Green Valley Skilled Nursing And Rehabilitation Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Pottsville, Pennsylvania.
- Location
- 1 Matthew Drive, Pottsville, Pennsylvania 17901
- CMS Provider Number
- 396086
- Inspections on file
- 19
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Green Valley Skilled Nursing And Rehabilitation Ce during CMS and state inspections, most recent first.
The facility failed to provide an ongoing program of activities to meet residents' needs, as three residents expressed concerns about the lack of activities on Sundays and Mondays. The activity calendar and staffing records confirmed no scheduled activities or assigned staff on these days. Residents had previously raised these issues during council meetings, but no action was taken.
The facility failed to monitor and address significant weight loss in two residents, leading to a deficiency in nutritional care. One resident experienced a 12.4 lb. weight loss over nine days, and another lost 38 lbs. over several months. Required reweights were not conducted, and physicians were not notified. Additionally, recommended nutritional interventions were not implemented, and there was a discrepancy in fluid restriction status.
A physician failed to act on pharmacist-identified medication irregularities for three residents with various mental health diagnoses. Despite multiple medication regimen reviews, the facility lacked documentation of the pharmacist's recommendations and the physician's responses, as confirmed by the Nursing Home Administrator.
A resident with severe cognitive impairment was improperly restrained using furniture to create a makeshift playpen, without a physician's order or consent. The facility failed to follow its policies on restraint utilization and resident rights, leading to a deficiency.
A facility failed to ensure accurate MDS assessments for a resident with paranoid schizophrenia and major depressive disorder. Despite a positive PASRR Level 1 screen and confirmation of eligibility for Level II services, the MDS assessment inaccurately reported the resident's mental illness status. This was confirmed by the RN assessment coordinator.
A facility failed to follow physician orders for a resident's PICC line management. The resident, with a PICC line for antibiotic therapy due to knee issues, had orders for specific antibiotics and saline flushes. However, the Medication Administration Record showed the PICC line was not consistently flushed as required, confirmed by the DON.
A resident with congestive heart failure did not receive proper maintenance of their oxygen equipment, as the facility failed to change the oxygen tubing weekly per policy. Observations over several days showed the tubing was not replaced, and the DON confirmed the oversight.
A facility failed to maintain a system of records for controlled drugs, specifically Oxycodone, for a resident with diabetes and prostate cancer. The resident was discharged with 10 Oxycodone tablets, but there was no documented accountability record as required by facility policy. The DON confirmed the lack of documentation, which is necessary to prevent unauthorized use and ensure accurate accounting.
A facility failed to document the clinical rationale for increasing an antipsychotic medication for a resident with severe cognitive impairment. Despite a psychiatric team meeting, there was no evidence of alternative treatments considered or resident involvement in the decision-making process. The DON confirmed the lack of documentation and the facility's responsibility to prevent unnecessary psychotropic medication.
The facility failed to maintain proper signage for the emergency generator's remote manual stop station, as observed during a survey. The absence of identifying signage was confirmed by the Administrator and Maintenance Director, indicating non-compliance with NFPA standards.
The facility was found deficient in maintaining proper signage for the Fire Department Connection of the sprinkler system. An observation revealed the absence of identifying signage, which was confirmed during an interview with the Administrator and Maintenance Director.
A resident with cerebral ischemia and dementia, requiring assistance from two staff members for transfers, sustained a sprained ankle when a nurse aide transferred the resident alone. The incident occurred during a transfer from the toilet to a wheelchair, resulting in the resident's left knee giving out and subsequent fall. The injury led to pain, swelling, and a decline in mobility and independence in activities of daily living. Interviews confirmed the failure to follow the care plan and physician orders for safe transfers.
The facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian. The current food service director is enrolled in an online course to become a certified dietary manager and is not yet qualified. The facility employs a part-time consultant dietitian who works approximately four hours per week. The previous full-time qualified food service director left the facility, and the position has not been filled.
The facility failed to maintain acceptable practices for food storage and service, including the use of unpasteurized eggs and improper dating of food items in the resident pantry refrigerator. These actions increased the risk of food-borne illness.
The facility failed to accommodate a resident with COPD and a bariatric wheelchair, preventing her from participating in activities due to the narrow width of the Activity Room door. Despite being aware of the issue and having a pending work order, the problem was not resolved, leading to the resident's inability to engage in her preferred activities.
The facility failed to follow its abuse prohibition procedures for screening and training a rehired nurse aide. The employee was rehired without an employment application, background check, contact with previous employers, or verification of certification. Additionally, the employee did not receive the required orientation training.
A resident who required two-person assistance for transfers was transferred by a single nurse aide, resulting in a sprained ankle. The incident was not reported to the State Survey Agency within the required time frames, violating the facility's abuse prohibition policy.
A resident with multiple diagnoses, including depression and dementia, expressed a desire to harm herself, but the facility failed to provide therapeutic social services or follow up on the resident's distress. The Director of Social Services was unaware of the statement, and no documentation of therapeutic intervention was found.
The facility failed to maintain accurate and complete clinical records for a resident with congestive heart failure, diabetes, chronic kidney disease, and GERD, who experienced weeping in her left lower extremity. Despite the resident's condition being noted, there was a lack of timely and accurate documentation regarding the facility's response and communication with the physician.
Lack of Scheduled Activities on Sundays and Mondays
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the needs, interests, and preferences of residents, as evidenced by concerns raised by three out of four residents during a group interview. The residents expressed dissatisfaction with the lack of activities on Sundays and Mondays, which was confirmed by a review of the activity calendar and staffing documentation showing no scheduled activities or assigned activity staff on these days throughout February 2025. The residents had previously raised these concerns during Resident Council meetings, but no action had been taken to address the issue. Resident 4, who is cognitively intact, expressed a preference for hymn singing on Sundays and desired at least one program on Sundays and Mondays. Resident 6, with moderate cognitive impairment, and Resident 8, also cognitively intact, indicated an interest in additional bingo activities and leading activities themselves. The Nursing Home Administrator confirmed the absence of activity staff on Sundays and Mondays and acknowledged the facility's responsibility to ensure residents' needs and preferences are met, as per 28 Pa. Code 201.29 (a) Resident rights.
Failure to Monitor and Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to monitor and address significant weight loss in two residents, leading to a deficiency in nutritional care. Resident 36 experienced a 12.4 lb. weight loss over nine days and a subsequent 7 lb. weight loss, yet the facility did not conduct required reweights or notify the physician and resident representative as per their policy. The Director of Nursing confirmed these lapses, acknowledging that the weight loss was not communicated to the physician each time it was noticed. Resident 20 also experienced a significant weight loss of 38 lbs. over several months. Despite a dietary referral and recommendations for daily weights and nutritional interventions, the facility did not conduct reweights or implement the recommended health shake. Additionally, there was a discrepancy in the resident's fluid restriction status, which had been discontinued but was still referenced in dietary notes. The Director of Nursing confirmed these failures, including the lack of communication with the physician and resident representative regarding the weight loss.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The deficiency involves the failure of a physician to act upon pharmacist-identified irregularities in the medication regimens of three residents. Resident 11, who was admitted with diagnoses including anxiety disorder, major depressive disorder, and dementia, had medication regimen reviews conducted on multiple occasions. Despite the pharmacist making recommendations during these reviews, the facility was unable to provide documentation of these recommendations or any response from the physician. Similarly, Resident 24, diagnosed with dementia and major depressive disorder, and Resident 4, diagnosed with paranoid schizophrenia and major depressive disorder, also had medication regimen reviews where the pharmacist made recommendations. However, the facility failed to document these recommendations or any physician response. The Nursing Home Administrator confirmed the lack of documentation for the pharmacist's recommendations and the physician's actions, which constitutes a deficiency under the relevant Pennsylvania Code sections.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints that were not required to treat a medical symptom. The resident, who was severely cognitively impaired and had a history of osteoarthritis and acute respiratory failure, was found on the floor near her bed and later placed in a makeshift playpen created by surrounding her with furniture. This action was taken without a physician's order, consent from the resident or her representative, or documented evidence that less restrictive measures had been attempted and failed. The resident's care plan included interventions for altered sleep and wake cycles, communication problems, and behavior issues related to suicidal ideation. Despite these interventions, the resident was found on the floor and later placed in a wheelchair at the nurse's station. When the resident expressed discomfort and requested to return to bed, she was instead placed on a mattress on the floor in the common area, surrounded by furniture to prevent her from moving. Witness statements from staff members confirmed the use of furniture as a restraint, with one staff member describing the action as abusive. The facility's Director of Nursing and Nursing Home Administrator acknowledged the lack of a documented physician order, care plan intervention, or consent for the use of the furniture as a restraint. The facility's policies on restraint utilization and resident rights were not followed, leading to the deficiency.
Inaccurate MDS Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of a resident. The resident in question was admitted with diagnoses of paranoid schizophrenia and major depressive disorder. A review of the resident's Pennsylvania Preadmission Screening Resident Review Identification (PASRR) Level 1 form indicated a positive screen for serious mental illness, necessitating a Level II evaluation. A subsequent letter from the Pennsylvania Department of Human Services confirmed the resident's eligibility for Level II services, requiring the facility to provide or arrange for mental health services. However, the significant change MDS assessment inaccurately reported that the resident was not considered a state Level II PASRR for serious mental illness. This inaccuracy was confirmed during an interview with the registered nurse assessment coordinator.
Failure to Follow PICC Line Management Orders
Penalty
Summary
The facility failed to provide person-centered care and adhere to physician orders for the management of a PICC line for a resident. The resident, who was admitted with a PICC line for antibiotic therapy due to a right total knee replacement and a left knee infection, had specific physician orders for the administration of Vancomycin HCL and Cefazolin Sodium. Additionally, there was an order for a Normal Saline flush to be used intravenously every shift before and after the administration of IV antibiotics. Upon review of the resident's February 2025 Medication Administration Record, it was found that the PICC line was not consistently flushed before and after the administration of each IV antibiotic as per the physician's orders and facility policy. This was confirmed during an interview with the Director of Nursing, who acknowledged the lack of documented evidence for the required flushing of the PICC line. This deficiency was noted under the 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
Failure to Maintain Oxygen Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in accordance with its policy, affecting one resident who required oxygen therapy. The facility's policy, last reviewed on December 14, 2024, mandates that oxygen tubing and humidifier bottles be changed weekly to ensure optimal functioning. However, observations revealed that the oxygen tubing attached to the resident's oxygen concentrator was not replaced as required. The tubing was dated January 20, 2025, and remained unchanged during observations on February 25, 26, and 27, 2025. The resident involved had been admitted with a diagnosis of congestive heart failure and had physician orders for oxygen therapy to manage shortness of breath. Despite the resident's need for respiratory support, the facility did not adhere to its policy of weekly tubing changes. The Director of Nursing confirmed the oversight, acknowledging that the tubing had not been replaced per the facility's guidelines, thus failing to maintain the resident's oxygen equipment properly.
Failure to Document Controlled Medication Accountability
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not maintaining a system of records for the receipt and disposition of controlled drugs, specifically Oxycodone, for one resident. The facility's policy requires that all controlled medications be accounted for, inventoried, and destroyed in the presence of two licensed clinicians, with documentation on the accountability record. However, for Resident 43, who was admitted with diagnoses including diabetes and prostate cancer, there was no documented evidence of a controlled medication accountability record for the Oxycodone 2.5 mg tablets prescribed for pain or dyspnea. Upon discharge, Resident 43 was sent home with medications, including 10 Oxycodone tablets, but the facility failed to provide documentation of the accountability record for these controlled medications. An interview with the Director of Nursing confirmed the absence of this documentation, which is required to prevent unauthorized use or misappropriation and ensure accurate accounting and disposition of controlled drugs.
Lack of Documentation for Antipsychotic Medication Increase
Penalty
Summary
The facility failed to ensure proper documentation and justification for the increase of an antipsychotic medication for a resident diagnosed with a psychotic disorder and dementia. The resident, who was admitted with severe cognitive impairment, had a care plan addressing potential physical aggression and impaired cognitive function. Despite a psychiatric interdisciplinary team meeting where new recommendations were made, the clinical record lacked documented evidence of the clinical rationale for increasing the resident's antipsychotic medication, alternative treatment options considered, or involvement of the resident or their representative in the decision-making process. The Director of Nursing confirmed the absence of documentation supporting the rationale for the dosage increase and acknowledged the facility's responsibility to ensure residents are free from unnecessary psychotropic medication. The medication administration records showed that the resident received the additional dose of Quetiapine Fumarate daily for a month, but there was no evidence of a clinical rationale or discussion of alternative interventions. This deficiency was identified through clinical record review and staff interviews, highlighting a failure in the facility's medication management practices.
Emergency Generator Signage Deficiency
Penalty
Summary
The facility failed to maintain proper signage for the emergency generator's remote manual stop station. During an observation conducted on February 12, 2025, at 1:05 PM, it was noted that the stop station lacked identifying signage. This deficiency was identified as affecting the entire component of the emergency generator system. An interview conducted during the exit conference with the Administrator and Maintenance Director on the same day confirmed the absence of the required signage. The lack of signage was acknowledged by the facility's representatives, indicating a failure to comply with the necessary maintenance and testing protocols as outlined in NFPA standards.
Plan Of Correction
The maintenance has installed a sticker identifying the remote manual stop station for the emergency generator. The NHA and maintenance director will tour the facility and grounds to identify any other locations which may need additional or new signage to maintain compliance. The NHA and maintenance director will review life safety regulations for signage to ensure that the facility is in compliance. The maintenance director will audit the sticker weekly with his generator checks to ensure the sticker remains in place. Results of the audit will be forwarded to the QAPI committee for review.
Deficiency in Fire Department Connection Signage
Penalty
Summary
The facility failed to maintain proper signage for the Fire Department Connection associated with the installed sprinkler system. During an observation on February 12, 2025, at 12:55 PM, it was noted that the Fire Department Connection lacked identifying signage. This deficiency was confirmed during an interview with the Administrator and Maintenance Director at the exit conference on the same day at 1:30 PM.
Plan Of Correction
The maintenance director has installed a reflective sign identifying the location of the fire department hookup. The NHA and maintenance director will tour the facility and grounds to identify any other locations which may need additional or new signage to maintain compliance. The NHA and maintenance director will review life safety regulations for signage to ensure that the facility is in compliance. The maintenance director will audit the fire department connection sign with his generator checks to ensure the sign remains in place. Results of the audit will be forwarded to the QAPI committee for review.
Inadequate Transfer Assistance Leads to Resident Injury and Decline
Penalty
Summary
The facility neglected to provide the necessary care and services to prevent physical harm to Resident 33, resulting in a sprained ankle and subsequent decline in activities of daily living. Resident 33, admitted with diagnoses of cerebral ischemia and dementia, had a care plan indicating the need for assistance from two staff members for transfers due to impaired balance and cognitive impairment. Despite physician orders and care plans specifying the requirement for two staff members during transfers, Employee A1, a nurse aide, transferred Resident 33 alone, leading to the ankle injury on February 29, 2024. The incident occurred during a transfer from the toilet to a wheelchair when Resident 33's left knee gave out, causing Employee A1 to lower the resident to the floor. Subsequent assessments revealed left ankle tenderness, edema, and pain, with the resident unable to bear weight on the ankle. Despite receiving Tylenol for pain management, Resident 33 continued to experience ankle pain and required a Hoyer lift for transfers until the swelling decreased. Physical therapy sessions post-injury noted the resident's complaints of left foot/ankle pain impacting transfer and ambulation abilities, leading to a decline in mobility and independence in activities of daily living. Interviews with Resident 33's family member and the Nursing Home Administrator confirmed the facility's failure to ensure the resident's safety, with Employee A1 neglecting to follow the care plan and physician orders for safe transfers. The family member expressed concerns about the setback in Resident 33's physical rehabilitation post-injury, affecting the resident's ability to walk and delaying potential discharge home. The Nursing Home Administrator acknowledged the deficiency in ensuring Resident 33's safety and the subsequent decline in the resident's activities of daily living due to the sprained ankle caused by inadequate transfer assistance.
Failure to Employ Qualified Food Service Director
Penalty
Summary
The facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian. An interview with the food service director (FSD) revealed that she was currently enrolled in an online course to become a certified dietary manager and was not yet qualified for the position according to regulatory criteria. The facility employed a part-time consultant dietitian who worked approximately four hours per week. Review of monthly time sheets confirmed this arrangement. The nursing home administrator confirmed that the previous full-time qualified food service director's last day of employment was on October 20, 2023, and that the facility did not currently employ a full-time qualified food service director.
Failure to Maintain Food Storage and Service Standards
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness. During an initial tour of the food and nutrition services department, it was observed that two cases of fresh shell eggs, which were not pasteurized, were present on a shelf in the walk-in refrigerator. The food service director (FSD) confirmed that these unpasteurized eggs were being used to serve dippy eggs and that they were ordered by mistake instead of pasteurized shell eggs from the food supplier. This practice is against CMS guidance and increases the risk of residents contracting Salmonella Enteritis. Further observations in the resident pantry refrigerator revealed several food storage and sanitation concerns. A thawed 4-ounce nutritional shake and a 10-gallon plastic bag containing 4-ounce nutritional shakes were not dated with a thaw or discard date, despite manufacturer instructions to use them within 14 days after thawing. Additionally, two plastic storage containers of applesauce, two 46-ounce bottles of thickened juice, and a 60-ounce bottle of apple juice were opened but not dated. A spill was also observed under the plastic pull-out crisper drawer of the refrigerator. The FSD confirmed that food and beverages were to be stored and thawed according to acceptable practices and that the food and nutrition services department and resident pantry were to be maintained in a sanitary manner to prevent potential contamination.
Failure to Accommodate Resident's Participation in Activities
Penalty
Summary
The facility failed to provide reasonable accommodations for Resident 41, who has chronic obstructive pulmonary disease (COPD) and uses a bariatric wheelchair with a 40-inch width. Despite being cognitively intact and having a care plan that included participation in activities such as bingo, arts and crafts, and spiritual services, Resident 41 was unable to attend many activities because her wheelchair could not fit through the 36-inch wide Activity Room door. This issue was confirmed by the Director of Maintenance, who had been aware of the problem and had a pending work order to address it, which had not been completed by the time of the survey. Resident 41 expressed frustration during an interview, stating that she had to sit in the hallway to listen to spiritual services because her wheelchair would not fit through the door. The Nursing Home Administrator confirmed that the facility failed to make reasonable accommodations to allow Resident 41 to participate in her chosen activities. The deficiency was identified under 28 Pa. Code 201.29 (a) Resident rights.
Failure to Implement Abuse Prohibition Procedures for Rehired Employee
Penalty
Summary
The facility failed to implement their established abuse prohibition procedures for fully screening and training one employee out of five reviewed. Specifically, Employee 1, a nurse aide, was rehired on December 23, 2023, without documented evidence of an employment application, a PA State Police criminal background check, contact with previous employers to screen for history of abuse or mistreatment, or verification of the employee's nurse aide certification. Additionally, there was no documentation that Employee 1 received orientation training, including abuse training, as required by the facility's policy. An interview with the Business Office Manager confirmed that the facility did not have an application packet for Employee 1's rehire and that the necessary background checks and verifications were not completed. The Business Office Manager also confirmed that Employee 1 did not receive the required orientation training upon rehire. This failure to follow established procedures for screening and training employees led to the deficiency identified in the report.
Failure to Timely Report Resident Neglect
Penalty
Summary
The facility failed to timely report an instance of resident neglect to the State Survey Agency. The incident involved Resident 33, who required the assistance of two staff members for transfers. On February 29, 2024, Employee A1, a nurse aide, attempted to transfer Resident 33 alone, resulting in the resident's left knee giving out and her being lowered to the floor. Initially, no injuries were reported, but later that day, Resident 33 experienced left ankle tenderness, edema, and pain, and was unable to bear weight on her ankle. A subsequent facility incident report confirmed that Employee A1 was aware of the two-person transfer requirement but chose to perform the transfer alone, leading to Resident 33's sprained ankle. The incident was not reported to the State Survey Agency within the required time frames. The facility's abuse prohibition policy mandates that all incidents of suspected neglect be thoroughly investigated and reported to the Pennsylvania Department of Health within five calendar days. Despite this policy, the neglect incident involving Resident 33 was not reported in a timely manner. The Nursing Home Administrator confirmed that the facility staff failed to ensure that Resident 33 received the necessary services to avoid physical harm and acknowledged the delay in reporting the neglect to the State Survey Agency.
Failure to Provide Therapeutic Social Services
Penalty
Summary
The facility failed to provide therapeutic social services to promote the mental and psychosocial well-being of a resident diagnosed with malignant neoplasm of the colon, COPD, depression, and dementia. The resident, who was moderately cognitively impaired with a BIMS score of 10, expressed a desire to harm herself by asking for scissors or a razor to slit her wrists. This statement of distress was documented in a behavior note, but there was no follow-up or provision of therapeutic social services documented in the resident's clinical record. An interview with the Director of Social Services revealed that she was unaware of the resident's statement and had not provided any follow-up or therapeutic social services. The Nursing Home Administrator confirmed the lack of documented evidence of therapeutic social services being provided to the resident following her statement of wanting to harm herself. This failure to address the resident's expressed distress constitutes a deficiency in providing medically-related social services to help the resident achieve the highest possible quality of life.
Failure to Maintain Accurate and Complete Clinical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records consistent with professional standards of practice by not timely and accurately documenting the response to a change in a resident's condition. Resident 40, who was admitted with diagnoses including congestive heart failure (CHF), diabetes, chronic kidney disease, and gastro-esophageal reflux disease (GERD), experienced weeping in her left lower extremity. Despite the resident's condition being noted in nursing documentation, there was a lack of timely and accurate documentation regarding the facility's response and communication with the physician about the resident's condition. On March 23, 2024, a nursing note indicated that the resident's left lower leg was weeping, but there was no immediate follow-up or documentation of physician notification. By March 26, 2024, the resident's condition had not improved, and she expressed concerns about her weeping legs and recent weight gain. The resident was unsure if the physician was aware of her condition. A nursing note later that day mentioned the physician was informed, but there was no corresponding physician progress note to confirm this. The Director of Nursing (DON) acknowledged the lack of documentation regarding the physician's visit and orders for the resident's leg dressings. The resident continued to express concerns about her condition, and the facility's failure to document timely and accurate responses to the resident's change in condition was confirmed by the Nursing Home Administrator (NHA). This deficiency highlights the facility's failure to ensure proper documentation and communication regarding the resident's care needs.
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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