Fox Subacute At South Philadelphia
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 1930 South Broad Street, Philadelphia, Pennsylvania 19145
- CMS Provider Number
- 396141
- Inspections on file
- 20
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Fox Subacute At South Philadelphia during CMS and state inspections, most recent first.
A bedbound, tracheostomy-dependent resident with anoxic brain damage and severe contractures, fully dependent on staff for bed mobility, sustained forehead lacerations, a black eye, and an oral cut during incontinence care when a CNA repositioned the resident in bed. After turning the resident onto the side and then back, the CNA and nursing staff observed active bleeding and blood on the headboard and bedframe. Investigation and DON interview determined the injuries were caused when the resident’s face contacted an exposed securing pin and knob on the bedframe, which were positioned below the mattress surface but reachable due to the resident’s "boomerang" body shape and misalignment on the bed during repositioning.
A resident with significant neurologic deficits, aphasia, and documented need for extensive assistance of two staff for bed mobility received incontinence care from a single CNA who did not obtain help despite knowing the two-person assist requirement. While the resident was positioned on the side for care, the resident’s legs went over the edge of the bed, and the resident slid to the floor as the CNA attempted to hold and lower the resident. Initial assessment showed stable VS and no reported pain, but later the resident reported right arm pain, and imaging revealed a comminuted fracture-dislocation of the right humeral head. The facility’s investigation determined that the CNA failed to follow the care plan and bed mobility orders, and the event was substantiated as neglect.
The facility failed to maintain smoke barrier doors to resist smoke passage, affecting one level. Observations revealed that double smoke doors near room 505 did not close smoke tight, and doors near room 526 had frame voids from removed hardware. These issues were confirmed in an interview with facility leadership.
The facility failed to properly store and identify medical gas cylinders on the fifth floor, as observed during a survey. Full and empty oxygen cylinders were mixed in the storage racks, violating NFPA 101 standards. This deficiency was confirmed in an interview with the facility's leadership.
Fox Subacute at South Philadelphia failed to evaluate the need for restraints and obtain informed consent for a resident using hand mitts. The resident, with chronic respiratory failure and a tracheostomy, had no documented assessment for the necessity of restraints or consideration of less restrictive alternatives. Additionally, the facility did not secure informed consent prior to restraint use, as confirmed by the DON.
Two residents with limited range of motion did not receive appropriate services to prevent further decline. One resident was observed without prescribed splints, which were found on the windowsill, while another resident had no devices in their room despite physician orders. An LPN confirmed the lack of adherence to the prescribed care.
A resident with severe cognitive impairment and multiple diagnoses, requiring assistance from two staff members for bed mobility, fell from bed when a nurse aide attempted to reposition them alone. The incident occurred as the aide turned away after removing a pillow, leading to the resident rolling onto the floor.
The facility failed to provide adequate catheter care for two residents, as their indwelling urinary catheter drainage bags were observed lying flat on the floor beside their beds. This was confirmed by staff members, indicating a failure to ensure proper catheter care as required by regulations.
The facility failed to properly label and store medications, with undated and expired vials found in medication storage areas and carts. Insulin vials on two medication carts were opened and undated, and tuberculin vials in a storage room were either undated or expired. These issues were confirmed by staff interviews.
The facility failed to maintain professional standards for food safety, with incomplete temperature logs for dish machines and refrigerators, and improper labeling of food items. Observations revealed missing temperature records for several days and unlabeled food in the walk-in refrigerator, indicating non-compliance with food safety protocols.
The facility failed to notify a resident's representative timely about a hospital transfer. The resident, diagnosed with Chronic Respiratory Failure, was sent to the ER for evaluation due to a distended abdomen, but there was no documentation of notification to the responsible party. This was confirmed by the Administrator and DON.
The facility failed to develop and implement a comprehensive care plan for the use of hand mitt restraints for a resident with Chronic Respiratory Failure. Despite a physician's order and observations confirming the use of hand mitts, the resident's care plan lacked documentation regarding these restraints. The DON confirmed the absence of a comprehensive care plan.
The facility failed to discard expired medications according to manufacturer instructions for one of the medication carts reviewed. An inspection revealed that Oxycodone HCl, Tramadol HCl, and Lorazepam tablets were expired but still stored in the cart. An LPN confirmed that these medications should have been discarded per policy.
The facility failed to maintain a medication error rate below five percent, with two observed errors: a nurse administered an incorrect dose of Vitamin D3, and another prepared an enteric-coated aspirin tablet for G-Tube administration. These errors resulted in an 8 percent medication error rate.
The facility failed to ensure food was stored, prepared, distributed, and served according to professional standards. Observations revealed open food items in freezers and expired or unlabeled items in the resident storage refrigerator, along with uncleaned spills. These findings were confirmed by the Food Service Director and Registered Dietician.
The facility failed to ensure that two nurse aides received the required 12 hours of annual in-service training. A review of training records and an interview with the DON confirmed the deficiency.
Resident Injured by Exposed Bedframe Components During Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe bedframe and environment free from accident hazards for a dependent, bedbound resident, resulting in actual harm. The resident had acute and chronic respiratory failure, anoxic brain damage, tracheostomy status, generalized muscle weakness, and was dependent on staff for bed mobility per the most recent MDS. The care plan indicated the resident required one-person assistance for bed mobility. During early morning incontinence care, a CNA turned the resident onto the left side and, after 30–40 seconds, turned the resident back and observed blood streaming from the eyebrow area, with blood noted on the wooden and metal parts of the headboard and bedframe. Clinical assessments documented two lacerations to the forehead above the eyes, swelling and bruising to the left eye, and a small cut inside the mouth, with blood in the oral cavity and discoloration and inflammation of the left eye. The resident was described as tracheostomy-dependent, bedbound, alert but not oriented, and requiring one-person assistance for bed mobility and incontinence care. The resident was transferred to the hospital via EMS after the injuries were identified, and the responsible party was notified. Staff statements consistently linked the onset of bleeding and visible injuries to the period immediately following repositioning for incontinence care. Investigation and observation identified exposed structural components of the bedframe as the likely source of injury. The DON reported that the resident’s facial injuries were believed to have occurred when the resident’s face contacted an exposed pin used to secure two pieces of the bedframe, with the sharp ends causing the lacerations as the resident was repositioned onto the back. The DON further believed that the black eye and forehead swelling were caused by contact with an exposed knob on the frame. Observation of the bedframe showed an exposed pin securing the connection between the base and headboard, located approximately two inches below the top of the deflated air mattress; the DON confirmed the mattress was inflated when in use and explained that the resident’s contractures caused a “boomerang” body shape, resulting in the head and feet overlapping the mattress edge during side positioning, and that the resident’s spine had not been aligned with the bed edge nearest the CNA at the time of the incident.
Failure to Follow Two-Person Assist Requirement During Incontinence Care Resulting in Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the resident’s required assistance level during incontinence care, resulting in neglect and actual harm. The resident involved had multiple significant medical conditions, including sequelae of cerebral infarction with aphasia, subdural hematoma, cognitive communication deficit, muscle weakness, tracheostomy status, and chronic respiratory failure. The resident’s quarterly MDS documented a need for extensive assistance of two or more staff for bed mobility, and the physician’s orders and care plan specified bed mobility as a two-person assist and transfers with a Hoyer lift requiring two staff. On the date of the incident, a CNA (Employee E3) provided incontinence care to the resident alone, despite the documented requirement for a two-person assist. During care, the CNA positioned the resident on the left side to complete incontinence care. While in this position, the resident extended the left leg out of the bed, followed by the right leg, and began sliding out of the bed feet first. The CNA yelled for help and attempted to hold the resident in the bed by grabbing around the trunk but was unable to prevent the resident from sliding off the bed. The CNA then assisted the resident to the floor while protecting the resident’s head. A nurse responded and found the resident on the floor with the CNA kneeling behind, supporting the resident’s head and upper body. The resident was assessed, returned to bed via Hoyer lift, and initial neurological checks and vital signs were stable, with the resident initially denying pain. Subsequently, the resident reported right arm pain, and due to the recent fall, an X-ray was ordered. Radiology results showed a comminuted fracture-dislocation of the right humeral head with anteroinferior dislocation from the glenoid, generalized soft tissue swelling, and mild degenerative changes. The facility’s internal investigation included interviews with the CNA and the DON. The CNA acknowledged awareness that the resident required a two-person assist but stated she believed it would be acceptable to provide care alone because the resident could help with the left hand. The CNA also stated she did not ask anyone for help before providing care. The DON later determined that the incident should be substantiated for neglect because the CNA failed to follow the documented two-person assist requirement for bed mobility, which led to the resident’s fall and resulting fracture. The resident was described as alert and oriented but severely aphasic, flaccid on the right side with minimal use of the left side, and dependent for personal care. An attempted interview by the DON confirmed the resident remembered falling but had difficulty consistently describing the event due to aphasia. Facility documentation and the internal investigation concluded that the CNA did not follow the two-person assist policy for bed mobility as documented in the resident’s care plan, and this failure to follow established safety procedures during care constituted neglect and resulted in actual harm in the form of a right humeral head fracture.
Smoke Barrier Door Deficiency
Penalty
Summary
The facility failed to maintain doors in smoke barrier walls to resist the passage of smoke, affecting one of six levels within the component. During an observation on February 13, 2025, it was noted that the double smoke doors next to room 505 did not close smoke tight. Additionally, the double smoke doors next to room 526 had voids in the door frame where hardware had been removed. These issues were confirmed during an interview at the exit conference with the Chief Operating Officer, Administrator, and Maintenance Director.
Plan Of Correction
1. No Residents were affected by this practice. 2. All other smoke doors were approved and functional. 3. Locksmith repaired the smoke door by room 505. Voids were closed up with steel fasteners by room 526 on 2/24/25. 4. Maintenance Dept will continue to monitor during weekly Preventative Maintenance rounds, and will bring findings to monthly Safety & QAPI Meetings overseen by the Administrator, x3 months.
Improper Storage of Medical Gas Cylinders
Penalty
Summary
The facility failed to properly store and identify medical gas cylinders, specifically oxygen cylinders, on the fifth floor. During an observation on February 13, 2025, it was noted that the portable oxygen storage room contained a mix of full and empty cylinders in both the full and empty racks. This improper storage practice was identified as a deficiency in the facility's compliance with NFPA 101 standards for gas equipment storage. The deficiency was confirmed during an interview at the exit conference with the Chief Operating Officer, Administrator, and Maintenance Director. The report highlights that the facility did not adhere to the required protocols for segregating full and empty cylinders, which is essential for maintaining safety and compliance with regulatory standards.
Plan Of Correction
1. No Residents were affected by this practice. 2. All other O2 storage was in compliance. 3. Back O2 Storage will now be labeled and store only Full tanks. Front O2 storage room will now be labeled and store only Empty tanks. Staff will be in-serviced on the new practice by 3/8/25. 4. Lead RT will audit for compliance weekly and will bring results of audits to monthly Safety & QAPI meetings overseen by the Administrator.
Failure to Evaluate and Obtain Consent for Restraint Use
Penalty
Summary
Fox Subacute at South Philadelphia was found to be non-compliant with federal and state regulations regarding the use of physical restraints. The facility failed to evaluate the need for restraints and did not assess the least restrictive measures for a resident who was using hand mitts as restraints. The resident, admitted with chronic respiratory failure and a tracheostomy, had a physician's order for hand mitts to be removed every two hours for skin integrity checks. However, there was no documented evidence of an evaluation of the necessity of these restraints or consideration of less restrictive alternatives. Additionally, the facility did not obtain informed consent prior to the use of restraints on the resident. The clinical records lacked documentation of informed consent, and the restraint consent provided during the survey was undated, offering no indication of when consent was obtained. The Director of Nursing confirmed these deficiencies, acknowledging the absence of evaluation and documented informed consent for the use of restraints on the resident.
Plan Of Correction
1. Resident R5 had a Restraint Assessment completed by the nurse. 2. Other Residents with Restraints were found to have complete Restraint documentation. 3. In-servicing was given to nurses regarding the Policy of obtaining consents and completing a Restraint assessment prior to applying the Restraint. 4. Random audits will be conducted weekly by ADON or designee to check for all components of Restraint application. Results of audits will be brought to the monthly QAPI meeting, x3 months, overseen by the Administrator.
Failure to Provide Appropriate ROM Services
Penalty
Summary
The facility failed to ensure that two residents with limited range of motion received appropriate services to prevent further decline in their condition. Resident R26 had physician orders for a hand grip splint and elbow positioning wedges to be alternated every four hours. However, observations revealed that the resident was not wearing any devices or splints during the survey, and the splints were found on the windowsill instead. An LPN confirmed that the resident should have been wearing the splints as per the physician's orders. Similarly, Resident R33 had physician orders for an abductor wedge to be positioned between the legs at all times as tolerated and bilateral upper extremity splints to be applied for four hours and removed for four hours. Observations showed that the resident was not wearing any devices or splints, and no such equipment was found in the resident's room. An LPN was unsure if the resident should be wearing any devices and could not locate them in the room. These findings indicate a failure to provide necessary care and services to maintain or improve the residents' range of motion and mobility.
Plan Of Correction
1. Residents R26 & R33 had splints obtained and applied per physician orders. 2. Other Residents with splints & devices were checked for proper appliance per physician orders. 3. Restorative C.N.A. and nurses were in-serviced on Policy for splints & devices. 4. Random Audits will be conducted by ADON or designee weekly to ensure proper application of splints/devices per orders. Results of audits will be brought to monthly QAPI meeting x3 months, overseen by the Administrator, by 3/31/25.
Inadequate Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate assistance to prevent a fall for Resident R33, who was reviewed for falls. Resident R33 had severe cognitive impairment and multiple diagnoses, including chronic respiratory failure and anoxic brain damage, and was dependent on others for all activities, requiring assistance from two or more helpers for bed mobility. Despite these needs, on December 5, 2024, a nurse aide attempted to reposition Resident R33 alone, which led to the resident falling from the bed. The incident occurred when the nurse aide, Employee E7, raised the bed, moved floor mats, and removed a pillow from under Resident R33's hip without the presence of another staff member to assist. As the nurse aide turned away to place the pillow on the mat, Resident R33 rolled onto the floor. The Director of Nursing confirmed that Resident R33 should have been assisted by two staff members during turning and repositioning in bed, as per the resident's care plan and facility policy.
Inadequate Catheter Care for Two Residents
Penalty
Summary
The facility failed to provide adequate catheter care for two residents, as evidenced by observations and staff interviews. Resident R4, who was admitted with chronic respiratory failure, anoxic brain damage, and urine retention, was observed with their indwelling urinary catheter drainage bag lying flat on the floor beside their bed. This observation was confirmed by a nurse aide, Employee E5, who acknowledged that the catheter drainage bag should not be on the floor. Similarly, Resident R39, admitted with chronic respiratory failure, muscle weakness, and urine retention, was also observed with their indwelling urinary catheter drainage bag lying flat on the floor beside their bed. This was confirmed by a registered nurse, Employee 6, who also acknowledged that the catheter drainage bag should not be on the floor. These findings indicate a failure to ensure proper catheter care for the residents, as required by the regulations.
Plan Of Correction
1. Resident R4 and R39's foley bag was removed from touching the floor. 2. Other Residents with foley bags were checked for location off of the floor. 3. C.N.A.'s in-serviced to ensure they are checking proper location of foley bags. 4. ADON or designee will conduct random audits weekly to ensure compliance. Results of audits will be shared at the monthly QAPI meeting x3 months, overseen by the Administrator.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper labeling and storage protocols for medications, as evidenced by observations and staff interviews. In Medication Storage Room Two, two tuberculin vials were found improperly managed; one vial was opened and undated, while the other was expired, having been opened on September 1, 2024, despite instructions to discard after 30 days. This was confirmed by a Registered Nurse, Employee E3, during an interview. Further deficiencies were noted on Medication Carts Four and Five. On Cart Five, five insulin vials, including Humalogs, Novalogs, and Lantus, were opened and undated. On Cart Four, two insulin vials, Novalog and Humalog, were opened on January 1, 2025, and exceeded the recommended 28-day usage period. These findings were confirmed by Employee E3 and Employee E5, a Licensed Practical Nurse, respectively. The facility's policy on medication storage, dated 2016, was not followed, leading to these deficiencies.
Plan Of Correction
1. All expired and/or undated medication that was identified was wasted. 2. Other medication storage areas were audited for compliance. 3. Nurses were in-serviced regarding labeling, dating and expired medications. 4. ADON or designee to complete random audits weekly on medication storage. Audits will be brought to monthly QAPI meeting x3 months, overseen by the Administrator.
Food Safety and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several lapses in food storage and temperature monitoring. During an inspection of the Food Service Department, it was discovered that the dish machine temperature log was incomplete, with no records available from February 4 to February 9, 2025. Similarly, the refrigerator temperature log had not been updated since December 29, 2024, indicating a lack of regular monitoring. Additionally, the three-compartment sink log showed no sanitizer recordings for the same period in February 2025. Further observations revealed improper labeling and dating of food items in the walk-in refrigerator. Boiled eggs were found without expiration dates, a container of dessert lacked an open date, package date, or expiration date, and three boxes of bread were not labeled with any dates. These deficiencies indicate a failure to comply with the facility's own policies and professional standards for food safety, potentially compromising the safety and quality of food served to residents.
Plan Of Correction
1. The dish machine log was completed. The refrigerator temperature log was completed. The 3 compartment sink log was completed. The unlabeled, undated food identified in the walk-in refrigerator was discarded. 2. All other food storage areas were checked for proper temp logs, labeling, and dating. 3. Food Service staff were in-serviced on proper labeling, food storage, and use of temperature logs. 4. Food Service Director or designee will conduct random weekly audits on the above items and will bring audits to the monthly QAPI meeting x3 months, overseen by the Administrator.
Failure to Notify Resident's Representative of Hospital Transfer
Penalty
Summary
The facility failed to ensure that the resident's representative was notified timely about a hospital transfer for Resident R47. Resident R47, who was admitted with a diagnosis of Chronic Respiratory Failure, had a progress note on January 10, 2024, indicating that labs were drawn and an abdominal X-ray was ordered due to a distended abdomen. The resident was subsequently sent to the emergency room for evaluation. However, there was no documentation that the responsible party was notified of the transfer. This was confirmed during an interview with the Administrator and Director of Nursing on April 12, 2024.
Failure to Develop Comprehensive Care Plan for Hand Mitt Restraints
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for the use of hand mitt restraints for Resident R37. The resident, who was admitted with a diagnosis of Chronic Respiratory Failure, had a physician's order dated April 4, 2024, for the use of hand mitts to prevent dislodgement of a new midline. Observations on April 9 and April 10, 2024, confirmed that the resident was wearing the hand mitts during activities and while in bed. However, a review of the resident's care plan revealed no documentation regarding the use of these restraints. The Director of Nursing confirmed on April 12, 2024, that there was no comprehensive care plan in place for the hand mitt restraints.
Expired Medications Not Discarded
Penalty
Summary
The facility did not ensure that medications were discarded according to manufacturer instructions for one of the three medication carts reviewed. During an inspection of Medication Cart Main B, conducted in the presence of a Licensed Nurse, it was found that several medications had expired but were not discarded. Specifically, Oxycodone HCl 5 mg tablets, Tramadol HCl 50 mg tablets, and Lorazepam 1 mg tablets were found to be expired and still stored in the cart. The Licensed Practical Nurse confirmed that these medications should have been discarded according to manufacturer instructions and facility policy.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate below five percent, as evidenced by two observed medication errors out of twenty-five medications reviewed. On April 9, 2024, a Licensed Nurse administered 1000 units of Vitamin D3 to a resident, contrary to the physician's order of 2000 units. The nurse confirmed the error upon interview. Additionally, a Registered Nurse prepared to administer an enteric-coated aspirin tablet via G-Tube to another resident, which was averted as enteric-coated tablets should not be crushed. The nurse also confirmed this error upon interview. These errors resulted in a medication error rate of 8 percent. The first error involved a resident who was prescribed 2000 units of Vitamin D3 daily for nutritional deficiency but received only 1000 units. The second error involved the preparation of an 81 mg enteric-coated aspirin tablet for G-Tube administration, which is inappropriate due to the nature of the tablet's coating. Both errors were confirmed by the respective nurses at the time of observation. The facility's medication error rate was calculated to be 8 percent, exceeding the acceptable threshold of 5 percent.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial tour of the Food Service Department, it was observed that a box of carrots in the walk-in freezer and a bag of breaded chicken tenders in the reach-in freezer were both open to the circulating air. These observations were confirmed by the Food Service Director. Additionally, the resident storage refrigerator contained several expired or unlabeled items, including a carton of milk, a container of tuna salad, a container of yogurt and granola, a container of yogurt and blueberries, a container of peaches, a container of macaroni salad, and a salad with tuna that appeared soggy. The refrigerator and freezer also had several spills that were not cleaned. The Registered Dietician confirmed these findings and stated that the kitchen is responsible for cleaning out the refrigerator once a week. The facility's untitled and undated policy for food storage states that food should be stored in compliance with applicable Federal, State, and Local regulations regarding sanitary food storage. However, the observations and interviews indicate that the facility failed to adhere to these standards, resulting in the identified deficiencies.
Failure to Provide Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aide staff received the required 12 hours of annual in-service training to maintain proficiency and competence. Specifically, two nurse aides, Employee E16 and Employee E17, did not meet this requirement. This deficiency was identified through a review of the nurse aides' training records, which revealed the lack of necessary training hours. An interview with the Director of Nursing, Employee E2, confirmed that there were no additional records of in-service training for these employees.
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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