or modify the pain management plan accordingly. The facility's policy required comprehensive pain assessments at specific intervals, but no such assessments were documented after October 2024. The Director of Nursing confirmed that no comprehensive pain reassessment had been conducted to determine the effectiveness or appropriateness of the resident's pain management regimen. The lack of reassessment and adjustment of the pain management plan did not align with professional standards of practice, clinical guidelines, or the facility's own policy. This resulted in the potential for unmanaged pain, unnecessary opioid exposure, or adverse medication effects, failing to ensure that the resident's pain management was individualized, effective, and consistent with their needs, goals, and preferences.
Plan Of Correction
Resident 28 was discharged from the facility. A 30 day look back audit of current resident's PRN opioid use will be completed to identify significant changes in pain. Any discrepancies found will have a comprehensive pain assessment completed to determine the effectiveness of the resident's pain management regime. RN licensed nurses will be educated regarding how to accurately complete comprehensive pain assessments. Licensed nurses will be educated regarding pain management policy. Random monthly audits will be completed by the DON/designee of PRN opioid use x 3 months. Random audits will be reviewed at monthly QAPI x 3 months.
Inaccurate Controlled Medication Records and Administration
Penalty
Summary
The facility failed to implement proper procedures for maintaining accurate controlled medication records and ensuring medication availability for a resident. Specifically, the controlled substance record for Morphine Sulfate Solution prescribed to a resident for severe pain showed that doses were signed out on multiple occasions, but there was no corresponding documentation on the Medication Administration Record (MAR) to confirm that the medication was administered. This discrepancy was confirmed by the Director of Nursing during an interview, highlighting inconsistencies in the controlled medication records. The resident involved was admitted with diagnoses including dementia and polyneuropathy and had a history of severe pain requiring both daily and as-needed pain medications. Despite the physician's order for Morphine Sulfate Solution to be administered as needed for severe pain, the lack of documentation on the MAR raised concerns about whether the resident received the necessary medication. The resident's cognitive impairment further complicated the situation, as they were unable to provide information regarding their pain or medication regimen during an interview.
Plan Of Correction
Resident 28 was discharged from the facility. The facility cannot retroactively correct missing documentation on the MAR. Licensed nursing staff will be educated on the Medication Administration policy. Medication Administration Competencies will be completed for Licensed nursing staff. Random weekly audits will be conducted by the DON/designee on controlled medication to ensure that the Narcotic sign out matches the MAR x4 weeks then monthly x 2. Results of the audits will be reviewed at monthly QAPI x 3 months.
Unjustified Duplicate Opioid Therapy for a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically concerning the use of duplicate opioid pain medications. Resident 28, who was admitted with diagnoses including dementia and polyneuropathy, was prescribed multiple opioid and non-opioid pain medications. These included Morphine Sulfate Solution, Fentanyl transdermal patch, Gabapentin, and Oxycodone HCL. The clinical record review did not provide documentation justifying the use of these duplicate opioid medications for the resident. During an interview, the Director of Nursing confirmed the absence of justification for the duplicate pain medication therapy for Resident 28. The resident's quarterly Minimum Data Set assessment indicated moderate cognitive impairment and frequent severe pain, necessitating staff assistance for daily activities. Despite these conditions, the lack of documented justification for the concurrent use of multiple opioid medications constituted a deficiency in the resident's care.
Plan Of Correction
Resident 28 was discharged from the facility. An audit of current residents receiving duplicate opioid pain medication will be completed to ensure documented justification. An education to the licensed nursing staff and the attending physicians will be completed regarding unnecessary medications. Monthly audits will be conducted by the DON/designee for 3 months for residents on duplicate pain medication to ensure documented justification. Results of the audits will be reviewed at monthly QAPI x 3 months.
Inaccurate Diagnosis of Delusional Disorder
Penalty
Summary
The facility failed to provide care and services in accordance with accepted professional standards of practice by inaccurately diagnosing a resident with delusional disorder without documented clinical evidence. The resident, who was admitted with Alzheimer's disease, was prescribed Olanzapine for delusional disorder, but there was no documented evidence of delusions or hallucinations to support this diagnosis. The consultant pharmacist recommended a diagnosis to justify the medication, but the resident's progress notes and psychological service provider's consult did not mention delusional disorder. The Director of Nursing confirmed that there was no documented evidence of a practitioner diagnosing the resident with delusional disorder, and the medical record should reflect accurate clinical findings. The comprehensive review of the resident's clinical record from admission through the survey period revealed no supporting clinical findings or practitioner verification for the diagnosis of delusional disorder, indicating a failure to meet professional standards of quality in the services provided.
Plan Of Correction
Resident 44's Olanzapine has begun to be titrated down until it can be discontinued since there is no supporting diagnosis. An education to licensed nurses and attending physicians will be completed for appropriate diagnosis of antipsychotics. An audit of the last 30 days of new admissions will be completed for appropriate diagnosis for antipsychotics. Any discrepancies will be corrected. New admits will be audited by the DON/designee for appropriate diagnosis for antipsychotics x 3 months. Any discrepancies will be corrected. Results of these audits will be reviewed at QAPI x 3 months.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, specifically Morphine Sulfate Solution, for a resident diagnosed with dementia and polyneuropathy. The medication was not labeled with the appropriate expiration or open dates, leading to its use well beyond the recommended 28-day period after opening. The Morphine Sulfate Solution was administered to the resident over a span of 20 months for one bottle and 18 months for another, far exceeding the guidelines for safe use. Staff interviews and observations revealed that the medication was administered multiple times without checking for expiration or open dates. An LPN noted the medication's color was faded, indicating potential degradation, yet continued to administer it without verifying its validity. Additionally, a new bottle retrieved from the emergency supply was found to be unlabeled, lacking essential information such as the medication name, concentration, dosing instructions, and prescribing provider. The Director of Nursing confirmed that the facility did not monitor the open or expiration dates of the medications, and staff failed to label the emergency supply medication properly. This oversight resulted in the administration of an unlabeled narcotic medication to the resident for nearly a month. The facility did not adhere to medication labeling protocols, leading to the use of expired and improperly labeled medications.
Plan Of Correction
The facility corrected the medication labeling error for resident 28 prior to the end of the survey. The pharmacy will be providing the facility with preprinted medication labels on cubex items to say, "see MAR for directions." The licensed nursing staff will write the date and the resident name on the label. The pharmacy policy will be updated regarding these changes. The licensed nursing staff will be educated regarding the updated pharmacy policy and procedure. The licensed nursing staff will be educated regarding the accuracy and completeness of the controlled drug count sheet. Monthly audits x 3 months will be completed by the DON/designee of the controlled drug count sheet including but not limited to comparing it to the MD order and correct medication and label. Results of the audits will be reviewed at monthly QAPI x 3 months.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on six out of twenty-one reviewed shifts. Specifically, on January 7, 2025, the evening shift had 7.3 nurse aides instead of the required 8 for a census of 88 residents. On January 7, 2024, the night shift had 5.17 nurse aides instead of the required 5.87 for a census of 88. On January 8, 2024, the evening shift had 5.37 nurse aides instead of the required 8.09 for a census of 89, and the night shift had 5.67 nurse aides instead of the required 5.87 for a census of 88. On January 9, 2024, the day shift had 8.3 nurse aides instead of the required 8.8 for a census of 88, and the evening shift had 6.73 nurse aides instead of the required 8 for a census of 88. 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 ratios during an interview on January 9, 2025.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely because it is by the provisions of federal and state law. The plan of correction represents the facility's credible allegation of compliance. The facility cannot retroactively correct the Nursing Assistant ratios. The facility focuses on retention of existing nursing assistants and recruitment of new nursing assistants through efforts of the staffing meetings and holding Nursing Assistant training courses in house. Bi-Weekly staffing meetings will be held to address good faith efforts towards meeting Nursing Assistant ratios. The HR/scheduler will make a good faith effort to recruit higher level staff to accommodate the ratios. Calculation of the daily nursing assistant ratios will be completed and reviewed for accuracy by the scheduler/designee. Daily ratios will be audited weekly x4 then monthly x2. The audits will be reviewed x 2 months at monthly QAPI.
Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on three shifts out of 21 reviewed, as evidenced by a review of the facility's weekly staffing records. On January 7, 2025, the evening shift had only 1.87 LPNs instead of the required 2.93 for a census of 88 residents. On January 8, 2025, the night shift had 0.87 LPNs instead of the required 2.2, and on January 9, 2025, the night shift had 1.03 LPNs instead of the required 2.2 for the same census. No additional higher-level staff were available to compensate for this deficiency. An interview with the Nursing Home Administrator confirmed the facility's failure to meet the required LPN to resident ratios on these dates.
Plan Of Correction
The facility cannot retroactively correct the LPN ratios. The facility focuses on retention of existing LPNs and recruitment of new LPNs through the efforts of the retention events and staffing meetings. Bi-Weekly staffing meetings will be held to address good faith efforts towards meeting LPN ratios. The HR/scheduler will make a good faith effort to recruit higher level staff to accommodate the ratios. Calculation of the daily LPN ratios will be completed and reviewed for accuracy by the scheduler/designee. Daily ratios will be audited weekly x4 then monthly x2. The audits will be reviewed x 2 months at monthly QAPI.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period. On January 7, 8, and 9, 2024, the facility's staffing levels were insufficient, providing only 2.75, 2.82, and 2.87 direct care nursing hours per resident, respectively. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 9, 2025, who acknowledged the facility's failure to consistently meet the required nursing care hours.
Plan Of Correction
The facility cannot retroactively correct the nursing hours. Calculation of daily PPD will be completed and reviewed for accuracy by the scheduler/designee. The NHA/designee and Human Resources/designee will continue recruitment efforts including but not limited to job postings, working with facility recruiter, sending needs out to agencies, and continuing to be a clinical site for nursing assistant classes. The facility focuses on retention of existing clinical staff and recruitment of new clinical staff through the efforts of the retention events and staffing meetings. Bi-Weekly staffing meetings will be held to address good faith efforts towards meeting nursing hours. Daily PPD will be audited weekly x4, then monthly x2. The audits will be presented to monthly QAPI x 2 months.
Failure to Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to implement effective fall prevention interventions and provide necessary staff supervision for a resident with a history of falls and unsafe behaviors. Resident 49, who was severely cognitively impaired and required extensive assistance for toileting and transfers, experienced two falls within a short period. The resident's care plan included various interventions to reduce fall risk, such as bed in the lowest position, call bell within reach, and motion sensor alarms. However, these interventions were not effectively implemented or monitored by the staff. On July 20, 2023, Resident 49 fell while at the nurse's station after being restless and unable to be redirected by the nursing staff. Despite being placed in a chair with an alarm for observation, the resident attempted to ambulate, resulting in a fall and head injury. The planned intervention to encourage rest periods after dinner was not documented as being offered to the resident. On August 10, 2023, the resident experienced another fall, this time unwitnessed, resulting in a fractured wrist. The resident had removed the clip alarm before attempting to stand, and there was no evidence of effective supervision or implementation of the planned interventions. Interviews with staff and review of clinical records confirmed that the nursing staff did not consistently offer the resident rest periods after dinner or maintain necessary supervision. The facility's documentation practices were insufficient to ensure that planned interventions were carried out. The Nursing Home Administrator acknowledged the lack of specific documentation and evidence of effective safety and fall prevention measures, leading to the resident's falls and injuries.
Failure to Update Care Plan for Significant Weight Loss
Penalty
Summary
The facility failed to review and revise the care plan for Resident 18 in response to a significant weight loss. Resident 18, who was admitted with a diagnosis of diabetes, experienced significant weight loss in February and March 2024. Although nutritional progress notes addressed the weight loss with supportive interventions, the resident's care plan, last revised on March 19, 2024, did not reflect the significant weight loss or include updated interventions and plans to monitor and prevent further decline in nutritional parameters. This deficiency was confirmed by the Nursing Home Administrator during an interview on March 24, 2024.
Failure to Implement Toileting Program and Evaluate Catheter Necessity
Penalty
Summary
The facility failed to assess and implement individualized measures to meet the toileting needs of Resident 70 and failed to evaluate the clinical necessity of an indwelling urinary catheter for Resident 49. Resident 70, who was admitted with diagnoses including overactive bladder, UTI, and Alzheimer's disease, had a plan of care that included a timed prompted toileting program. However, the facility did not implement this program as required, and the Director of Nursing confirmed the lack of documented evidence for its implementation during the survey ending March 22, 2024. Resident 49, admitted with diagnoses including dementia and chronic kidney disease, had an indwelling urinary catheter inserted on December 12, 2023, due to suspected urinary retention and chronic UTI. The facility's policy required daily evaluation of the catheter's necessity and prompt removal when no longer needed. However, the clinical record revealed no evidence of a urology evaluation or a plan to remove the catheter. The Director of Nursing confirmed the absence of physician documentation to support the catheter's use and the lack of a urology follow-up. The deficiencies were identified through a review of clinical records, facility policies, investigative reports, and staff interviews. The facility's failure to implement the toileting program for Resident 70 and to evaluate the necessity of the indwelling catheter for Resident 49 were confirmed by the Director of Nursing and other staff members during the survey. These actions were in violation of the facility's policies and state regulations, specifically 28 Pa. Code 211.12 (d)(3)(5) Nursing services and 28 Pa. Code 211.10 (a)(c)(d) Resident care policies.
Failure to Document Clinical Rationale for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychoactive drugs by not documenting the prescriber’s clinical rationale for the use of a psychotropic medication and the justification for the use of duplicate drug therapy for dementia with psychosis. Resident 11, who was admitted with diagnoses including dementia and psychosis, had a physician order for Seroquel 25 mg twice a day. Despite a reduction in the morning dose to 12.5 mg, the resident displayed increased behavioral symptoms, leading to a change in medication to Risperdal 0.5 mg at bedtime. However, there was no documented evidence from the prescriber of the clinical necessity for the concurrent use of two antipsychotic medications, which was confirmed during an interview with the Director of Nursing. The resident's clinical record revealed severe cognitive impairment with a BIMS score of 2. Behavioral health notes indicated that the resident exhibited intermittent behaviors, confusion, disorganization, and labile moods. Nursing notes documented instances of the resident becoming verbally and physically aggressive. Despite these observations, the facility did not provide documented evidence justifying the concurrent use of Seroquel and Risperdal, leading to the identified deficiency.
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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