Gardens At Gettysburg, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Gettysburg, Pennsylvania.
- Location
- 741 Chambersburg Road, Gettysburg, Pennsylvania 17325
- CMS Provider Number
- 395247
- Inspections on file
- 34
- Latest survey
- May 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Gardens At Gettysburg, The during CMS and state inspections, most recent first.
Surveyors found that care plans were not updated to reflect the current needs and preferences of four residents, including the use of a CPAP mask, pressure offloading boots, an anticoagulant medication, and an arm sling. Staff confirmed these omissions, indicating that care plans did not accurately represent the residents' care requirements.
A resident with severe cognitive impairment, dependent on staff for ADL assistance, was observed with unclean fingernails and facial stubble, and reported not receiving regular showers or nail care. Documentation and interviews confirmed inconsistent provision of personal hygiene and grooming, resulting in a deficiency for failure to maintain adequate care.
A resident with COPD was found with oxygen concentrator tubing disconnected from the humidification bottle, resulting in no oxygen flow despite the nasal cannula being in place. The LPN immediately reattached the tubing upon discovery, and interviews revealed conflicting explanations for the disconnection. The facility's policy did not address humidification bottle use, and staff failed to ensure the resident received appropriate respiratory care.
A resident with epilepsy and bipolar disorder did not receive prescribed anti-seizure medications after returning from the hospital, due to a failure in reviewing and continuing the medication orders. The facility's policy required timely medical assessments, but the medication regimen review and physician's note did not address the continuation of Lamictal and Gabapentin. The resident was later found unresponsive, highlighting the lapse in medication administration.
The facility failed to ensure accurate MDS assessments for four residents, leading to discrepancies in documentation. A resident with chronic embolism was inaccurately recorded as not receiving anticoagulant medication, while another with dementia was noted for wandering behaviors not reflected in the MDS. A third resident's MDS incorrectly stated no antipsychotic medication was given and reported a fall with major injury that did not occur. Lastly, a resident receiving enteral feeding was inaccurately documented as not receiving nutrition via a feeding tube. These errors were confirmed by the NHA.
A resident with severe dementia and muscle weakness experienced a fall with major injury. Despite placing the resident's mattress on the floor as a safety measure, the facility failed to update the care plan to include this intervention. The Nursing Home Administrator acknowledged the oversight, which was contrary to the facility's policy requiring timely care plan revisions.
A resident with a Foley catheter did not have documented orders for its use or care for six days after admission, leading to a deficiency in preventing urinary tract infections. The Nursing Home Administrator confirmed the delay was due to pending confirmation of orders in the electronic record.
The facility failed to provide timely practitioner services for two residents with pressure injuries. One resident with Alzheimer's and peripheral vascular disease had a pressure injury identified but not evaluated or treated for nine days. Another resident with a sacral skin alteration was not evaluated by a wound consultant until eight days after admission due to a scheduling oversight, resulting in delayed treatment orders.
A facility failed to accurately document oxygen administration for a resident with COPD and anoxic brain damage. Observations showed the resident receiving oxygen, but records indicated otherwise, and the Treatment Administration Record showed discontinued oxygen. An error in entering the order led to its absence from the TAR, resulting in incomplete clinical records.
A resident with osteoporosis and osteoarthritis did not receive their prescribed Miacalcin Nasal Solution on multiple occasions due to pharmacy issues. The facility failed to notify the physician about the missed doses, as confirmed by the Nursing Home Administrator.
A resident with peripheral vascular disease and congestive heart failure developed a stage II pressure ulcer on the left foot. Despite recommendations for daily treatment by a wound consultant, there was a gap in treatment orders from the time of discovery until several days later. The Nursing Home Administrator acknowledged that treatment orders should have been implemented immediately.
A resident with osteoporosis and osteoarthritis did not receive their prescribed Miacalcin Nasal Solution on multiple occasions due to the facility's failure to ensure the medication was available. The medication was not administered from February 22 to 26 and on May 16, as the pharmacy required facility approval to fill the non-covered medication, causing delays.
An LPN administered the wrong medication to a resident, who ingested a pill not prescribed to her. The error was identified and reported immediately, and the resident was monitored for side effects. The DON and NHA confirmed the LPN did not follow the facility's medication administration policy.
Failure to Update and Revise Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised to reflect the current needs and preferences of four residents. For one resident with diabetes and muscle weakness, observations showed a CPAP mask left out on the bedside stand according to the resident's preference, but the care plan did not document this preference. Another resident with diabetes and protein-calorie malnutrition was observed wearing bilateral pressure offloading boots, yet the care plan addressing pressure ulcer risk did not include the use of these boots. A third resident with dementia, depression, and atrial fibrillation was prescribed Apixaban, an anticoagulant, but the care plan did not reflect the use of this medication. Additionally, a resident with a history of cerebral infarction and hypertension was observed using a left arm sling, but the care plan did not mention the use of the sling. In each case, staff interviews confirmed that these interventions or preferences should have been included in the respective care plans.
Failure to Maintain Adequate Personal Hygiene and Grooming for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with dementia, who was dependent on staff for assistance with activities of daily living (ADLs), did not consistently receive adequate personal hygiene and grooming. The resident's clinical record indicated severe cognitive impairment, requiring supervision or touch assistance for bathing and partial to moderate assistance with personal hygiene, including shaving and hand/face washing. Despite these needs, observations revealed the resident had a brown substance under his fingernails and was not shaved, with facial stubble present. The resident expressed that his nails needed cleaning and requested a shower, although he did not mind some facial hair. Documentation showed that showers and bed baths were provided intermittently over the previous 30 days, but there were gaps in the provision of these services. Further observations confirmed that, while the resident's fingernails were trimmed, two fingernails still had a brown substance underneath, and the resident remained unshaved. Interviews with the resident and the Nursing Home Administrator (NHA) corroborated these findings, with the NHA acknowledging the need for nail cleaning and stating that the resident was educated on hand hygiene. The resident later confirmed that his fingernails were cleaned, but minimal residue remained. The deficiency was cited under 28 Pa code 211.12.(d)(1)(5) for nursing services, as the facility failed to maintain adequate personal hygiene and grooming for a resident dependent on staff assistance.
Failure to Ensure Proper Oxygen Therapy Setup
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) and difficulty walking was not provided with safe and appropriate respiratory care as required. During an observation, the resident's oxygen concentrator tubing was found disconnected from the humidification bottle, which is necessary to add moisture to the oxygen. The resident had the nasal cannula in place but was not receiving any oxygen flow at the time of the observation. The facility's policy on oxygen therapy did not address the use of a humidification bottle, and the tubing was immediately reattached by a Licensed Practical Nurse upon discovery. Interviews revealed conflicting accounts regarding how the tubing became disconnected. The resident stated she does not remove the tubing from the concentrator to the humidification bottle, while the Nursing Home Administrator indicated that the resident sometimes disconnects the tubing while using the restroom. Regardless, the deficiency was identified as staff failed to ensure the oxygen equipment was properly set up and functioning, resulting in the resident not receiving prescribed oxygen therapy.
Failure to Review and Administer Anti-Seizure Medications
Penalty
Summary
The facility failed to ensure that a resident's total program of care, including medications, was accurately reviewed at each physician visit. The resident, who had a history of symptomatic epilepsy, bipolar disorder, and migraines, was admitted with orders for Lamictal and Gabapentin to manage seizures. After a hospital visit for acute enterocolitis, the resident returned with discharge orders for these medications to be continued for only seven days. The facility's documentation showed that the medications were discontinued after this period, and they were not administered from October 15 to October 30, 2024. The facility's policy required timely medical assessments and appropriate medical regimens, but the October 8, 2024, medication regimen review and the physician's note from October 9, 2024, did not address the continuation of the anti-seizure medications. The resident was later found unresponsive and sent to the hospital, where it was determined that the medications had been discontinued without proper documentation or a gradual reduction, as recommended by the FDA. The Nursing Home Administrator confirmed the lapse in medication administration and the lack of documentation supporting the discontinuation.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate resident assessments for four residents, leading to discrepancies in their Minimum Data Set (MDS) assessments. Resident 14, diagnosed with chronic embolism and thrombosis, was documented as receiving Xarelto, an anticoagulant, daily in May 2024. However, the MDS assessment inaccurately indicated that the resident did not receive anticoagulant medication during the look-back period. Similarly, Resident 52, with frontotemporal neurocognitive disorder and dementia, was noted in progress notes to exhibit wandering behaviors, yet the MDS assessment failed to reflect these behaviors. Resident 56, diagnosed with severe unspecified dementia and muscle weakness, was documented as receiving Aripiprazole daily, but the MDS assessment incorrectly stated that no antipsychotic medication was administered. Additionally, the MDS inaccurately reported a fall with major injury, which was not supported by the clinical record. Resident 69, with dysphagia and gastrostomy status, was documented as receiving daily enteral feeding, but the MDS assessment incorrectly indicated no nutrition via a feeding tube. These errors were confirmed by the Nursing Home Administrator during interviews.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that the care plan for a resident was reviewed and revised in a timely manner following a significant change in the resident's condition. Resident 56, who has severe unspecified dementia with agitation and muscle weakness, experienced a fall with a major injury. Despite the fall and the subsequent placement of the resident's mattress on the floor as a safety intervention, the care plan was not updated to reflect this new intervention. The facility's policy requires that care plans be revised as residents' conditions change, but this was not adhered to in the case of Resident 56. During interviews, the Nursing Home Administrator acknowledged that the care plan should have been updated to include the mattress intervention, as it was implemented due to the ineffectiveness of previous fall interventions. This oversight was identified during a survey, highlighting a deficiency in the facility's adherence to its own care planning policies.
Failure to Document and Provide Timely Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections and complications related to the use of a Foley catheter for a resident. The resident, who had diagnoses including obstructive and reflux uropathy and hemiplegia following a cerebral infarction, was admitted with a Foley catheter. However, there were no documented orders related to the presence, indication for use, or care of the catheter until six days after admission. During this period, the clinical record lacked documentation of daily care or maintenance of the Foley catheter. The Nursing Home Administrator confirmed that the orders and documentation for catheter use and care were not timely. The orders were entered into the electronic record at admission but were pending confirmation, which delayed their appearance on the Medication/Treatment Administration Records until the issue was discovered and corrected.
Delayed Practitioner Services for Pressure Injuries
Penalty
Summary
The facility failed to ensure timely practitioner services for two residents with skin integrity concerns. Resident 26, diagnosed with Alzheimer's disease and peripheral vascular disease, was noted to have a dark area of discoloration on the left outer ankle on May 7, 2024. Despite the need for a wound team assessment, there was no evidence that a physician or practitioner was notified or evaluated the wound until May 16, 2024, when a nurse practitioner determined it to be a pressure injury. During this period, no treatment was prescribed, and the Nursing Home Administrator confirmed the lack of practitioner notification and evaluation. Resident 92, admitted with a sacral skin alteration and a history of pressure ulcers, was expected to be seen by a wound consultant the day after admission. However, due to a scheduling oversight, the wound consultant was not informed, and the resident's wound was not evaluated until eight days later, on May 16, 2024. The physician's initial assessment on May 9, 2024, noted a stage III pressure injury but did not include a treatment plan. Consequently, no treatment orders were documented until May 20, 2024. The Nursing Home Administrator acknowledged the delay in evaluation and treatment.
Failure to Document Oxygen Administration
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for a resident who was receiving oxygen therapy. The facility's policy on oxygen administration, last revised in October 2010, requires detailed documentation of oxygen setup or adjustment, including the date and time of the procedure, the name and title of the individual performing it, the rate of oxygen flow, route, rationale, frequency, duration, and assessment data. However, the clinical record for a resident with chronic obstructive pulmonary disease (COPD) and anoxic brain damage did not reflect accurate documentation of oxygen administration. Observations revealed that the resident was receiving oxygen at 2 liters per minute via nasal cannula, but the clinical record progress notes indicated that the last entry was dated several days prior, stating the resident was not receiving oxygen. Further review of the resident's Treatment Administration Record (TAR) showed that oxygen administration was discontinued earlier in the month, despite the resident being observed with oxygen. Interviews with the Nursing Home Administrator confirmed that the oxygen administration should have been documented, and an error in entering the oxygen order led to its absence from the TAR. This lack of documentation and failure to update the resident's medical records as per the facility's policy resulted in a deficiency in maintaining accurate and complete clinical records.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for a resident diagnosed with osteoporosis and osteoarthritis. The resident had a physician's order for Miacalcin Nasal Solution, a medication to prevent bone loss, to be administered daily. However, the Medication Administration Records (MARs) indicated that the medication was not administered on several occasions in February and May 2024. Specifically, the medication was not given from February 22 to 26, 2024, and on May 16, 2024. The nursing progress notes revealed that the medication was unavailable due to issues with the pharmacy, including needing approval from the Director of Nursing and awaiting delivery. Despite these missed doses, there was no documentation indicating that the physician was notified of the missed medication. During an interview, the Nursing Home Administrator confirmed the lack of evidence that the physician was informed about the missed doses, which constitutes a failure to meet the resident's physical needs as per professional standards.
Failure to Provide Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent infection of a pressure ulcer for one resident. The resident, who had diagnoses including peripheral vascular disease and congestive heart failure, was evaluated by a wound consultant on May 16, 2024, for a new stage II pressure injury on her left medial distal foot. The wound consultant recommended daily treatment, including cleansing the area with wound cleanser, applying calcium alginate, and securing it with bordered gauze. However, the clinical record of the resident did not show any treatment orders for the wound between May 16, 2024, and May 21, 2024. The active physician orders for treatment were only effective starting May 21, 2024, indicating a gap in care. During an interview, the Nursing Home Administrator acknowledged that treatment orders should have been in place immediately following the discovery of the new skin concern.
Medication Administration Deficiency for a Resident
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of medications for a resident diagnosed with osteoporosis and osteoarthritis. The resident had a physician's order for Miacalcin Nasal Solution, a medication to help prevent bone loss, to be administered daily. However, the Medication Administration Records (MARs) indicated that the medication was not administered on several occasions, specifically from February 22 to 26, 2024, and on May 16, 2024. The nursing progress notes revealed that the medication was unavailable due to issues with the pharmacy, which required approval from the facility to fill the prescription as it was a non-covered medication. This process caused delays in obtaining the medication. During an interview, the Nursing Home Administrator confirmed that the medication was not administered because the staff could not locate it, and the pharmacy needed facility approval to provide a replacement. The administrator did not have additional information regarding the missed dose on May 16, 2024.
Medication Administration Error
Penalty
Summary
The facility failed to follow professional standards of practice in medication administration for one resident. An LPN administered medication intended for another resident to Resident 1, who had diagnoses including tibia and fibula fractures and chronic obstructive pulmonary disease (COPD). The error occurred when Resident 1 was handed Resident 2's medications and ingested one pill before realizing the mistake. The ingested pill was identified as Tamsulosin, a medication not prescribed to Resident 1 during her stay at the facility. The Director of Nursing (DON) confirmed that the LPN did not adhere to the facility's medication administration policy, which mandates that medications be administered according to the written orders of the attending physician. The incident was reported immediately, and the physician was notified to monitor Resident 1 for any side effects. The Nursing Home Administrator (NHA) also confirmed the policy breach by the LPN, leading to the medication error.
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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