Gettysburg Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gettysburg, Pennsylvania.
- Location
- 867 York Road, Gettysburg, Pennsylvania 17325
- CMS Provider Number
- 395733
- Inspections on file
- 27
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Gettysburg Center during CMS and state inspections, most recent first.
A resident with CHF and chronic kidney disease was on a physician-ordered 1500 ml/day fluid restriction divided between dietary and nursing, with care plan interventions to offer fluids within restriction parameters. Facility policy assigned nursing responsibility for tracking total fluid intake but lacked guidance on actions when restrictions were exceeded. Over several months, MAR review showed the resident repeatedly exceeded the nursing fluid allotment, yet there was no documentation that the physician was notified. The record also lacked documentation of fluids taken with meals, so total 24-hour intake was never determined. The DON confirmed that dietary fluid intake was not recorded, that the resident exceeded allotted nursing fluids on multiple occasions, and that staff did not total all fluids over each 24-hour period.
A resident with GERD and peripheral vascular disease was observed in bed with eight medications left on the overbed table, which the resident stated an LPN had left for self-administration after breakfast. Facility medication administration policy lacked a requirement for staff to remain with residents and observe medication ingestion. Review of the clinical record showed no MD order, care plan, or evaluation authorizing self-administration of medications for this resident, and the administrator confirmed medications should not have been left at the bedside.
Surveyors found that medications on two medication carts were not labeled or discarded according to facility policy. On one cart, an RN had an opened single-dose haloperidol vial stored loose with insulin pens, without any resident name or date. On another cart, an LPN had a lispro insulin pen for a resident that was kept beyond the 28-day discard period and a Lantus insulin pen for another resident that was opened but not dated, despite the facility’s requirement to date insulin when first used and discard lispro after 28 days. The DON later confirmed that medications were expected to be labeled, stored, and discarded per policy and manufacturer guidelines.
The facility did not follow its diet extension sheets and approved menus for residents on regular diets, affecting all residents reviewed on this diet. The diet manual required that regular diets provide adequate nutrients through three balanced meals and up to three snacks daily. However, during a lunch meal service, residents on regular diets were served rotini pasta salad using a 3‑oz scoop instead of the 1/2 cup (4 oz) portion specified on the diet extension sheets. In an interview, the NHA acknowledged that meals were expected to be prepared and served according to menus approved by the dietician and physician, but the observed portions did not match those requirements.
Staff failed to follow infection prevention and control policies during wound care, medication storage, and medication administration. A resident with a stage 4 pressure ulcer and MDRO risk had an order and care plan for Enhanced Barrier Precautions, including gown and glove use for wound care, but an RN performed a dressing change without wearing a gown. An LPN stored a personal jacket in a medication cart drawer with medications and, during medication administration for another resident, placed an inhaler and antibiotic eye drops directly on the overbed table without a clean barrier, did not wear gloves to administer the eye drops, and did not wear gloves when applying a lidocaine patch, then returned the medication boxes to the cart drawer.
Two residents who required assistance with activities of daily living did not receive scheduled showers on multiple occasions, with documentation marked as 'not applicable' instead of indicating a refusal or other reason. Both residents had care plans emphasizing the importance of personal hygiene and choice in bathing method, but the facility did not ensure these services were provided or properly documented.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition.
A registered nurse failed to follow infection control protocols by using a single-dose syringe to administer medication to two residents, one of whom was being treated for a bacterial infection. The incident was reported by a resident after she was mistakenly given her spouse's medication and the same syringe was then used for her spouse. Facility policy and CDC guidelines prohibit this practice, and the administrator confirmed the breach.
A resident with a history of falls and complex medical conditions required extensive assist of two for bed mobility, but an agency nurse aide provided care alone, contrary to the care plan. During turning, the resident fell from bed, resulting in severe pain and a displaced orthopedic appliance in the arm, as confirmed by x-ray and facility documentation.
A resident with a history of falls and complex medical conditions required extensive assist of two staff for bed mobility, but was instead assisted by a single agency nurse aide. During care, the resident was rolled away from the aide and fell from a high bed, resulting in a displaced fracture and broken surgical hardware. Facility records and staff interviews confirmed that the care plan and facility policy were not followed, leading to the accident.
The facility did not ensure timely assessment and physician notification for two residents experiencing significant changes in condition. In one case, a resident with multiple comorbidities had confusion, low blood pressure, and unrelieved pain, but the supervising RN did not assess or notify the physician as required. In another case, a resident with hemiparesis and malnutrition had repeated nausea, vomiting, and medication refusals, but LPNs failed to escalate the situation to an RN or inform the physician, resulting in a lack of appropriate intervention.
The facility failed to provide required transfer notices to three residents or their representatives upon hospital transfers. The notices lacked essential information, including appeal rights and Ombudsman contact details. The Nursing Home Administrator confirmed the deficiency.
The facility failed to store medications according to professional standards, as observed in three medication carts with loose pills and granular dust. An LPN was unaware of cleaning procedures, and the NHA admitted the lack of a policy for cart inspection and cleaning.
A facility failed to update a care plan for a resident with congestive heart failure and anxiety, who often refuses care and shaves her own face. The care plan, last revised months ago, did not reflect these practices. The DON acknowledged the oversight during an interview.
A resident with a stage IV sacral pressure ulcer did not receive care consistent with professional standards. The facility's policy required labeling dressings with the date and initials, but an observation revealed no dressing was in place to indicate the last change. The RN could not explain the missing dressing, and the NHA confirmed the dressing should have been in place and labeled.
A facility failed to prevent contamination of a urinary catheter for a resident with obstructive uropathy and hydronephrosis. The facility's policy requires catheter tubing to be secured and kept off the floor. However, during an observation, the resident was seen with the catheter tubing dragging on the ground while being transported in a wheelchair. The Nursing Home Administrator confirmed that the tubing should not have been touching the ground.
A resident with dysphagia did not receive all items and correct portions as per the menu. The resident's meal was served with incorrect portion sizes and missing items on two consecutive days. Dietary aides confirmed the errors, and the Nursing Home Administrator acknowledged the expectation for correct service.
The facility did not update the required nurse staffing information daily, as observed on two consecutive days when the posted information was outdated. The Nursing Home Administrator confirmed that the expectation was for daily updates.
The facility failed to meet operational standards due to incomplete life safety drawings and lack of documentation for carbon monoxide alarm testing and protocols. Interviews confirmed these deficiencies, including the inability to verify alarm audibility and evacuation procedures.
The facility did not conduct the necessary annual and tri-annual maintenance and testing on its sprinkler systems, as required by NFPA 25. A document review revealed missing documentation for the wet system's annual inspection and the dry system's annual and 3-year tests. This was confirmed by the Administrator and Maintenance Director during an exit conference.
The facility failed to maintain and test its emergency generator system as required. Documentation was missing for diesel fuel quality testing, an annual 90-minute load bank test, and a 3-year, 4-hour load test. These deficiencies were confirmed during an exit conference with the Administrator and Maintenance Director.
The facility failed to maintain emergency lighting as required by NFPA 101. Documentation review showed a lack of monthly and annual testing of battery-powered emergency lighting sources, confirmed by the Acting Administrator and Director of Maintenance. An observation also revealed a non-operational battery back-up lighting unit in the Maintenance Mechanical Room.
The facility failed to maintain hazardous area doors, as the 'Dock Area' door did not self-close due to a missing device, and the Kitchen Storage door failed to latch due to a missing lock cylinder. These issues were confirmed by the administration and maintenance staff.
The facility failed to document monthly 'quick checks' on the Kitchen Suppression System and semiannual cleaning of the kitchen exhaust ductwork. During a review, it was found that the facility lacked records of these checks and cleanings, with the last documented cleaning dated October 10, 2024. This was confirmed by the Administrator and Maintenance Director.
The facility did not provide documentation verifying the annual testing and inspection of the fire alarm system within the past year. This issue was confirmed during a document review and an exit conference with the Administrator and Maintenance Director.
The facility failed to document monthly and annual inspections of portable fire extinguishers as required by NFPA 10. During a review, it was found that there was no documentation verifying that these inspections had been conducted. This was confirmed by the Administrator and Maintenance Director during an exit conference.
The facility failed to conduct required fire drills for all shifts during the second quarter of 2024, affecting the entire component. This deficiency was confirmed through documentation review and an interview with the Administrator and Maintenance Director, highlighting a lapse in ensuring staff readiness for fire emergencies.
The facility failed to document the annual inspection of all fire-rated doors in six smoke compartments, as required by NFPA standards. This was confirmed during a review and an exit conference with the Administrator and Maintenance Director.
A facility failed to follow its policy and physician's orders to monitor a resident's weight weekly for four weeks. The resident, with a history of diabetes, dementia, and a stage 4 pressure ulcer, was not weighed on three specified dates, despite having a nutritional risk. This oversight was acknowledged by the NHA.
The facility failed to provide appropriate therapeutic diets for residents, affecting those on renal and consistent carbohydrate diets. Observations showed incorrect food items served, such as stewed tomatoes instead of seasoned beets and chocolate ice cream instead of fruit sherbet. Interviews confirmed the unavailability of correct items on the tray line, despite their presence in the kitchen. Residents expressed concerns about their dietary needs not being met.
A resident was not informed about her financial responsibility for transportation to medical appointments, resulting in an unexpected bill. The absence of an Admissions Director at the time of admission contributed to the lack of communication regarding transportation options and costs.
The facility failed to notify the resident, resident representative, and the Office of the State Long-Term Care Ombudsman in writing before transferring or discharging residents to the hospital. This deficiency was identified for three residents with various medical conditions, and the facility admitted to not being aware of the notification requirements.
The facility failed to protect the personal property of two residents, one who passed away and another who left against medical advice. The required inventory of personal effects was not completed or communicated to the residents' representatives, as confirmed by the Nursing Home Administrator.
The facility failed to update a resident's care plan to include the use of a bed-side commode, despite the resident having muscle weakness and hemiplegia. The DON acknowledged the oversight.
The facility failed to document post-dialysis assessments for a resident with heart failure and stage 5 chronic kidney disease. Staff did not complete the required post-dialysis treatment sections on the Hemodialysis Communication Record sheets, despite the facility's policy mandating such documentation.
The facility failed to store medications according to professional standards, as observed with a medicine cup filled with Senna S tablets in the North 1 Medication cart. Staff had transferred the medication from a large bottle, contrary to facility policy.
The facility failed to follow infection control practices during medication administration for a resident with breast cancer and congestive heart failure. An LPN was observed dispensing medications into her bare hand before placing them into a medicine cup, contrary to the facility's policy and the DON's expectations.
Failure to Monitor and Document Fluid Intake for Resident on Fluid Restriction
Penalty
Summary
The facility failed to adequately monitor and manage fluid intake for a resident on a physician-ordered fluid restriction, resulting in a failure to ensure proper hydration and adherence to the ordered restriction. Facility policy titled "Fluid Restriction" assigned nursing services responsibility for tracking and documenting total volume consumed, but the policy did not provide guidance on what measures staff should take if a resident exceeded ordered fluid restrictions. The resident had diagnoses including acute on chronic diastolic congestive heart failure and hypertensive heart and chronic kidney disease with heart failure, and had an order for a regular/liberalized diet with a 1500 cc fluid restriction, divided as 800 cc from dietary and 700 cc from nursing. The resident’s care plan identified risk for dehydration and nutritional risk, with interventions such as offering small amounts of fluids frequently and enforcing the 1500 ml fluid restriction, but the nurse aide Kardex only noted that the resident was on fluid restrictions without further directions. The dietary tray ticket indicated a 1500 ml per day restriction and a maximum of 240 ml per meal. Review of Medication Administration Records from August through mid-March showed that the resident exceeded the allotted nursing fluid portion on multiple dates across several months. Despite these repeated exceedances, the clinical record contained no documentation that the physician was notified when the resident went over the ordered nursing fluid allowance. Additionally, there was no documentation of fluids consumed from meal trays during this period, so the resident’s total 24-hour fluid intake was not determined. In an interview, the DON confirmed there was no documentation of dietary fluid intake with meals, that nurse aides verbally reported fluids to nurses, that the resident did exceed allotted nursing fluids on some occasions, and that there was no documentation showing all fluids were totaled for each 24-hour period, despite the expectation that staff follow fluid restriction orders and notify the physician when they are exceeded.
Medications Left at Bedside Without Orders or Evaluation for Self-Administration
Penalty
Summary
The facility failed to ensure that medications were administered in accordance with professional standards of practice for one resident. Facility policy on Medication Administration, General Guidelines, dated January 2025, did not contain any expectation that employees administering medications must remain with the resident and observe ingestion. Review of the Pennsylvania Nursing Practice Act, Chapter 21.145, indicated that an LPN administers medications and carries out therapeutic treatments as ordered by an authorized practitioner. For the identified resident, clinical record review showed diagnoses of GERD without esophagitis and peripheral vascular disease. On observation, the resident was seen sitting in bed with eight pills left on the overbed table, including aspirin 81 mg, bupropion ER 150 mg, bupropion ER 300 mg, calcitriol 0.5 mcg, two tablets of vitamin B12 500 mcg, metoprolol 50 mg, and senna 8.5 mg. The resident reported that an LPN had left the medications there for her to take after she finished breakfast. Review of the physician’s orders did not show any order for self-administration of medications, and the care plan did not include a self-administration of medication plan. The clinical record also lacked any evaluation of the resident for self-administration of medications. The Nursing Home Administrator confirmed that the resident should not have had medications left at the bedside.
Improper Labeling and Expired Insulin and Haloperidol on Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to properly label and discard medications in accordance with its own policies and accepted professional standards. Review of the facility’s “Storage of Medication” policy dated January 2025 and its appendix “Medications with Shortened Expiration Dates” (2007) showed that medications and biologicals must be stored to maintain integrity, insulin vials and pens must be dated when first used, and lispro insulin must be discarded 28 days after opening. During observation of the South Wing B Hall medication cart with a registered nurse, surveyors found an opened 1 ml single-dose vial of haloperidol lying loose in a plastic bin with insulin pens, without a resident name or date on the vial. The nurse confirmed the vial was not labeled or dated and acknowledged it should have been discarded after single use. On the South Wing C Hall medication cart, observed with an LPN, surveyors identified a lispro insulin pen for Resident 74 dated as opened on February 16, 2026, which exceeded the 28-day discard timeframe specified in the facility’s policy. They also found a Lantus insulin pen for Resident 5 that had been opened but was not dated, although the pharmacy label showed it had been dispensed on March 13, 2026. The LPN confirmed that Resident 74’s insulin pen was beyond the 28-day expiration and should have been discarded, and acknowledged that the Lantus pen should have been dated when opened and that she may have been the nurse who opened it without dating it. In a subsequent interview, the DON stated she expected medications to be labeled and stored properly and discarded when expired per policy or manufacturer guidelines.
Failure to Follow Diet Extension Sheets for Regular Diet Menus
Penalty
Summary
The facility failed to follow its diet extension sheets and approved menus to meet the nutritional needs and preferences of residents on regular diets for all 79 residents reviewed. The facility’s diet and nutrition care manual, reviewed February 16, 2026, specified that the regular diet should provide adequate nutrients as recommended by the Dietary Guidelines and National Research Council, using these guidelines to provide three balanced meals and up to three snacks daily. During observation of a lunch meal service on March 17, 2026, residents on regular diets were served rotini pasta salad using a 3‑ounce scoop. Review of the diet extension sheets for that lunch meal showed that residents on regular diets were to receive 1/2 cup (4 ounces) of rotini pasta salad, indicating that the served portion did not match the diet extension sheet. In an interview, the Nursing Home Administrator stated that she would expect resident meals to be prepared and served in accordance with menus approved by the dietician and physician, confirming that the observed practice did not align with facility expectations and written guidance.
Failure to Follow Infection Control and Medication Handling Policies
Penalty
Summary
The deficiency involves failure to implement infection prevention and control policies, including Enhanced Barrier Precautions and medication administration protocols. Resident 92 had a stage 4 pressure ulcer of the right buttock and dementia, with physician orders for enhanced barrier infection precautions and a care plan identifying risk for MDRO colonization/infection due to chronic wounds. The care plan required use of gown and gloves for high-contact activities, including wound care. During an observed dressing change to Resident 92’s sacral pressure ulcer, a registered nurse completed the ordered wound care without wearing a gown at any time, contrary to the resident’s care plan and the facility’s Enhanced Barrier Precautions policy. The Nursing Home Administrator later stated she would expect employees to use appropriate personal protective equipment. Additional deficiencies were identified related to infection control and medication handling on the South Wing C Hall medication cart and during medication administration. An LPN stored a personal jacket in the bottom drawer of the medication cart along with medications and acknowledged that the jacket should not be in the cart; the DON confirmed staff personal items should not be stored in medication carts. In a separate observation of medication administration for another resident, the same LPN placed the resident’s inhaler and antibiotic eye drops, in their boxes, directly on the overbed table without a clean barrier, did not apply gloves before administering antibiotic eye drops, and did not wear gloves when applying a lidocaine patch. After administration, the LPN returned the inhaler and eye drop boxes to the medication cart drawer. The LPN acknowledged she should have used a clean barrier and worn gloves, and the DON confirmed that gloves and a clean barrier were required by facility policy.
Failure to Provide Scheduled Personal Hygiene Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary care and services to maintain adequate personal hygiene and grooming for two residents who were dependent on staff for activities of daily living. For one resident with hypertension and chronic obstructive pulmonary disease, the clinical record and Kardex indicated the importance of allowing the resident to choose their preferred method of bathing, with scheduled shower days on Mondays and Thursdays. However, documentation showed that on several scheduled shower days, the resident did not receive a shower, and the task was marked as 'not applicable' rather than indicating a refusal or another reason for not providing the care. Similarly, another resident with dementia and hypertensive heart disease had a care plan emphasizing the importance of engaging in meaningful daily routines, including the choice of bathing method, with scheduled shower days on Mondays and Fridays. The clinical record revealed that on multiple scheduled shower days, the resident did not receive a shower, and the task was again marked as 'not applicable.' During an interview, the Nursing Home Administrator stated that if a resident refused a shower, it should be documented as a refusal, not as 'not applicable.'
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Improper Syringe Use Breaches Infection Control Protocol
Penalty
Summary
A deficiency occurred when a registered nurse used a single-dose syringe to administer medication to two different residents, which is a breach of infection prevention and control practices. The incident involved a resident who was asleep when the nurse placed a syringe in her mouth, containing medication intended for her spouse, who was on hospice care. The resident immediately objected, but reported tasting some of the medication before the syringe was removed. The nurse then used the same syringe to administer morphine to the resident's spouse. This action was reported by the resident to nursing staff later that morning and to her daughter in the evening. The resident was being treated for bacterial sinusitis with antibiotics at the time of the incident. The facility's infection control policy, consistent with CDC guidelines, requires that single-dose syringes never be used for more than one patient. The administrator confirmed that the syringe should have been discarded after its initial use and acknowledged that the event should have been reported by the nurse involved. The nurse in question is no longer employed at the facility.
Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that a resident was protected from neglect, resulting in actual harm. According to the resident's care plan, the individual required extensive assistance from two staff members for bed mobility due to a history of falls and multiple medical conditions, including chronic kidney disease, atrial fibrillation, and previous fractures. Despite this, an agency nurse aide attempted to provide care alone and did not follow the care plan instructions. During the process of turning the resident, the resident rolled off the opposite side of the bed and fell, landing with her feet touching the ground first. Following the fall, the resident complained of severe pain in multiple areas and was found to have a displaced orthopedic appliance in her left arm, as confirmed by x-ray. The incident was documented in progress notes and confirmed by staff interviews and facility investigation. The nurse aide involved had previously received training on safe turning and repositioning practices but failed to adhere to the required protocol, directly leading to the resident's fall and subsequent injury.
Failure to Provide Adequate Assistance During Bed Mobility Results in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that a resident received adequate assistance to prevent accidents, resulting in harm. According to the care plan, the resident required extensive assistance of two staff members for bed mobility due to a history of falls and multiple medical conditions, including chronic kidney disease and atrial fibrillation. Despite this, an agency nurse aide provided care and attempted to turn and reposition the resident alone. During this process, the resident was rolled away from the aide and fell out of bed, landing on the floor. The bed was reported to be in a high position at the time of the incident, and the resident's roommate confirmed the bed's position and hearing the fall. Following the fall, the resident experienced severe pain and was found to have a displaced fracture in the left humerus, with x-rays revealing broken hardware from a previous surgical repair. The incident reports and staff interviews confirmed that the care plan was not followed, as only one staff member assisted the resident instead of two. The facility's policy required implementation and documentation of patient-centered interventions according to individual risk factors, which was not adhered to in this case.
Failure to Provide Timely Assessment and Physician Notification for Changes in Condition
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for two residents, resulting in unmet physical, mental, and psychosocial needs. For one resident with a history of hypertension, bradycardia, and chronic pain syndrome, documentation showed that she experienced confusion, low blood pressure, and unrelieved pain. Despite her family's request for hospital transfer and her significantly abnormal vital signs, the agency RN supervisor dismissed the request and did not perform a nursing assessment or notify the physician. The resident was eventually transferred to the hospital by another nurse, where she was diagnosed with septic shock, acute kidney injury, and a urinary tract infection. In the case of another resident with hemiparesis, diabetes, and severe protein-calorie malnutrition, progress notes indicated repeated episodes of nausea, vomiting, and medication refusal over two days. There were no physician orders to address her symptoms, and meal intake was not documented after the onset of her symptoms. The LPNs did not notify an RN of the resident's condition, nor was there evidence that an RN assessed the resident or that the physician was informed of her ongoing symptoms and medication refusals. Staff interviews confirmed that the expected protocol was not followed in both cases. The nursing home administrator and a registered nurse acknowledged that the chain of command was not properly executed for the first resident and that the LPNs should have escalated the second resident's condition to an RN for assessment and physician notification. These failures were in violation of facility policies and state regulations regarding management, resident care policies, and nursing services.
Failure to Provide Required Transfer Notices
Penalty
Summary
The facility failed to provide the required transfer notices to residents or their representatives upon transfer to a hospital. This deficiency was identified for three residents who were hospitalized. For Resident 63, the clinical record showed multiple hospital transfers, but the transfer notices lacked a statement of the resident's appeal rights and the contact information for the Office of the State Long-Term Care Ombudsman. The Nursing Home Administrator confirmed that the transfer notices should have included this information. Resident 77 was transferred to the hospital twice due to acute medical changes, but there was no evidence of transfer notices being provided to the resident or their representative. Similarly, Resident 84 was transferred to the hospital following a fall with a fracture, but no written notification was provided to her or her representative. The Nursing Home Administrator confirmed the absence of the required transfer notices for these residents.
Medication Storage Deficiency in Facility
Penalty
Summary
The facility failed to ensure that medications were stored in a manner that met professional standards, as observed in three medication carts located in North Hall B, North Hall C, and South Hall A. During observations on February 19, 2025, surveyors found multiple loose pills, both whole and fragmented, as well as multi-colored granular dust consistent with crushed or degraded pills in the drawers and at the bottom of the medication carts. Additionally, a blister-pack of medications, filled by the pharmacy in April 2024 for a resident who had been discharged in the same month, was found lodged behind the lowest drawer of the North B Hall medication cart. Interviews with staff revealed a lack of awareness and procedures regarding the cleaning of medication carts. Employee 3, an LPN, was unaware of the facility's procedure for cleaning the medication carts, while Employee 4, another LPN, was familiar with the procedure as she was recently hired. The Nursing Home Administrator admitted that the facility did not have a policy or procedure in place to address how often medication carts should be inspected and cleaned, although it was the facility's expectation that the carts remain clean.
Care Plan Not Updated for Resident's Self-Care Practices
Penalty
Summary
The facility failed to ensure the care plan for a resident was reviewed and revised appropriately. The resident, who has diagnoses of congestive heart failure and anxiety, was observed lying in bed with facial hair. The care plan, last revised on August 31, 2024, did not include any mention of the resident's refusal of care or her practice of completing her own facial shaving. An interview with the Director of Nursing revealed that the resident often refuses care and shaves her own face when necessary, which should have been included in the care plan.
Failure to Provide Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, identified as Resident 54, who had a stage IV sacral pressure ulcer. The facility's policy required that after applying and securing a clean dressing, staff should label it with the date and initials. However, during an observation of wound care, it was found that there was no dressing in place to indicate when the last dressing change was completed. Employee 6, a Registered Nurse, could not explain the absence of the dressing and acknowledged that there should have been a dressing in place from the previous day. Resident 54 had clinical diagnoses including a stage IV sacral pressure ulcer and bipolar disorder. The physician's orders for February 2025 specified wound care to the sacrum every evening shift, which included cleansing with normal saline solution, lightly packing with calcium alginate, and covering with bordered gauze island dressing. The Nursing Home Administrator confirmed that the dressing should have been in place and properly labeled according to the facility's policy.
Failure to Prevent Contamination of Urinary Catheter
Penalty
Summary
The facility failed to ensure the protection from contamination of a urinary catheter for one resident with an indwelling catheter. The facility's policy, revised on February 1, 2023, requires that catheter tubing be secured to keep the drainage bag below the level of the patient's bladder and off the floor. Resident 17, who has diagnoses including obstructive uropathy and hydronephrosis, utilizes an indwelling Foley catheter as part of his care plan, which also specifies keeping the catheter off the floor. However, during an observation on February 18, 2025, the resident was seen being transported in a wheelchair with the catheter tubing dragging on the ground underneath the chair. The Nursing Home Administrator confirmed that the expectation was for the catheter tubing not to touch the ground.
Failure to Serve Correct Menu Items and Portions
Penalty
Summary
The facility failed to serve all items on the posted menu and in the appropriate quantities for a resident with dysphagia, who required a pureed diet. The resident's clinical record indicated a need for a regular/liberalized diet with dysphagia puree texture, effective from September 26, 2024. On February 18, 2025, the resident's lunch meal ticket specified several items, including pureed sweet and sour meatballs, pureed boiled potatoes, pureed white rice, pureed warm bread, pudding, and brown gravy. However, during meal service, the dietary aide used a #16 scoop instead of the required #8 scoop for the meatballs, resulting in a smaller portion. Additionally, the resident did not receive the pureed rice as indicated on the meal ticket. On the following day, February 19, 2025, the resident was supposed to receive 2 ounces of brown gravy with her meal, as per the lunch meal ticket. However, an observation revealed that the gravy was missing from the resident's tray. Interviews with the dietary aides confirmed the omissions and incorrect portioning. The Nursing Home Administrator acknowledged that the resident should have received all items in the correct portion sizes, as per the facility's expectations.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing information on a daily basis. Observations on February 19 and February 20, 2025, revealed that the posted nursing staff information was outdated, showing the date of February 18, 2025. During an interview with the Nursing Home Administrator on February 20, 2025, it was confirmed that the facility's expectation was for the staffing information to be updated daily.
Deficiencies in Life Safety Drawings and Carbon Monoxide Alarm Protocols
Penalty
Summary
The facility failed to meet the minimum standards for operation as required by the Department and other state and local agencies. During a review of documentation and interviews conducted on February 4, 2025, it was found that the facility's life safety drawings were incomplete. Specifically, they lacked critical information such as resident room capacities, door swing designation, space/room designators, and highlighted rated assemblies. This deficiency was confirmed in an interview with the Acting Administrator and Director of Maintenance. Additionally, the facility did not have documentation of annual testing and inspection of installed Carbon Monoxide Alarms, as required by the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act. The facility also could not verify that the installed carbon monoxide alarms were audible to on-duty staff, nor did it have documentation verifying evacuation and alarm protocols. These deficiencies were confirmed during interviews with the Acting Administrator and Director of Maintenance.
Plan Of Correction
Facility drawings will include resident room capacities, door swing designation, and space/room designators. Annual testing and inspection of installed carbon monoxide alarms will be completed. Carbon monoxide alarms will be placed where on-duty staff can hear the alarms. Facility staff will be educated on carbon monoxide alarms. Maintenance staff will be educated on the facility drawing. One carbon monoxide test will be completed monthly for 2 months. Audit results will be reviewed at the next QAPI meeting.
Failure to Perform Required Sprinkler System Maintenance
Penalty
Summary
The facility failed to perform required annual and tri-annual maintenance and testing on its sprinkler systems, as mandated by NFPA 25. During a document review on February 4, 2025, it was discovered that the facility did not have documentation for the annual inspection of the wet system, including the main drain and control valves, nor for the dry system's annual trip test and the 3-year full flow trip test. This deficiency was confirmed during an exit conference with the Administrator and Maintenance Director, who acknowledged that the inspections were not performed.
Plan Of Correction
The facility will have a sprinkler inspection completed on 3/4/25. The maintenance staff will be educated on completing a sprinkler inspection annually. A quarterly audit will be completed to ensure a sprinkler inspection was completed. Audit results will be reported to the next QAPI meeting.
Deficiency in Emergency Generator Maintenance and Testing
Penalty
Summary
The facility failed to meet the requirements for maintenance and testing of its emergency generator system, which serves the entire component. During a document review and interview process, it was discovered that the facility did not have documentation verifying that the quality of diesel fuel for the emergency generator had been inspected within the previous twelve months. This was confirmed during an exit conference with the Administrator and Maintenance Director, who acknowledged the lack of verification for diesel fuel quality testing. Additionally, the facility was unable to provide documentation for critical tests of the emergency generator. Specifically, there was no record of an annual 90-minute load bank test or a 3-year, 4-hour load test being performed. These deficiencies were confirmed during the exit conference, indicating a failure to adhere to the required maintenance and testing protocols for the emergency power system as outlined by NFPA standards.
Plan Of Correction
Diesel fuel for the generator will be inspected. A 90-minute load bank test will be completed as well as a 4 hour load test. Maintenance staff will be educated on the necessary inspections needed for the emergency generator. A semi annual audit will be completed to ensure that the necessary tests for the emergency generator have occurred. Audit results will be reported to QAPI.
Deficiency in Emergency Lighting Maintenance
Penalty
Summary
The facility was found to be deficient in maintaining emergency lighting as required by NFPA 101. During a document review, it was discovered that the facility did not conduct the necessary functional monthly and annual testing of battery-powered emergency lighting sources. This was confirmed through an interview with the Acting Administrator and Director of Maintenance. Additionally, an observation revealed that the battery back-up lighting unit in the Maintenance Mechanical Room failed to operate, indicating a lack of proper maintenance and testing of emergency lighting fixtures throughout the facility.
Plan Of Correction
Annual testing and monthly testing of battery powered emergency lighting will occur. Maintenance mechanical room battery will be replaced. Annual lighting check will occur by 3/15/25. Maintenance staff will be educated on completing monthly and annual testing of battery powered emergency lighting. A quarterly audit will occur to ensure that monthly testing of battery powered emergency lighting is occurring. Audit results will be reported at the next QAPI meeting.
Deficiencies in Hazardous Area Door Maintenance
Penalty
Summary
The facility was found to have deficiencies in maintaining the safety of hazardous areas, as evidenced by the failure of certain doors to self-close and positively latch. During an observation on February 4, 2025, at 12:15 PM, it was noted that the right leaf of the 'Dock Area' door did not self-close due to the absence of a self-closing device. This deficiency was confirmed during an interview with the Acting Administrator and Director of Maintenance later that day. Additionally, another observation at 12:20 PM on the same day revealed that the Kitchen Storage door failed to positively latch because it lacked a lock cylinder. This issue was also confirmed during the exit conference with the facility's administration and maintenance leadership. These deficiencies affected two of the six smoke zones within the facility, indicating a failure to comply with the required fire safety standards for hazardous areas.
Plan Of Correction
Self-closing device and a magnetic lock will be added to the dock door. Lock cylinder will be added to the kitchen storage door. I am requesting a time limited waiver for this self-closing device and magnetic lock due to the hardware not being here until after 3/24/25. I sent you a letter requesting the TLW. The dock door work will be completed by 8/1/25. All hazardous areas will have a self-closing device to the doors. 3. Maintenance staff will be educated on Hazardous areas within the building needing self-closing devices. 4. A quarterly audit will occur for all hazardous areas having self-closing devices. The Audit will address hazardous doors self-closing and positively latch. Audit results will be reviewed at the next QAPI meeting.
Lack of Documentation for Kitchen Suppression System and Ductwork Cleaning
Penalty
Summary
The facility failed to maintain proper documentation of the Kitchen Suppression System's monthly 'quick checks' and semiannual cleaning of the kitchen exhaust ductwork. During a document review on February 4, 2025, it was found that the facility did not have records of the monthly checks being performed on the Kitchen Suppression System. This was confirmed during an interview with the Administrator and Maintenance Director, who acknowledged the absence of such documentation. Additionally, the facility was unable to provide evidence of the kitchen exhaust ductwork being cleaned semiannually within the past year. The only available documentation was from October 10, 2024, indicating a lapse in maintaining the required cleaning schedule. This deficiency was also confirmed during the exit conference with the facility's administration and maintenance personnel.
Plan Of Correction
Quick checks will be completed monthly on the kitchen suppression system. Going forward, the kitchen exhaust ductwork will be cleaned semiannually. Quick checks will be completed monthly and the kitchen exhaust ductwork will be cleaned semi-annually going forward. Maintenance staff will be educated on completing monthly quick checks on the kitchen suppression system and having exhaust ductwork cleaned semiannually. Audits will be completed semi-annually regarding the kitchen suppression system and exhaust ductwork. Audit results will be reported to QAPI.
Failure to Document Annual Fire Alarm System Testing
Penalty
Summary
The facility failed to provide documentation verifying that the annual testing and inspection of the fire alarm system had occurred within the previous twelve months. This deficiency was identified during a document review conducted on February 4, 2025, between 9:30 AM and 11:15 AM. The absence of this documentation affects the entire component of the fire alarm system. During an exit conference on the same day at 2:00 PM, both the Administrator and Maintenance Director confirmed the lack of documentation for the required annual testing and inspection.
Plan Of Correction
Annual inspection completed on March 15, 2024. Fire alarm system will be inspected annually going forward. Maintenance staff will be educated on having the fire alarm system inspected annually. Fire alarm system audit will be completed semi-annually to be sure that the fire inspections are occurring and results reported at the next QAPI meeting.
Failure to Document Fire Extinguisher Inspections
Penalty
Summary
The facility failed to comply with the requirements for the inspection and maintenance of portable fire extinguishers as outlined in NFPA 10. During a document review on February 4, 2025, it was discovered that the facility did not have documentation to verify that monthly visual inspections of the fire extinguishers had been conducted. Additionally, there was no documentation available to confirm that the annual inspection of the fire extinguishers had been performed. These deficiencies were confirmed during an exit conference with the Administrator and Maintenance Director, who acknowledged the lack of documentation for both monthly and annual inspections.
Plan Of Correction
Visual inspections of fire extinguishers will be completed monthly. An annual fire extinguisher inspection will be completed. Maintenance staff will be educated on completing visual inspections monthly on fire extinguishers and having an annual inspection completed on fire extinguishers. A monthly audit will be completed to ensure visual inspections of fire extinguishers are occurring and an annual fire extinguisher inspection was completed. Audit results will be reported at the next QAPI meeting.
Failure to Conduct Required Fire Drills
Penalty
Summary
The facility failed to conduct and perform required fire drills, which are essential for ensuring staff readiness in case of a fire emergency. Specifically, the facility did not perform fire drills for all three shifts during the second quarter of 2024. This deficiency was identified through a review of documentation and confirmed during an interview with the Administrator and Maintenance Director. The absence of these drills affects the entire component of the facility, as fire drills are crucial for familiarizing staff with emergency procedures and ensuring they are prepared for unexpected fire conditions.
Plan Of Correction
Fire drills will be performed, one per shift, per quarter. Maintenance staff will be educated on completing fire drills on one shift per quarter. An audit will occur quarterly to ensure fire drills will be performed one per shift, per quarter. Audit results will be reported to QAPI.
Incomplete Fire Door Inspection Documentation
Penalty
Summary
The facility failed to provide documentation of the annual fire door inspection for all fire-rated doors in six of six smoke compartments. During a document review conducted on February 4, 2025, between 9:30 AM and 11:15 AM, it was revealed that the facility's records did not include all the fire-rated doors as required by NFPA 101 and NFPA 80 standards. This deficiency was confirmed during an exit conference with the Administrator and Maintenance Director, where they acknowledged the absence of complete documentation for the annual fire door inspection.
Plan Of Correction
Fire doors will be inspected annually. Maintenance staff will be educated in completing an annual fire door inspection. Fire doors will be audited semi-annually and the results of the audits will be reported to QAPI.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to adhere to its policy and physician's orders regarding the monitoring of a resident's weight. The policy required that new admissions be weighed weekly for four weeks, and a physician's order specified that weights should be taken every Saturday during the day shift for four weeks. However, the facility did not record the resident's weight on three specified dates, despite the resident having a nutritional risk due to decreased oral intake, dementia, and increased nutrient needs related to a stage 4 sacral pressure ulcer. The resident, who had a history of type 2 diabetes mellitus and dementia, was admitted with a weight of 118.4 pounds. By the next recorded weight, the resident had lost 2.2 pounds. The failure to obtain weights as ordered was acknowledged by the Nursing Home Administrator, indicating a lapse in following both the physician's orders and the facility's policy, which could have impacted the resident's care and monitoring of their nutritional status.
Failure to Provide Therapeutic Diets
Penalty
Summary
The facility failed to provide appropriate therapeutic diets for residents on June 5, 2024, affecting three residents on a renal diet and two residents on a consistent carbohydrate diet. Observations revealed that residents on a renal diet were served stewed tomatoes instead of seasoned beets and chocolate ice cream instead of fruit sherbet. Additionally, residents on a consistent carbohydrate diet did not receive the correct bread items as specified in their dietary orders. Interviews with dietary staff confirmed the unavailability of the correct food items on the tray line, despite their presence in the kitchen. Resident 1, diagnosed with end-stage renal disease and diabetes mellitus type II, did not receive the prescribed seasoned beets. Resident 2, with diabetes mellitus type II and chronic kidney disease, was missing a dinner roll from their meal tray. Resident 3, who also has chronic kidney disease and diabetes mellitus type II, expressed ongoing concerns about their renal diet not being followed, as evidenced by receiving incorrect food items. Resident 4, with similar diagnoses, received a dinner roll instead of wheat bread. Resident 12, who also has diabetes mellitus type II and chronic kidney disease, had previously filed a grievance about their renal diet not being followed, specifically regarding the excessive serving of potatoes.
Failure to Inform Resident of Transportation Costs
Penalty
Summary
The facility failed to inform and assist a resident in making transportation arrangements based on financial conditions. A review of the clinical record for a resident revealed that she required transportation to four medical orthopedic appointments. The resident was not informed upon admission that she was financially responsible for the transportation costs or that she had the option of having family transport her. Consequently, the resident received an unexpected bill for the transportation costs. Interviews with the Director of Nursing confirmed that there was no Admissions Director at the time of the resident's admission, which led to the lack of communication regarding transportation responsibilities and options.
Failure to Notify Resident Representatives and Ombudsman Before Transfers
Penalty
Summary
The facility failed to notify the resident, resident representative, and the Office of the State Long-Term Care Ombudsman in writing before transferring or discharging residents to the hospital. This deficiency was identified through clinical record reviews and staff interviews for three residents. Resident 21, with diagnoses including type two diabetes mellitus and atrial fibrillation, was transferred to the hospital multiple times without the required notifications. Similarly, Resident 84, diagnosed with dementia and Parkinson's disease, was transferred to the hospital without proper notification. Resident 297, with diagnoses including protein-calorie malnutrition and dementia, was also transferred to the hospital without the necessary notifications being sent to the resident representative and the Ombudsman office. During interviews, the Nursing Home Administrator (NHA) and Director of Nursing (DON) admitted that the facility had not been notifying the Ombudsman due to the absence of an Admissions Director and a lack of awareness that such notifications were required. The facility was unable to provide evidence of the required transfer notices and Ombudsman notifications for the hospital transfers of Residents 21, 84, and 297. This failure to notify is a violation of the regulations outlined in 28 Pa. Code 201.14(a) and 28 Pa. Code 201.18(b)(3).
Failure to Protect Residents' Personal Property
Penalty
Summary
The facility failed to ensure the protection of residents' personal property while in the facility and upon discharge or after death for two residents. The facility's policy required personnel to identify and record residents' belongings upon admission and update the inventory with any additional items brought in after admission. However, for Resident 95, who had diagnoses including dementia, diabetes mellitus, and chronic kidney disease, there was no inventory of personal effects or communication with the resident's representative regarding the return of personal property after the resident's death. Similarly, Resident 96, who had dementia and a history of falls, left the facility against medical advice, and there was no inventory of personal effects or communication with the resident's representative regarding the return of personal property after discharge. The facility could not locate the Inventory Of Personal Effects forms for both residents, as revealed during interviews with the Nursing Home Administrator (NHA). The NHA confirmed that the inventory should have been initiated during admission and signed upon discharge, but this was not done for Residents 95 and 96.
Failure to Update Care Plan for Resident's Bed-Side Commode
Penalty
Summary
The facility failed to ensure the care plan was reviewed and revised for one of the residents, identified as Resident 88. Resident 88 had diagnoses including muscle weakness and hemiplegia. During an observation, it was noted that Resident 88 had a bed-side commode in her room, which she confirmed belonged to her. However, a review of her care plan revealed that it did not include any directions for the use of the bed-side commode. The Director of Nursing acknowledged that the care plan should have been updated to include this information.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to provide and document post-dialysis assessments for a resident who required hemodialysis. According to the facility's policy, staff were required to complete a post-dialysis assessment upon the resident's return from the dialysis center. This assessment included documenting the condition of the access site, vital signs, presence of bruit or thrill, post-dialysis complications, and any new orders from the dialysis center. However, for Resident 150, who had diagnoses including heart failure and stage 5 chronic kidney disease, the post-dialysis treatment sections on the Hemodialysis Communication Record sheets dated March 8 and 18, 2024, were not completed by the facility staff. These forms were reviewed and signed by a facility medical practitioner but lacked the necessary post-dialysis documentation by the nursing staff. During an interview, the Nursing Home Administrator confirmed that it was the facility's expectation for staff to complete the post-dialysis assessment when a resident returns from dialysis treatment. The failure to document these assessments was identified through clinical record review, facility policy review, and staff interviews, indicating a lapse in adherence to the established protocol for monitoring and documenting the condition of residents post-dialysis.
Improper Medication Storage
Penalty
Summary
The facility failed to ensure medications were stored in a manner that met professional standards. During an observation of the North 1 Medication cart, a medicine cup filled with small, round, red tablets labeled as Senna S was found in the top drawer. This medicine cup was stored alongside multiple manufacturer-provided over-the-counter medicine containers. The facility policy requires that medications and biologicals be stored in their original containers and prohibits non-pharmacy personnel from transferring medications between containers. However, it was noted that the Senna S tablets had been transferred from a large bottle into the medicine cup by staff, which is against the facility's policy. During staff interviews, an LPN indicated that the medicine was placed in the cup because the pharmacy had sent a large bottle of Senna S. The Nursing Home Administrator confirmed that medications should be stored in their original containers as received from the pharmacy. This deficiency was identified based on observations, staff interviews, and a review of the facility's policy on medication storage and expiration dating.
Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
The facility failed to provide medications in a manner consistent with infection control practices for one of four residents observed for medication administration. During the preparation of medications for Resident 3, who has diagnoses including breast cancer and congestive heart failure, a Licensed Practical Nurse (LPN) was observed dispensing nine separate medications from multi-dose containers into her bare hand before placing them into a medicine cup. Additionally, the LPN dispensed one medication from a blister-pack into her bare hand before placing it into the medicine cup. These actions were observed during a medication administration on March 19, 2024, at approximately 9:05 AM. The Director of Nursing (DON) revealed during a staff interview that it was her expectation that staff only handle medications with gloved hands. This practice was not followed by the LPN, leading to a breach in infection control protocols. The facility's policy on general dose preparation and medication administration, last revised on January 1, 2022, was not adhered to during this incident. The deficiency was identified under 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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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