Green Ridge Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Scranton, Pennsylvania.
- Location
- 2741 Boulevard Avenue, Scranton, Pennsylvania 18509
- CMS Provider Number
- 395067
- Inspections on file
- 20
- Latest survey
- November 14, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Green Ridge Care Center during CMS and state inspections, most recent first.
A resident with fibromyalgia, rheumatoid arthritis, and a rotator cuff tear received PRN Percocet for mild to moderate pain, contrary to the prescription for severe pain. The facility did not attempt non-pharmacological interventions before administering the medication, as confirmed by the Nursing Home Administrator and DON.
The facility failed to implement antibiotic stewardship protocols, leading to unnecessary antibiotic administration for two residents. One resident received Cefdinir for a suspected UTI without meeting criteria, while another received Rocephin despite unremarkable lab results and no infection signs. The Infection Preventionist confirmed noncompliance with infection control guidelines.
A resident with atrial fibrillation, who was cognitively intact, expressed a desire to be discharged home. However, the facility failed to document and update an individualized discharge plan, resulting in no clear plan by the time of the survey. The Nursing Home Administrator confirmed the lack of documentation for the resident's discharge goals.
The facility failed to ensure that the drug regimens for two residents were free from unnecessary antibiotics. One resident received Cefdinir for a suspected UTI without essential clinical indicators, while another was given Rocephin without meeting McGeer's Criteria or having lab evidence of infection. The facility's Infection Preventionist and DON confirmed these deficiencies, indicating a lack of adherence to the antibiotic stewardship program.
A resident with Medicaid payor source was not offered routine annual dental services for nearly two years. The resident later experienced facial pain and was treated for parotitis, a serious gum infection. The facility's Director of Nursing confirmed the oversight.
The facility did not meet the required LPN to resident ratios on two shifts. On one day shift, there were 3.03 LPNs instead of the required 3.72 for 93 residents. On a night shift, there were 2.28 LPNs instead of the required 2.35 for 94 residents. No additional higher-level staff were available to compensate for this deficiency.
The facility did not maintain a hazardous area enclosure in the 400 Hall storage room near Resident Room 406. The door failed to latch properly, and there was an unsealed penetration around the latching hardware. These issues were confirmed by the Facility Administrator and Facilities Manager.
The facility failed to maintain the automatic sprinkler system, affecting the entire floor. Four unsealed penetrations were found in the entrance canopy due to the relocation of four out of six sprinkler heads. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
The facility was found to have deficiencies in maintaining corridor doors, as observed during a survey. The door to a resident room in the 300 Hall and the door to the Lounge in the 100 Hall both required adjustments to fully close into their frames. These issues were confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility failed to maintain smoke barrier walls with a two-hour fire resistance rating, affecting two of six smoke compartments. Observations revealed unsealed penetrations around PVC sprinkler piping and fire alarm wire above the ceiling near a resident room. This was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility did not conduct the required quarterly fire drills for staff, missing the 2nd Shift drill for the 2nd quarter and the 3rd Shift drill for the 4th quarter of 2024. This was confirmed during an interview with the Facility Administrator and the Facilities Manager.
The facility failed to meet the required nurse aide to resident ratios across multiple shifts, with 14 out of 21 shifts reviewed showing deficiencies. For example, on one day, the day shift had 7.77 nurse aides instead of the required 9.00 for a census of 90 residents, and the night shift had 4.30 nurse aides instead of the required 6.00. No additional higher-level staff were available to compensate for these deficiencies.
The facility did not meet the required 3.2 hours of direct resident care per resident on multiple occasions, as confirmed by the Nursing Home Administrator. A review of staffing levels showed that on several dates, the facility provided less than the mandated nursing care hours, with the lowest being 2.95 hours.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide effective pain management for a resident, identified as Resident 18, who was admitted with diagnoses including fibromyalgia, rheumatoid arthritis, and a complete rotator cuff tear. The facility's policy required an evaluation of pain severity using appropriate scales and the use of non-pharmacological interventions before administering PRN narcotic pain medication. However, the facility did not adhere to this policy. The resident's clinical records showed that PRN Percocet was administered multiple times for pain levels that were documented as mild to moderate, despite the medication being prescribed only for severe pain. Additionally, there was no evidence that non-pharmacological interventions were attempted or documented as ineffective prior to the administration of the medication. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the lack of consistent attempts and documentation of non-pharmacological interventions before administering PRN pain medication. They also acknowledged that the staff administered narcotic pain medication intended for severe pain to the resident when the documented pain levels were only mild to moderate. This indicates a failure to follow the facility's pain management policy and to provide appropriate care as per the resident's needs and physician's orders.
Plan Of Correction
The DON / designee will complete a pain observation for R18. A review for R18's current pain medication and alternative pain management strategies will be completed to determine if the current orders address the current pain severity and that there are alternative pain management strategies in place to offer before resorting to medication. To identify other residents that have the potential to be affected, the DON / designee will complete an audit for current residents taking PRN pain medications to verify if medications are being given as ordered per the pain severity listed and alternative pain management strategies were offered before resorting to medication. Follow up will occur based on the results of the audit. To prevent this from reoccurring, the DON / designee will educate licensed nurses on the Pain Management Policy including administering medications based on severity of the pain and offering/documenting alternative pain management strategies before resorting to medication. To monitor and maintain compliance, the DON / designee will audit 10 residents' records who have received PRN pain medication to ensure that alternative pain management strategies were attempted before resorting to medication and if a medication was administered it was given per the resident's pain severity, as ordered by the physician. The audits will be completed weekly times 4 weeks and then monthly times 3. The results of the audits will be forwarded to QAPI committee for further review and recommendations.
Failure to Implement Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to consistently implement its antibiotic stewardship protocols for two residents, leading to the unnecessary administration of antibiotics. For one resident, admitted with dementia and congestive heart failure, the facility's infection tracker form indicated a suspected urinary tract infection (UTI). However, the completed assessment showed that the resident did not meet the McGeer's criteria for initiating antibiotic therapy, as they lacked the necessary symptoms such as fever or acute dysuria. Despite this, a physician's order prescribed Cefdinir, which was administered for seven days, contrary to the facility's antibiotic stewardship policy. Another resident, admitted with type II diabetes, dysphagia, and cerebral infarction, was catheterized to obtain a urine specimen due to an elevated white blood cell count. Despite unremarkable urinalysis results and no clinical signs of infection, the resident received two doses of Rocephin. The facility's Infection Preventionist confirmed the failure to implement antibiotic stewardship protocols, resulting in the initiation and continuation of antibiotic therapy without documented clinical necessity, inconsistent use of infection surveillance tools, and noncompliance with infection prevention and control guidelines.
Plan Of Correction
The facility is unable to correct the findings identified for R34 and R71. To identify other residents that have the potential to be affected, the IP / designee will audit the past 2 weeks for antibiotics that were ordered to determine if the McGeer's criteria had been completed to clinically justify the use of the antibiotic. Follow up will occur based on the audit findings. To prevent this from reoccurring, the DON / designee will educate the IP and licensed nurses on consistent implementation of the antibiotic stewardship protocols for initiating antibiotic use in accordance with the established infection prevention and control guidelines. To monitor and maintain compliance, the DON / designee will conduct audits of the IP's logs to ensure adherence to the established antibiotic stewardship program including clinical justification for use. The audits will be completed weekly times 4 weeks and then monthly times 3. The results of the audits will be forwarded to the QAPI committee for further review and recommendations.
Failure to Implement Individualized Discharge Plan
Penalty
Summary
The facility failed to develop and implement an individualized discharge plan for a resident, identified as Resident 3, who was admitted with a diagnosis of atrial fibrillation. Despite being cognitively intact, as indicated by a BIMS score of 15, the resident expressed a desire to be discharged home. However, there was a significant gap in the documentation of discharge planning, with social service notes indicating the resident's wish to go home dated August 28, 2024, and the next note not appearing until November 18, 2024. This lack of documentation and follow-up resulted in no clear discharge plan being in place by the time of the survey ending January 31, 2025. The comprehensive care plan for the resident did not reflect any updates or revisions to address the resident's current discharge goals or long-term placement desires. During an interview, the Nursing Home Administrator confirmed the absence of documented evidence of a current discharge goal and plan for the resident. This oversight highlights a failure in the facility's discharge planning process, as it did not adequately address the resident's expressed wishes or ensure a timely and effective transition plan.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. This statement applies to all observations listed below. Resident 3 had their discharge plan revised, to reflect the resident's current desire for discharge. To identify other residents that have the potential to be affected, the Social Service Director / designee will review the short-term residents in-house to assure that an individualized discharge plan reflects the residents' current desire for discharge or long-term placement. To prevent this from re-occurring, Social Services will be re-educated to follow up on documentation noted in the medical record of a resident change related discharge planning to discharge home or remain long-term and the care plan will be updated to reflect the residents' wishes. To monitor and maintain compliance, the Social Service Director / designee will randomly review social service notes each week of five short term residents for documentation related to discharge planning and check that the care plan on discharge reflects the residents' current discharge plan as documented in the clinical notes. The audits will be completed weekly times 4 weeks and then monthly times 2. The results of the audits will be forwarded to QAPI committee for further review and recommendations.
Failure to Ensure Drug Regimen Free from Unnecessary Antibiotics
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were free from unnecessary medications, specifically antibiotics, as required by §483.45(d). Resident 34 was administered Cefdinir for a suspected urinary tract infection (UTI) despite lacking essential clinical indicators such as fever, dysuria, leukocytosis, or gross hematuria. The only criterion met was a urine culture with >100,000 CFU/mL of a single organism, which alone was insufficient to justify antibiotic therapy. This resulted in the resident receiving fourteen doses of an unnecessary antibiotic. Resident 71 was prescribed Rocephin, an antibiotic, without meeting McGeer's Criteria or having laboratory evidence of an infection. The resident's urinalysis results were unremarkable, and the urine culture showed no growth, although the white blood cell count was elevated. Despite this, Rocephin was administered for two days. The facility's Director of Nursing confirmed that the required "Infection Tracker form with McGeer's Criteria - 2024" was not completed to clinically justify the use of the antibiotic. The facility's Infection Preventionist and Director of Nursing confirmed the deficiencies in antibiotic prescribing practices. The Infection Preventionist acknowledged that Resident 34 did not meet the requirements for antibiotic treatment, while the Director of Nursing reported that the prescribing physician for Resident 71 was aware that the signs and symptoms did not meet McGeer's protocol for prescribing an antibiotic. These failures indicate a lack of adherence to the facility's antibiotic stewardship program and resulted in the administration of unnecessary medications.
Plan Of Correction
The facility is unable to correct the findings identified for R34 and R71. To identify other residents that have the potential to be affected, the IP / designee will audit the past 2 weeks for antibiotics that were ordered to determine if the McGeer's criteria had been completed to clinically justify the use of the antibiotic. Follow up will occur based on the audit findings. To prevent this from reoccurring, the DON/ designee will educate the licensed nurses and providers related to providing documented evidence of clinical necessity for administration of antibiotics and unnecessary medication prescribing practices. To monitor and maintain compliance, the IP / designee will complete audits during the clinical morning meetings for residents with antibiotics ordered to verify there is documented evidence of clinical necessity for ordering the antibiotic. The audits will be completed 5 days per week times 4 weeks and then weekly times 4. The results of the audits will be forwarded to QAPI committee for further review and recommendations.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to offer routine annual dental services to a resident whose payor source was Medicaid. The resident, identified as Resident 23, was admitted to the facility on September 7, 2018. A review of the resident's clinical record revealed that from November 16, 2022, until October 20, 2024, the facility did not offer dental services to the resident. This oversight was confirmed during an interview with the Director of Nursing on November 30, 2025. Additionally, the resident experienced a medical issue related to dental care. On July 31, 2024, the resident complained of left-sided facial pain, and the facility's contracted CRNP noted new orders for Clindamycin to treat parotitis, a serious gum infection. This incident highlights the facility's failure to provide necessary routine dental services, which may have contributed to the resident's dental-related health issue.
Plan Of Correction
Resident 23 routine dental service has been scheduled. To identify other residents that have the potential to be affected, the Social Service Director will complete a list of current long-term residents' last annual dental appointment and schedule each resident's routine dental services as they become due from the last routine dental appointment. To prevent this from re-occurring, the Social Service Director will maintain a spreadsheet of current long-term residents' last routine dental appointment and ensure the next annual routine is scheduled timely each year. To monitor and maintain compliance, the Social Service Director will report at the monthly QAPI meeting the residents who are scheduled in the upcoming month to have routine dental services. The spreadsheet will be audited by NHA/designee weekly times 4 weeks and then monthly times 2. The results of the audits will be forwarded to the QAPI committee for further review and recommendations.
Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on two specific shifts out of 21 shifts reviewed. On January 23, 2025, during the day shift, the facility had 3.03 LPNs instead of the required 3.72 for a census of 93 residents. Similarly, on January 26, 2025, during the night shift, the facility had 2.28 LPNs instead of the required 2.35 for a census of 94 residents. There were no additional higher-level staff available to compensate for this deficiency. An interview with the Nursing Home Administrator confirmed the facility's failure to meet the required staffing ratios on these dates.
Plan Of Correction
The facility is unable to retroactively correct the cited issue. Staffing meetings will be held 5 days a week with the scheduler, Director of Nursing, and Nursing Home Administrator to review the current day LPN staffing ratios and upcoming week to ensure appropriate staffing levels for LPN staffing ratios for each shift. The facility is focusing on retention of existing LPNs and recruitment of new LPN nurses through the efforts of the Human Resources manager and the Administrator working on the facility recruitment and retention plan to maintain required state ratios. If the projected staffing ratios do not meet minimum, then the facility will reach out to current staff and local staffing agencies using as needed bonuses to enlist staff or agency staff to meet the minimum requirement. The facility will continue to recruit staff through all platforms. Daily audits of the schedules will be conducted for 7 days for 2 weeks and weekly for 2 months. The results will be reviewed at Quality Assurance and Performance Improvement meetings until substantial compliance of the state ratio can be met through the hiring and retention plan.
Hazardous Area Enclosure Deficiency in Storage Room
Penalty
Summary
The facility failed to maintain a hazardous area enclosure on the 400 Hall, specifically in the storage room near Resident Room 406. During an observation, it was noted that the storage room door did not latch into the frame when tested, and there was an unsealed penetration around the latching hardware of the door. These deficiencies were confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
Plan Of Correction
Door cannot be fixed. New purchase of door was approved and ordered to replace old door. Other storage doors will be checked for latching and any penetrations. The Maintenance Director/designee will continue to monitor supply doors on daily rounds. The Maintenance Director will add doors on preventive schedule to assure doors fully close into frame.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in one location, affecting the entire floor. During an observation on January 14, 2025, at 10:50 a.m., it was discovered that there were four unsealed penetrations in the entrance canopy. This issue arose due to the relocation of four out of six sprinkler heads. The deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 12:00 p.m.
Plan Of Correction
The 4 unsealed penetrations of the entrance canopy at the main entrance were sealed. Other areas outside with sprinklers will be checked for any unsealed penetrations. Maintenance Director was educated on if contractors do repairs or installations the area worked on will be checked to assure no penetrations. The maintenance director will add a contractor log to verify areas worked on by contractors has no penetration areas when work is completed.
Corridor Door Deficiencies in Facility
Penalty
Summary
The facility failed to maintain two corridor openings, which was observed during a survey conducted on January 14, 2025. The surveyors noted that the door to Resident Room 307 in the 300 Hall did not fully close into its frame, indicating a need for adjustment. This deficiency was observed at 11:09 a.m. Additionally, the door to the Lounge in the 100 Hall was also found to require adjustment to ensure it fully closed into its frame. This observation was made at 11:23 a.m. The deficiencies were confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 12:00 p.m.
Plan Of Correction
Resident door room 307 and lounge door in hallway 100 were adjusted to fully close into frame. Other resident doors and lounge doors will be checked to assure doors fully close into frame. The Maintenance Director/designee will continue to monitor doors on daily rounds. The Maintenance Director will add doors on preventive schedule to assure doors fully close into frame.
Unsealed Penetrations in Smoke Barrier Walls
Penalty
Summary
The facility failed to maintain smoke barrier walls to provide at least a two-hour fire resistance rating, affecting two of six smoke compartments. During an observation on January 14, 2025, at 11:43 a.m., it was noted that there were two unsealed penetrations in the two-hour fire/smoke wall above the ceiling near Resident Room 512 in the 500 Hall. The unsealed penetrations were identified around orange PVC sprinkler piping and red fire alarm wire. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 12:00 p.m.
Plan Of Correction
Unsealed penetration around orange PVC sprinkling piping and around the red fire alarm wire were fire caulked to provide at least a two-hour fire resistance. Other hallways will have sprinklers checked for any penetrations and repaired. The Maintenance Director was educated on if contractors do repairs or installations the area worked on will be checked to assure no penetrations. The Maintenance Director will add a contractor log to verify areas worked on by contractors has no penetration areas when work is completed.
Failure to Conduct Required Quarterly Fire Drills
Penalty
Summary
The facility failed to conduct the required quarterly fire drills for staff, as evidenced by documentation review and interviews. Specifically, the facility did not perform the 2nd Shift fire drill for the 2nd quarter of 2024 and the 3rd Shift fire drill for the 4th quarter of 2024. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
Plan Of Correction
Cannot correct fire drill not completed on 2nd shift for 2nd quarter and the 3rd shift drill for the 4th quarter. Current fire drills were checked for 1st quarter of 2025 and in compliance. Maintenance Director was educated on regulation that fire drills are held expected or unexpected times under varying conditions, at least quarterly on each shift. The Administrator / designee will review fire drill documentation monthly to assure each shift is completed in each quarter.
Inadequate Nurse Aide Staffing Levels
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios across multiple shifts, as evidenced by a review of staffing records and staff interviews. Specifically, the facility did not provide the minimum number of nurse aides needed for the day, evening, and night shifts on 14 out of 21 reviewed shifts. For instance, on January 7, 2025, the day shift had 8.00 nurse aides instead of the required 8.90 for a census of 89 residents, and the night shift had 4.69 nurse aides instead of the required 5.93. Similar deficiencies were noted on subsequent days, with the facility consistently falling short of the required staffing levels. The report highlights specific instances where the facility's staffing levels were inadequate, such as on January 10, 2025, when the day shift had 7.77 nurse aides instead of the required 9.00 for a census of 90 residents. Additionally, on the same day, the night shift had only 4.30 nurse aides, falling short of the required 6.00. The facility did not have additional higher-level staff available to compensate for these deficiencies, indicating a systemic issue in maintaining adequate staffing levels to meet regulatory requirements.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. This statement applies to all observations listed below. The facility is unable to retroactively correct the cited issue. Staffing meetings will be held 5 days a week with the scheduler, Director of Nursing and Nursing Home Administrator, to review the current day CNA staffing ratios and upcoming days of the week and following week to ensure appropriate staffing levels for CNA staffing ratios for each shift. The facility is focusing on retention of existing nurse aides and recruitment of new nurse aides through the efforts of the Human Resources manager and the Administrator working on facility recruitment and retention plan to maintain required state ratios. If the projected staffing ratios do not meet minimum, then the facility will reach out to current staff and staffing agency using as needed bonuses to enlist staff or agency staff to meet the minimum requirement. The facility will continue to recruit staff through all platforms. Daily audits of the schedules will be conducted for 7 days and weekly for 2 weeks. The results will be reviewed at Quality Assurance and Performance Improvement meetings until substantial compliance of the state ratio can be met through the hiring and retention plan over the next 90 days.
Facility Fails to Meet Required Nursing Care Hours
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios, as confirmed by an interview with the Nursing Home Administrator on January 14, 2025. The regulation effective July 1, 2024, mandates a minimum of 3.2 hours of direct resident care per resident in each 24-hour period. However, a review of the facility's staffing levels revealed that on several dates in January 2025, the facility did not meet this requirement. Specifically, on January 7, 9, 10, 11, 12, and 13, the facility provided less than the required 3.2 hours of direct care nursing per resident, with the lowest being 2.95 hours on January 10, 2025. This deficiency was confirmed through a review of nurse staffing, state regulation, and staff interviews.
Plan Of Correction
The facility cannot retroactively correct the nursing care state minimum hours. Staffing meetings will be held 5 days a week with the scheduler, Director of Nursing, and Nursing Home Administrator to review the current day nursing of minimum care state hours each day of 3.20 and review the upcoming days of the week and following week to ensure appropriate nursing minimum care state hours each day of 3.20. The facility is focusing on retention of existing nurse aides and recruitment of new nurse aides through the efforts of the Human Resources manager and the Administrator working on the facility recruitment and retention plan to maintain required minimum state daily nursing hours of 3.2 PPD. If the projected daily state minimum staffing ratios do not meet minimum, then the facility will reach out to current staff and staffing agency using as needed bonuses to enlist staff or agency staff to meet the state minimum hours required. The facility will continue to recruit staff through all platforms over the next 90 days to hire and retain staff to meet the state daily nursing care hours of 3.2. Daily audits by the NHA or designee of the daily minimum state nursing care hours will be conducted for 7 days and weekly for 2 weeks. The results will be reviewed at Quality Assurance and Performance Improvement meetings until substantial compliance of the state minimum general nursing care hours can be met through the hiring and retention plan over the next 90 days.
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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