Forest Hills Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Weatherly, Pennsylvania.
- Location
- 1000 Evergreen Avenue, Weatherly, Pennsylvania 18255
- CMS Provider Number
- 395464
- Inspections on file
- 36
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Forest Hills Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and behavioral issues was not consistently provided with required one-to-one supervision, allowing another resident to physically strike them during an altercation over music. Staff documentation and direct observation confirmed lapses in supervision, resulting in the resident sustaining a possible nasal fracture.
A resident with severe cognitive impairment and behavioral disturbances physically abused another cognitively impaired resident during an altercation over the bathroom, resulting in the victim sustaining fractures to the arm and leg that required hospitalization and surgery. Both residents had documented histories of agitation and aggression, and care plans were in place, but the incident still occurred and was classified as physical abuse by the facility.
The facility failed to maintain a sanitary environment in Garage 1, where approximately 50 garbage bags containing various refuse were stored, emitting a foul odor and obstructing egress. The trash compactor had been filled since early January, and excess waste was stored in the garage until an additional pick-up could be scheduled. The Director of Maintenance and the NHA acknowledged the unsanitary conditions and the facility's responsibility to provide a sanitary environment.
A resident with Type 2 diabetes and dementia did not receive their Lantus medication on time on multiple occasions, as documented in their MAR for several months. The facility's policy requires medications to be administered within one hour of the prescribed time, but this was not adhered to, as confirmed by the DON.
A pharmacist failed to identify irregularities in a resident's medication regimen, including incorrect dosage and lack of supporting diagnosis for ABH gel, during monthly reviews. The resident, with dementia and under hospice care for Parkinson's, had frequent administration of the medication without proper evaluation. The DON could not provide evidence of reported irregularities.
A facility failed to ensure a physician evaluated the appropriateness of a PRN antipsychotic medication every 14 days for a resident with dementia. The resident was prescribed ABH gel for anxiety or agitation, with orders extending beyond the 14-day requirement without documented clinical necessity. The medication was administered multiple times over several months, and the DON could not provide evidence of evaluation or rationale for extending the order.
The facility failed to maintain accurate clinical records for three residents. Two residents' records lacked documentation of a bed bug incident and related assessments, while another resident's psychiatric evaluation was inaccurately documented, omitting suicidal ideations and incorrectly stating the use of psychotropic medications. The DON confirmed these documentation lapses.
The facility failed to coordinate hospice services for two residents, resulting in a lack of documented communication between hospice and facility staff. Both residents had terminal prognoses and required integrated care, but their hospice communication binders lacked evidence of care provided. The DON could not provide documentation of communication, violating facility policies and state regulations.
A resident with cognitive impairment expressed suicidal ideations, but the facility failed to include these concerns in her care plan. Despite being sent to the emergency department and evaluated by psychiatry, her care plan did not address her safety needs related to her suicidal thoughts, as confirmed by staff interviews.
A resident with a history of morbid obesity, diabetes, and limb amputations engaged in unsafe vaping behaviors, setting off smoke alarms in their room. Despite being cognitively intact and aware of the facility's smoking policy, the resident's care plan was not updated to address these behaviors. Interviews with staff confirmed the lack of care plan revisions, highlighting a deficiency in the facility's response to the resident's non-compliance with the smoking policy.
A resident with COPD and myeloid leukemia received Oxycodone outside the prescribed parameters for pain management. The care plan required medication for pain levels 4-10, but staff administered it for lower pain levels, confirmed by the DON.
A facility failed to create a person-centered care plan for a resident with PTSD, neglecting to identify and mitigate triggers that could cause re-traumatization. Despite the resident's active PTSD diagnosis, the care plan lacked specific interventions, and staff confirmed the absence of a trauma-informed approach tailored to the resident's needs.
The facility failed to ensure residents were fully informed and competent to consent to changes in their Medicare Advantage plans, affecting three residents. Staff discussed insurance changes without residents initiating requests, and there was no documentation of residents' understanding or cognitive assessment prior to disenrollment.
The facility failed to maintain a homelike environment by not ensuring operational heating and adequate hot water temperatures. A wall heating unit in a resident room was non-functional, and the shower room's water temperatures were too low, leading to residents being taken to another shower room for care. Staff confirmed the issue had persisted for weeks.
The facility failed to maintain sanitary practices for managing infectious waste. Infectious waste was found in an open storage shed outside the kitchen, with the shed's doors open and a large accumulation of dried leaves under the waste. The Nursing Home Administrator confirmed the improper storage.
A resident, who was moderately cognitively impaired and required extensive assistance with ADLs, was not provided with the necessary services to maintain adequate personal hygiene. Despite the facility's protocol of showering residents at least once a week, documentation revealed that the resident was only showered once in a month. The DON confirmed the facility's failure to adhere to the planned frequency of showers.
Failure to Consistently Implement One-to-One Supervision Resulting in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that a resident was protected from physical abuse by another resident due to inconsistent implementation of required one-to-one supervision. According to the facility's abuse prohibition policy and the resident's care plan, one-to-one supervision was mandated for a resident with severe cognitive impairment and behavioral symptoms, including impulsive and combative behaviors. Despite these requirements, documentation and direct observation revealed lapses in supervision, allowing another resident to approach and physically strike the resident under one-to-one supervision. The incident occurred when a cognitively intact resident became agitated by music being played at the nurses' station, removed the speaker, and threw it on the floor. This led to an escalation between the two residents, with spitting and verbal exchanges, followed by the cognitively intact resident striking the other resident in the face multiple times. Witness statements from staff indicated that the assigned nurse aide was present but was unable to prevent the altercation, and the documentation did not consistently demonstrate that one-to-one supervision was effectively maintained at the time of the incident. The resident who was struck sustained a possible nondisplaced nasal fracture and was transported to the hospital for evaluation. Further observation during the survey revealed ongoing noncompliance with the one-to-one supervision policy, as the resident requiring supervision was observed without a staff member in direct line of sight or within reach. Interviews with staff, including the assigned nurse aide and the Director of Nursing, confirmed that one-to-one supervision was required but not consistently implemented. These failures directly contributed to the resident's exposure to physical abuse by another resident.
Resident-to-Resident Physical Abuse Resulting in Serious Injury
Penalty
Summary
A deficiency occurred when a resident sustained serious injuries, including fractures to the humerus and femur, as a result of being physically abused by another resident. The incident took place when one resident, who had a history of dementia with behavioral disturbances and bipolar disorder, entered another resident's room and pushed her after an altercation over the bathroom. Both residents involved were severely cognitively impaired, with documented histories of agitation, aggression, and previous behavioral issues, including verbal and physical outbursts. The facility's records indicated that the resident who perpetrated the abuse had a care plan in place addressing their aggressive behaviors, with interventions such as medication administration, behavioral redirection, and removal from public areas when disruptive. The victim also had a care plan noting risks for psychosocial well-being and a history of agitation and aggression. Despite these care plans, the incident occurred, resulting in the victim being found on the floor in pain, requiring emergency medical attention and subsequent hospitalization for surgical intervention. Documentation showed that staff responded to the incident by separating the residents, initiating neurological checks, and notifying the physician and resident representatives. The event was classified as physical abuse by the facility, and an internal investigation was initiated. The incident was reported to the appropriate protective authorities, and the facility's abuse prohibition policy was reviewed as part of the investigation.
Unsanitary Conditions in Facility Garage
Penalty
Summary
The facility failed to maintain a sanitary environment in one of its buildings, specifically Garage 1, as observed on January 13, 2025. Approximately 50 filled clear plastic garbage bags were stored on the ground, containing various refuse such as blue latex gloves, used resident briefs, bed protective barriers, and human and food waste. Additionally, cardboard boxes and loose latex gloves were scattered on the garage floor. The bags were piled about 4 feet high and extended 20 feet across the garage floor, obstructing the egress to enter the building beyond 8 feet. The building emitted an unpleasant and foul odor, indicating a lack of sanitation. Interviews with staff revealed that the trash compactor had been filled since January 1, 2025, and the excess garbage was stored in the garage until an additional pick-up could be scheduled. The Director of Maintenance acknowledged the situation, explaining that the compactor would fill up again before the next scheduled pickup, necessitating an additional waste removal service. The Nursing Home Administrator confirmed the presence of the garbage bags and acknowledged the facility's responsibility to maintain a sanitary environment for residents, staff, and the public. The deficiency highlights the facility's failure to manage waste effectively, leading to unsanitary conditions in a building used by staff.
Plan Of Correction
This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. While no resident/residents were directly affected, all garbage cited in the deficiency was removed via a 30-yard dumpster before the surveyor exited the facility. 2. Based on the rationale in number one, no other residents have the potential to be directly affected. 3. Should the need arise, in the future, to temporarily store garbage until a pick-up is possible, it will be stored in appropriate covered containers, in building 1, which is not a part of the licensed facility, to assure a safe, functional, sanitary, and comfortable environment for residents, staff and the public. 4. The Maintenance Director/designee will monitor building #1, twice daily x 4 weeks, then 1x daily thereafter. All Dietary, Housekeeping, and Maintenance staff will be inserviced on the process to properly store garbage temporarily in a safe, functional, and sanitary way until a pickup can be arranged. Results of audits will be presented monthly in QAPI.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards by not ensuring timely administration of medications for a resident. Specifically, Resident 129, who was diagnosed with Type 2 diabetes and dementia with agitation, was prescribed Lantus, a medication for diabetes, to be administered daily at 9:30 AM. However, the Medication Administration Record (MAR) for April, May, and June 2024 showed multiple instances where the Lantus injection was administered more than one hour past the scheduled time, contrary to the facility's policy of administering medications within one hour of their prescribed time. The late administration of Lantus was confirmed by the Director of Nursing during an interview, acknowledging that it was inconsistent with professional standards for diabetes management. The Pennsylvania Code and the American Nurses Association Principles for Nursing Documentation emphasize the importance of timely medication administration and accurate documentation to ensure high-quality care. The repeated delays in administering the Lantus injection indicate a deficiency in adhering to these standards, as evidenced by the specific dates and times when the medication was administered late.
Pharmacist Fails to Identify Medication Irregularities
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a thorough monthly drug regimen review for a resident, leading to the oversight of several irregularities in the resident's medication orders. The resident, who was admitted with dementia and later received hospice care for Parkinson's disease, had a physician order for ABH gel, which included Ativan, Benadryl, and Haldol. The order specified an incorrect dosage of Benadryl and lacked a supporting diagnosis for the use of the medication. Additionally, there was no documented evidence that the physician evaluated the continued need for the prn antipsychotic medication every 14 days. The pharmacist did not identify these irregularities during the monthly medication reviews from August 2023 through June 2024. The resident's MAR indicated frequent administration of the ABH gel, yet the pharmacist failed to report the incorrect dosage, the absence of a supporting diagnosis, and the increased use of the prn medication. During an interview, the DON could not provide evidence that the pharmacist had reported or identified any irregularities in the resident's medication regimen reviews.
Failure to Evaluate PRN Antipsychotic Medication Appropriateness
Penalty
Summary
The facility failed to ensure that a physician evaluated the appropriateness of an as-needed anti-psychotic medication every 14 days for a resident diagnosed with dementia. The resident was prescribed ABH gel, a combination of Ativan, Benadryl, and Haldol, to be applied topically every 6 hours as needed for anxiety or agitation. The physician's orders for this medication were issued for 30-day durations on two occasions, without documentation of the clinical necessity for extending the PRN order beyond the 14-day requirement. Additionally, there was no evidence in the resident's clinical record that the use and need for the PRN antipsychotic had been evaluated for continued appropriateness. The medication administration record revealed that the ABH gel was administered 25 times in May, 15 times in June, and 6 times in July. During an interview, the Director of Nursing was unable to provide documented evidence that the physician had evaluated the resident's use of the PRN antipsychotic for continued appropriateness or documented the clinical rationale for extending the order. This lack of documentation and evaluation led to the deficiency cited under F756, as well as violations of specific Pennsylvania Code regulations related to medical director and pharmacy services.
Deficiencies in Clinical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for three residents, as required by professional standards of practice. For two residents, the facility did not document the presence of bed bugs in their room, nor did it record any physical assessments for potential effects such as bites or skin irritation. Additionally, there was no documentation indicating that the residents' representatives were informed of the room changes due to the bed bug issue. The Director of Nursing confirmed that these assessments were performed but not documented in the clinical records. For another resident, the facility failed to accurately document the resident's psychiatric evaluation. The resident had expressed suicidal ideations, but the psychiatry note did not reference this critical information. Furthermore, the note inaccurately stated that the resident was receiving psychotropic medications, although the medication administration record showed no such prescriptions or administration at that time. The Director of Nursing confirmed the inaccuracies in the psychiatric documentation. These deficiencies highlight a failure in maintaining accurate and complete medical records, which is essential for ensuring informed decision-making and high-quality care. The lack of documentation regarding the bed bug incident and the resident's psychiatric evaluation indicates a significant oversight in the facility's record-keeping practices.
Failure to Coordinate Hospice Services
Penalty
Summary
The facility failed to ensure the coordination of hospice services with facility services to meet the needs of two residents, identified as Resident 98 and Resident 101. Resident 101 was admitted with diagnoses including dementia and atherosclerotic heart disease, and had a terminal prognosis with hospice care related to cerebral atherosclerosis. The care plan required collaboration between nursing staff and the hospice team to meet the resident's needs, with scheduled visits from hospice nurse aides and a registered nurse. Similarly, Resident 98, diagnosed with Parkinson's disease and quadriplegia, was under hospice care with a care plan that also required integrated care from facility and hospice staff. However, there was no documented evidence of communication between hospice staff and facility nursing staff in the residents' clinical records or hospice communication binders. An observation revealed that the hospice communication binder for both residents contained no documentation of care provided by hospice staff. During an interview, the Director of Nursing was unable to provide evidence of communication between hospice staff and facility staff regarding the care and services provided to Residents 98 and 101. The lack of documentation and communication was a violation of the facility's policies and state regulations, which require proper coordination and documentation of care to ensure residents' physical and psychosocial needs are met.
Failure to Develop Comprehensive Care Plan for Suicidal Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who expressed suicidal ideations and distress. The resident, who was admitted with diagnoses including anoxic brain damage and disorientation, was noted to have stated intentions to harm herself. Despite these statements, the resident's care plan did not address her expressed suicidal thoughts or wishes to die. The facility's staff, including the Director of Nursing and Social Services, confirmed that the care plan lacked specific measures to address the resident's safety needs related to her suicidal ideations. The resident was moderately cognitively impaired and had no functional limitations in her range of motion. After expressing suicidal thoughts, she was sent to the emergency department for evaluation and later returned to the facility. A psychiatric evaluation noted her anxiety and depression but did not reference her previous suicidal statements. The lack of a person-centered care plan that included these critical safety concerns was confirmed by staff interviews, highlighting a deficiency in addressing the resident's individualized needs.
Failure to Update Care Plan for Resident's Unsafe Smoking Behaviors
Penalty
Summary
The facility failed to review and revise a resident's care plan concerning unsafe smoking behaviors and non-compliance with the facility's smoking policy. The resident, who was cognitively intact with a BIMS score of 15, had a history of morbid obesity, diabetes, pressure ulcers, opioid abuse, and limb amputations. Despite being aware of the facility's smoking policy, the resident engaged in vaping in his room on multiple occasions, setting off smoke alarms and prompting intervention from staff and the fire department. The resident's care plan, which addressed various behavioral issues, did not include updates related to his vaping activities or non-compliance with the smoking policy. Interviews with facility staff, including a social worker and the Director of Nursing, confirmed that the resident's care plan had not been updated to reflect the resident's smoking contract or his non-compliance with the facility's smoking policy. Despite meetings with the resident to discuss the smoking contract and the resident's acknowledgment of the policy, there was no documented evidence of care plan revisions to address these issues. This oversight was identified during a survey conducted in July 2024.
Improper Administration of Pain Medication
Penalty
Summary
The facility failed to administer pain medication in accordance with physician orders for a resident diagnosed with chronic obstructive pulmonary disease and myeloid leukemia. The resident's care plan indicated a potential for pain related to cancer, rib fracture, and pneumonia, with interventions to administer medications as per physician orders. A physician's order dated June 3, 2024, specified that Oxycodone HCL Oral Tablet 5 mg should be administered every six hours as needed for moderate to severe pain, rated from 4 to 10 on a pain scale. However, the medication administration record revealed that the facility staff administered the opioid medication outside the prescribed parameters. The resident received Oxycodone on several occasions for pain levels of 0 and 3, which were below the prescribed threshold. The Director of Nursing confirmed that the facility staff administered the medication outside the parameters of the physician's orders, acknowledging the facility's responsibility to ensure compliance with the prescribed pain management plan.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, who was admitted with multiple diagnoses including PTSD, major depression, intellectual disability, and dementia, had an annual Minimum Data Set assessment indicating an active diagnosis of PTSD. Despite this, the care plan did not include specific interventions to identify and mitigate triggers that could re-traumatize the resident. The care plan, initially dated January 8, 2024, lacked documented evidence of attempts to identify the resident's triggers or to develop strategies to decrease exposure to these triggers. Interviews with facility staff, including a social worker and the Director of Nursing, confirmed the absence of a trauma-informed care approach tailored to the resident's needs. The social worker acknowledged that the facility had not identified the resident's specific past experiences or attempted to gather information from the resident's family or past social and medical history to develop appropriate interventions. The Director of Nursing confirmed that the facility did not provide trauma-informed care in accordance with professional standards, failing to account for the resident's specific experiences to prevent re-traumatization.
Failure to Ensure Informed Consent for Medicare Plan Changes
Penalty
Summary
The facility failed to develop and implement policies and procedures in accordance with CMS guidance to protect residents from being disenrolled from Medicare Health Plans without their informed consent. The deficiency was identified through a review of clinical records, CMS guidance, facility documentation, and interviews with staff and residents. The facility did not ensure that residents were fully informed of the risks associated with disenrolling from Medicare Advantage plans, nor did they assess the residents' cognitive competence to make such decisions. Three residents were affected by this deficiency. Resident 3, who was cognitively intact with a BIMS score of 13, was disenrolled from her Medicare Advantage plan without documented evidence of her initiating the request or understanding the implications. Similarly, Resident 4, also cognitively intact, was disenrolled from his plan without proper documentation of his or his representative's understanding of the change. Resident 5, who was not available for interview, was also disenrolled without evidence of initiating the request or understanding the change. Interviews with facility staff, including the Business Office Manager and the Nursing Home Administrator, confirmed that the facility lacked operational policies and procedures for assisting residents with changes to their Medicare health care coverage. The staff admitted to discussing insurance changes with residents during open enrollment without the residents initiating these requests, which contributed to the deficiency.
Inadequate Maintenance of Heating and Water Temperatures
Penalty
Summary
The facility failed to provide maintenance services necessary to maintain a comfortable and homelike environment for residents. Specifically, one of the two wall heating units in a resident room was not operational, and the hot water temperatures in the area 4 shower room were inadequate, with the shower water at 88 degrees Fahrenheit and the sink water at 80 degrees Fahrenheit. During observations, two nurse aides confirmed that the water temperatures had been cold for weeks, preventing resident showers and personal care in that shower room. As a result, residents from this side of the unit had to be taken to the shower room on the opposite side for care. The facility administrator acknowledged that maintenance services were expected to ensure comfortable water and room temperatures.
Improper Storage of Infectious Waste
Penalty
Summary
The facility failed to maintain sanitary practices for managing infectious and hazardous waste storage on its grounds. During an observation on April 1, 2024, at 11 AM, multiple red plastic bags and closed cardboard boxes containing infectious waste were found in an open storage shed located in a parking area outside the facility's kitchen. The shed's doors were open, exposing the waste. Additionally, there was a large accumulation of dried leaves under the bags and boxes of infectious waste. The Nursing Home Administrator confirmed during an interview at approximately 1 PM on the same day that the infectious waste was not stored properly in the storage shed.
Failure to Maintain Adequate Personal Hygiene for a Resident
Penalty
Summary
The facility failed to provide necessary services to maintain adequate personal hygiene and grooming for a resident who was dependent on staff for assistance with bathing and showering. Resident 2, who was moderately cognitively impaired and required extensive assistance with activities of daily living, including bathing, reported to the surveyor that she had only been showered once recently, despite the facility's protocol of showering residents at least once a week. The Director of Nursing confirmed that the nurse aide is responsible for documenting when a resident is showered in the electronic clinical record. A review of Resident 2's clinical records revealed that she was admitted with diagnoses including hemiplegia and communication deficit, necessitating assistance with personal care. The quarterly MDS Assessment indicated her need for extensive assistance with ADLs. However, documentation from March 6, 2024, to March 29, 2024, showed that Resident 2 was only showered once during this period, with no evidence of being offered or receiving a shower or tub bath weekly as required. The Director of Nursing acknowledged the facility's inability to demonstrate compliance with the planned frequency of showers.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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