Haida Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Hastings, Pennsylvania.
- Location
- 397 Third Avenue Extension, Hastings, Pennsylvania 16646
- CMS Provider Number
- 395592
- Inspections on file
- 30
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Haida Nursing And Rehab during CMS and state inspections, most recent first.
Two residents with cognitive impairment and psychiatric diagnoses received as-needed psychotropic medications without documented evidence that nonpharmacological interventions were attempted prior to administration. The DON confirmed the lack of documentation for these interventions, contrary to facility policy and regulatory requirements.
The facility did not inform two residents' representatives in advance about the risks, benefits, and alternatives before starting or increasing psychotropic medications, as required by policy. Documentation confirming that this information was provided was missing from the clinical records, despite medication changes for residents with cognitive impairment and behavioral symptoms.
The facility did not meet the required NA-to-resident staffing ratios on several shifts, as the number of NAs scheduled and providing care was below the minimum required for the facility's census. No additional higher-level staff were available to compensate for these shortfalls, as confirmed by the Nursing Home Administrator.
The facility did not provide the required minimum hours of direct resident care on three days, as confirmed by nursing schedules and staff interviews. On these days, the hours of care per resident fell below the regulatory standard.
A facility failed to notify a resident's family member about changes in treatment and physician's orders, despite the resident having an Advanced Directive requiring family notification. The resident, diagnosed with Parkinson's disease and dementia, was prescribed new medications, but there was no documented evidence of family notification, confirmed by the DON.
A resident with Crohn's disease, diabetes, and hemiplegia was not sent to the hospital as ordered by a physician after a family member expressed concern about a possible stroke. Despite the physician's directive, the DON assessed the resident and decided against the transfer, leading to a failure in executing the order and a deficiency in care.
A facility failed to document a resident's medical assessments and physician's orders accurately, leading to a deficiency. The resident, with Crohn's disease, diabetes, and hemiplegia, was suspected of having a stroke by family members. Despite assessments by a nurse and the DON, and a physician's order to send the resident to the hospital, these were not recorded in the clinical record.
The facility failed to provide written notification to residents, their responsible parties, and the LTC ombudsman regarding hospital transfers for seven residents with various medical conditions. This deficiency was confirmed through record reviews and staff interviews, revealing a lack of documentation for the required notifications.
The facility failed to notify residents and their representatives in writing about the bed-hold policy during hospital transfers for five residents with conditions such as CHF, pneumonia, and sepsis. The DON confirmed the oversight, violating state codes.
The facility failed to maintain accurate clinical records for two residents, leading to documentation deficiencies. One resident's Lorazepam medication records showed discrepancies, confirmed by the DON. Another resident's shower preferences were not accurately documented, with only one shower recorded despite multiple opportunities. The DON confirmed issues with the charting system.
A facility did not complete a professional licensure check for an LPN before hiring, contrary to its abuse prevention policy. The check, required to prevent hiring individuals with disciplinary actions, was delayed by two months due to an error by the HR Director, who ran the check on the LPN's graduate license instead of the permanent one.
The facility inaccurately completed MDS assessments for three residents. One resident was incorrectly coded as receiving insulin instead of Victoza, a non-insulin diabetes medication. Another resident's use of a topical antibiotic was not recorded, and a third resident's insulin administration was omitted from the MDS. These errors were confirmed by the RNAC.
The facility failed to develop care plans for two residents, one using smokeless tobacco and another requiring IV antibiotics and PICC line care. The absence of care plans for these specific needs was confirmed by the DON.
A resident with quadriplegia developed a Stage III pressure ulcer on the left heel due to rubbing against a wheelchair footrest. During wound care, an LPN failed to change gloves or perform hand hygiene between tasks, as confirmed by the Infection Preventionist, potentially risking infection.
A resident with hemiplegia/hemiparalysis did not receive the required contracture management intervention of having a rolled towel in her left hand, as per physician's orders and care plan. Observations confirmed the absence of the towel, which was acknowledged by a nurse aide and the DON.
A facility failed to assess the safety of an air mattress for a resident with cognitive impairment and a Stage 3 pressure ulcer. The resident was receiving hospice services and required assistance for care needs. The DON confirmed that no safety assessment was conducted before the air mattress was used, and hospice staff placed it without informing the facility.
A facility failed to ensure proper IV therapy administration and monitoring for a resident. The resident's PICC line was not flushed as required, and arm circumference was not measured on specified dates, despite physician's orders and facility policy. This was confirmed by the DON.
A facility failed to ensure that a physician wrote progress notes for a resident's visits. The resident, who was cognitively intact and required maximum assistance, was seen by a physician on multiple occasions due to increased behaviors and family concerns. However, no progress notes were documented in the clinical record. The DON confirmed the absence of notes and stated that the physician was behind in documentation.
A resident with quadriplegia was prescribed hydrocodone-acetaminophen for pain, but the medication label was improperly altered with pen without the required change sticker. Interviews confirmed that the label should not have been modified, violating facility policy and state regulations.
The facility's QAPI committee failed to address repeated deficiencies in MDS accuracy, individualized care plans, and medication management. Despite previous corrective plans, a recent survey found ongoing issues with inaccurate MDS assessments, inadequate care plans, and improper medication storage and labeling.
A resident with a documented diagnosis of diabetes and orders for insulin and blood sugar checks was admitted to a facility. However, these orders were not identified or clarified with the physician, leading to the resident's hospitalization due to hyperglycemia. Staff interviews confirmed the oversight in reviewing and incorporating the necessary medical information into the resident's chart.
The facility failed to follow infection control guidelines during a COVID-19 outbreak and for residents requiring Enhanced Barrier Precautions. Staff did not consistently wear required PPE, such as N95 masks and eye shields, when caring for COVID-positive residents. Additionally, residents on Enhanced Barrier Precautions did not have accessible PPE in their rooms, and staff were observed handling medical devices without gloves or gowns. The Assistant Director of Nursing confirmed these lapses in protocol.
The facility failed to ensure that a resident received adequate supervision and care as per her care plan. Despite requiring extensive assistance, a nurse aide provided incontinence care alone, leading to the resident falling out of bed and sustaining a right hip fracture. The resident was hospitalized for surgery due to the injury.
Failure to Document Nonpharmacological Interventions Before Administering Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from unnecessary psychotropic medications for two residents. Facility policy required that psychotropic medications only be used when nonpharmacological interventions were clinically contraindicated, and that such medications should not be used for staff convenience or as a chemical restraint. For one resident with severe cognitive impairment, dementia, and anxiety, clinical records showed repeated administration of Alprazolam as needed for anxiety, but there was no documented evidence that nonpharmacological interventions were attempted prior to each administration. This was confirmed by the Director of Nursing, who acknowledged the lack of documentation for attempted nonpharmacological approaches before giving the medication. Similarly, another resident with cognitive impairment, dementia, depression, and anxiety received Lorazepam as needed for anxiety on multiple occasions. Review of the clinical record revealed no documentation that nonpharmacological interventions were attempted before administering the medication. The Director of Nursing also confirmed the absence of such documentation for this resident. These findings indicate that the facility did not follow its own policy or regulatory requirements regarding the use of psychotropic medications and the documentation of nonpharmacological interventions.
Failure to Inform Resident Representatives of Psychotropic Medication Risks and Alternatives
Penalty
Summary
The facility failed to inform resident representatives in advance about the risks, benefits, and treatment alternatives prior to initiating or increasing psychotropic medications for two residents. Facility policy requires that before starting or increasing psychotropic medications, the resident, family, or representative must be informed of the benefits, risks, and alternatives, including black box warnings for antipsychotics, and that this communication must be documented. For one resident with severe cognitive impairment and diagnoses of dementia and anxiety, Buspar was initiated for agitation without documented evidence that the representative was informed in advance of the medication's risks, benefits, or alternatives. The Director of Nursing confirmed the absence of such documentation in the clinical record. For another resident with cognitive impairment and diagnoses of dementia, depression, and anxiety, Seroquel was increased and later further adjusted due to behavioral escalation and agitation. Although nursing notes indicated that the representative was notified of dosage changes, there was no documented evidence that the representative was informed in advance of the risks, benefits, or treatment alternatives prior to the medication changes. The Director of Nursing confirmed that the required documentation was not present in the clinical record for these medication adjustments.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident staffing ratios on multiple occasions, as evidenced by a review of nursing schedules, staffing information, and staff interviews. Specifically, on four separate shifts, the number of NAs scheduled and providing care was below the minimum required based on the facility's census. On the night shift of July 19, 2025, with a census of 75 residents, only 4.73 NAs were present when 5 were required. On the day shift of July 20, 2025, 7.47 NAs were present instead of the required 7.5 for 75 residents. On the evening shift of July 25, 2025, 6.97 NAs were present when 7.18 were required for 79 residents. On the day shift of July 27, 2025, 7.5 NAs were present instead of the required 8 for 80 residents. No additional higher-level staff were available to compensate for these deficiencies. The Nursing Home Administrator confirmed that the facility did not meet the required NA-to-resident staffing ratios for the days listed.
Plan Of Correction
1.) The facility is unable to correct the cited two of 21 days on the day shift, one of 21 days on the evening shift, and one of 21 days on the night shift for minimum nurse aides. There were no concerns noted due to staffing. 2.) Education will be provided to the Scheduler and Registered Nurse staff on the nurse aide ratios per shift. The facility has a labor management meeting to discuss staffing levels and needs. The facility can utilize agency and nursing management to assist with maintaining the ratio. 3.) Director of Nursing or designee will audit the nurse aide staffing ratio daily times 5 days, weekly times 3 weeks, and monthly times 2 months. 4.) Results of the audit will be reviewed at the Quality Assurance Performance Improvement meeting. P 5520
Failure to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to provide the required minimum hours of direct resident care per day as mandated by regulation. Specifically, a review of nursing schedules for the period between July 14 and August 3, 2025, showed that on three separate days, the facility provided less than the required 3.20 hours of direct care per resident. The actual hours provided were 3.19, 3.16, and 3.13 on the respective days. This deficiency was confirmed through staff interviews, including with the Nursing Home Administrator, who acknowledged that the facility did not meet the required daily hours of direct resident care on the identified dates.
Plan Of Correction
1.) The facility is unable to correct the cited three of 21 days that it failed to provide 3.20 hours of direct resident care for each resident. There were no concerns noted due to the direct care hours. 2.) Education will be provided to the Scheduler and Registered Nurse staff on providing 3.20 hours of direct care per resident. The facility has a labor management meeting to discuss staffing levels and needs. The facility can utilize agency and nursing management to assist with maintaining the 3.20 staffing hours per resident. 3.) Director of Nursing or designee will audit the daily hours of direct resident care for each resident daily times 5 days, weekly times 3 weeks, and monthly times 2 months. 4.) Results of the audit will be reviewed at the Quality Assurance Performance Improvement meeting.
Failure to Notify Family of Treatment Changes
Penalty
Summary
The facility failed to ensure timely notification of a resident's representative regarding changes in treatment and physician's orders. Specifically, for one resident, there was no documented evidence that the resident's power of attorney and interested family member was informed about new physician's orders for medications prescribed on two separate occasions. The resident, who had a diagnosis of Parkinson's disease and dementia, was moderately impaired and had an Advanced Directive in place, which required staff to keep the family informed of changes in condition. Despite the facility's policy requiring documentation of family notifications, there was no record of communication with the resident's family member about the new orders for Paxil and Anafranil. The Director of Nursing confirmed that the family member was not notified about these changes. This oversight was identified during a review of policies, clinical records, and staff interviews, highlighting a deficiency in the facility's adherence to its own documentation and notification procedures.
Plan Of Correction
1. Resident 7 remains in the facility; residents medical record was reviewed by the physician and medications remain appropriate. Family member is aware of all medication's orders. 2. The Director of Nursing/Designee will review progress notes and 24-hour report daily to ensure notification to resident's representatives are informed of any medication changes and document the notification in the medical record. 3. The Director of Nursing/Designee will educate the Registered nurses on the importance of notifying Resident's representative on any medication changes, and documenting in the medical record of any medication changes. 4. The Director of Nursing/Designee will audit daily by reviewing progress notes and the 24-hour report to ensure notification to Resident's representative on medication changes and documentation was completed on any medication changes. This audit will be completed daily 5 times for two weeks, then three times a week times 2 weeks, then weekly times two weeks, then monthly times two months. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met. 5. The completion date will be 02/11/2025.
Failure to Follow Physician's Orders for Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident received care and treatment in accordance with professional standards of practice by not following a physician's order to send the resident to the hospital. The resident, who had Crohn's disease, diabetes, and hemiplegia, was assessed by a registered nurse after a family member expressed concern that the resident might be having a stroke. Although the resident was awake, alert, and oriented, the physician was contacted and gave an order to send the resident to the hospital. However, the order was not documented in the electronic medical record, and the resident was not sent to the hospital as instructed. Interviews with staff revealed a breakdown in communication and decision-making. The Director of Nursing assessed the resident and decided not to send her to the hospital, contrary to the physician's order. The registered nurse, who was new to the facility, did not document the order because the Director of Nursing instructed otherwise. This led to a failure in executing the physician's directive, as the resident's family was informed that the resident would be sent to the hospital, but this did not occur. The incident highlights a lapse in following professional standards and physician orders, resulting in a deficiency in the care provided to the resident.
Plan Of Correction
1. Resident 2 no longer resides in the facility. 2. Residents that have a change in condition will have a full assessment completed by the Registered Nurse with documentation in the medical record. The Registered Nurse will immediately call the physician informing him of the assessment and the change in condition. The Registered Nurse will then implement orders received and update the resident's representative of orders. 3. The Director of Nursing and the Registered Nurses will be educated by the facility Consultant/Designee on assessing residents with change of conditions and following the physician's orders, along with implementing physician's orders, updating resident's representatives, and completing documentation in the medical record. 4. An audit will be completed by the facility consultant/Designee on any resident with a change of condition to ensure a complete assessment was performed, with physician notification, orders implemented, complete documentation in the medical record, and resident representative updated. This audit will be completed daily 5 times a week for two weeks, then three times a week for two weeks, then weekly for two weeks, then monthly for two months. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met. 5. The completion date will be 02/11/2025.
Incomplete Documentation of Resident's Medical Records
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for a resident, leading to a deficiency. The facility's policy required documentation to be objective, complete, and accurate. However, for one resident with Crohn's disease, diabetes, and hemiplegia, there was no documented evidence of assessments conducted by a registered nurse and the Director of Nursing, nor the physician's orders to send the resident to the hospital. The resident's family expressed concerns about the resident's condition, suspecting a stroke, but the assessments and subsequent physician's orders were not recorded in the clinical record. The registered nurse involved admitted to forgetting to update the electronic medical record with her assessments and the physician's orders. The Director of Nursing also confirmed the lack of documentation. The physician indicated that he was not aware of why the resident was not sent to the hospital as ordered. The Regional Director of Clinical Services confirmed the absence of documentation and noted that the nurse had been asked to write a statement after a family grievance was raised. This lack of documentation violated the facility's policy and state regulations, resulting in a deficiency.
Plan Of Correction
1. Resident 2 no longer resides in the facility. 2. DON/Designee will review progress notes and 24-hour report daily to ensure complete documentation of resident's assessments, Physician notification, and Resident representative is completed in the medical record. 3. The Director of Nursing/Designee will educate Registered nurses on the importance of documenting complete assessments, Physician notification, orders received by the Physician, and updating of resident's representatives in the medical record. 4. The Director of Nursing/Designee will audit daily by reviewing progress notes and the 24-hour report to ensure complete assessments, Physician notification, orders received by the Physician, and resident Representatives notification is documented in the medical record. This audit will be completed daily 5 times for two weeks, then three times a week times 2 weeks, then weekly times two weeks, then monthly times two months. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met. 5. The completion date will be 02/11/2025.
Failure to Notify Residents and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents, their responsible parties, and the long-term care ombudsman regarding the reasons for hospital transfers. This deficiency was identified for seven residents who were transferred to the hospital for various medical conditions, including congestive heart failure, urinary tract infection, possible pneumonia, hypoosmolarity hyperglycemic state, lethargy and disorientation, sepsis, aspiration pneumonia, and a change in mental condition. In each case, there was no documented evidence that the required written notices were provided to the relevant parties. The deficiency was confirmed through clinical record reviews and staff interviews, specifically with the Director of Nursing, who acknowledged the lack of written notifications. The failure to provide these notifications is a violation of the residents' rights as outlined in the facility's discharge policy and resident rights regulations. The absence of documentation for these notifications indicates a systemic issue in the facility's process for handling hospital transfers.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide a written notice of its bed-hold policy to residents and/or their representatives at the time of transfer to a hospital for five residents. This deficiency was identified through a review of policies, clinical records, and staff interviews. Specifically, the nursing notes for Residents 1, 22, 27, 29, and 53 revealed that each was transferred to a hospital for various medical conditions, including congestive heart failure, hypoosmolarity hyperglycemic state, pneumonia, sepsis, and aspiration pneumonia. However, there was no documented evidence that these residents or their responsible parties were notified about the facility's bed-hold policy at the time of their transfer. The Director of Nursing confirmed during an interview that the facility did not provide the required bed-hold notice to the affected residents or their responsible parties. This oversight is a violation of the facility's responsibility to inform residents and their representatives about the duration for which their bed would be held during hospital transfers or therapeutic leaves, as required by the relevant state codes.
Inaccurate Clinical Records and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain accurate clinical records for two residents, leading to deficiencies in documentation. For one resident, a quarterly Minimum Data Set (MDS) assessment indicated cognitive impairment and dependency on staff for daily care, with a diagnosis of depression. Physician's orders prescribed Lorazepam for anxiety, but discrepancies were found in the medication administration records. The controlled drug accountability sheet showed an incorrect remaining amount of Lorazepam, which was confirmed by the Director of Nursing upon observation. Another resident, who was cognitively intact, had a preference for showers documented in their Kardex. However, the shower log for two months showed only one documented shower out of 18 opportunities. An interview with the resident revealed they received showers twice a week, but the Director of Nursing confirmed that the shower record was not correctly entered into the charting system, preventing accurate documentation.
Failure to Timely Verify LPN Licensure
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not completing a professional licensure check prior to hiring a licensed practical nurse. The policy, dated August 27, 2024, mandates that the facility should not employ individuals with disciplinary actions against their professional license due to findings of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property. However, the personnel file review revealed that the licensure check for the nurse, hired on September 3, 2024, was not conducted until November 4, 2024, two months post-hire. An interview with the Director of Human Resources confirmed the delay, attributing it to an error where the check was mistakenly run on the nurse's graduate license instead of her permanent license.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents, as identified during a review of clinical records and staff interviews. For one resident, the MDS assessment incorrectly indicated that the resident received insulin, when in fact, the resident was administered Victoza, a non-insulin medication for diabetes. This error was confirmed by the Registered Nurse Assessment Coordinator (RNAC) during an interview. Another resident's MDS assessment failed to record the administration of a topical antibiotic, Silvadene, which was applied twice daily during the assessment period. Additionally, a third resident's MDS assessment did not reflect the administration of insulin, despite physician orders and medication records indicating daily insulin administration. These inaccuracies were also confirmed by the RNAC, highlighting a pattern of incorrect MDS coding for these residents.
Failure to Develop Care Plans for Specific Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were developed to reflect the specific care needs of two residents. For one resident, who was cognitively intact and diagnosed with quadriplegia, the facility did not create a care plan addressing the resident's use of smokeless tobacco, despite the resident being observed with tobacco products and confirming their use. This oversight was confirmed by the Director of Nursing during an interview. Another resident, who had physician's orders for intravenous antibiotics and a PICC line, did not have a care plan developed to address the care of the PICC line and the need for antibiotics. The resident's Medication Administration Record indicated that the resident received the prescribed IV antibiotics and had the PICC line flushed and monitored as ordered. However, there was no documented evidence of a care plan for these medical needs, which was also confirmed by the Director of Nursing.
Failure in Pressure Ulcer Care and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper pressure ulcer care for one resident, identified as Resident 19, who had a facility-acquired Stage III pressure ulcer on the left inner heel. The resident, who was cognitively intact and diagnosed with quadriplegia, reported that his heels were rubbing against the back of his wheelchair footrest, which contributed to the development of the ulcer. Physician's orders were in place for wound care, including cleansing the wound, applying bacitracin antibiotic, collagen, and securing with a border dressing twice a day. During an observation of wound care, an LPN did not adhere to proper hand hygiene protocols. After removing the soiled dressing and cleaning the wound, the LPN failed to change gloves or perform hand hygiene before applying new dressings. This was confirmed by the LPN and the Infection Preventionist, who stated that staff are expected to change gloves and perform hand hygiene between dirty and clean tasks. This failure to follow hand hygiene protocols during wound care could potentially lead to infection, compromising the resident's health.
Failure to Implement Contracture Management for a Resident
Penalty
Summary
The facility failed to provide physician-ordered contracture management interventions for a resident, identified as Resident 65, who was cognitively impaired and diagnosed with hemiplegia/hemiparalysis. According to the resident's care plan and physician's orders, a rolled towel was to be placed in the resident's left hand at all times, except during morning and evening care, and checked every shift for placement and integrity. However, observations on November 4, 2024, revealed that the resident did not have the rolled towel in her left hand as required. This was confirmed by an interview with Nurse Aide 3, who acknowledged the absence of the towel, and the Director of Nursing, who confirmed the requirement for the towel's presence.
Failure to Assess Safety of Air Mattress for Resident
Penalty
Summary
The facility failed to complete safety assessments for a resident who used an air mattress, which is a deficiency in ensuring a safe environment free from accident hazards. The facility's policy on support surface guidelines, dated August 27, 2024, required assessments for appropriate pressure-reducing and relieving devices for residents at risk for skin breakdown. The resident in question, identified as Resident 47, was cognitively impaired, required assistance for care needs, had a Stage 3 pressure ulcer on admission, and was receiving hospice services. Observations on November 7, 2024, revealed that the resident was lying on an air mattress without documented evidence of an assessment for potential safety hazards prior to its use. The Director of Nursing confirmed that no such assessment was conducted, and the hospice staff placed the mattress without informing the facility.
Failure to Properly Administer and Monitor IV Therapy
Penalty
Summary
The facility failed to ensure the proper administration and monitoring of intravenous (IV) therapy for a resident, specifically regarding the flushing of a peripherally-inserted central catheter (PICC line) and the measurement of arm circumference. According to the facility's policy, a 10 milliliter saline flush was required before each medication infusion. Physician's orders for the resident specified that the PICC line should be flushed with 10 cubic centimeters of 0.9 percent sodium chloride every shift, before and after medication administration, and that the circumference of the upper arm at the PICC insertion site should be measured every shift and as needed. However, the Medication Administration Record (MAR) for the resident indicated that while the resident received IV meropenem from November 3 through 7, 2024, there was no documented evidence that the PICC line was flushed as required or that the arm circumference was measured on November 2, 3, and 7, 2024. An interview with the Director of Nursing confirmed the lack of documentation for these required procedures, indicating a failure to adhere to the physician's orders and facility policy.
Physician Documentation Deficiency
Penalty
Summary
The facility failed to ensure that the physician wrote a progress note for each visit for a resident, identified as Resident 15. The resident was cognitively intact and required maximum assistance from staff for care. On three separate occasions, the resident was seen by a physician due to increased behaviors and concerns from family members. However, there was no documented evidence of a provider's progress note in the clinical record for these visits. The Director of Nursing confirmed the absence of the physician's notes and mentioned that the physician was behind in his documentation, requiring the facility to contact the office for the notes.
Improper Medication Labeling for Resident
Penalty
Summary
The facility failed to ensure that medications were properly labeled and dated, as evidenced by the case of a resident who was cognitively intact and required assistance with care needs due to quadriplegia. The resident was prescribed hydrocodone-acetaminophen for pain management, with specific instructions to take the medication at bedtime and every six hours as needed for moderate pain. However, during an observation of the medication cart, it was found that the medication label had been altered with pen to include additional instructions, without the required sticker indicating a change in order. Interviews with staff, including a Licensed Practical Nurse and the Nursing Home Administrator, confirmed that the medication label should not have been altered. The facility's policy clearly stated that medication labels should not be modified by nursing personnel, and any changes in physician's directions should be indicated with a sticker, not by writing directly on the label. This failure to adhere to labeling protocols resulted in a deficiency as per the facility's policies and state regulations.
Repeated Deficiencies in MDS Accuracy, Care Plans, and Medication Management
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations, as evidenced by repeated deficiencies identified in a survey ending November 7, 2024. These deficiencies included inaccuracies in Minimum Data Sets (MDS) assessments, failure to develop individualized care plans, and improper storage and labeling of medications. The facility had previously developed plans of correction for these issues following a survey ending December 7, 2023, which included implementing quality assurance systems and conducting audits. However, the current survey revealed that these measures were ineffective in addressing the recurring deficiencies. Specifically, the QAPI committee was unable to correct deficient practices related to accurate MDS assessments, as cited under F641. Additionally, the committee failed to address issues in developing comprehensive person-centered care plans, as cited under F656. Furthermore, the committee was ineffective in ensuring proper storage and labeling of medications, as cited under F761. These findings indicate that the facility's efforts to implement corrective actions and maintain compliance with regulations were insufficient, leading to repeated deficiencies in critical areas of care and service delivery.
Failure to Clarify Diabetes Diagnosis and Orders
Penalty
Summary
The facility failed to clarify a physician's orders and a diagnosis of diabetes for a resident, resulting in the resident's hospitalization. The resident, who was admitted from a hospital and was cognitively impaired and dependent on staff for care, had a documented diagnosis of diabetes mellitus and orders for insulin and blood sugar checks. However, there was no evidence in the clinical record that these orders were identified and clarified with the physician. As a result, the resident's blood glucose level reached 923 mg/dL, leading to their transfer to a local hospital with hyperglycemia and altered mental status. Interviews with various staff members, including a Licensed Practical Nurse, Registered Dietician, Medical Director, Registered Nurse Assessment Coordinator, and Registered Nurse, confirmed that the diagnosis and orders were missed. The Registered Dietician noted that the resident's diet was initially controlled for carbohydrates but was changed due to the absence of a diabetes diagnosis. The Registered Nurse Assessment Coordinator and other nursing staff acknowledged that the paperwork from the resident's Primary Care Provider, which included the diabetes diagnosis and treatment orders, should have been reviewed and incorporated into the resident's medical chart but was overlooked.
Infection Control Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to adhere to infection control guidelines from CMS and the CDC during a COVID-19 outbreak, as well as for residents requiring Enhanced Barrier Precautions (EBP). The facility's policy, dated August 27, 2024, stated that it would follow current guidelines for managing COVID-19, including ensuring the availability of necessary supplies such as PPE. However, observations and staff interviews revealed that the facility did not consistently implement these guidelines. For instance, during a facility tour, it was observed that staff caring for residents with COVID-19 did not wear the required PPE, including N95 masks and eye shields, despite these being mandated by physician orders and facility protocols. Several residents were affected by the facility's failure to implement proper infection control measures. Resident 1, who was COVID-positive, was observed in a room with the door open, and staff were seen exiting the room without wearing the full PPE required for droplet precautions. Similarly, Resident 2, also COVID-positive, was cared for by staff who did not wear N95 masks or eye shields, even though these were available in the isolation station outside the resident's room. The Assistant Director of Nursing/Infection Preventionist confirmed that staff should have been wearing full PPE, including protective eye shields, N95 masks, gowns, and gloves, as per the facility protocol and physician's orders. The facility also failed to implement Enhanced Barrier Precautions for residents with indwelling catheters or other medical devices. For example, Resident 3, who had an indwelling catheter, was transferred by staff without gloves or gowns, and the isolation station in the resident's room was empty. Similar deficiencies were noted for Residents 5, 6, and 7, who were on EBP but did not have accessible PPE in their rooms. The Assistant Director of Nursing/Infection Preventionist acknowledged that isolation stations should be stocked with appropriate PPE and accessible for staff when caring for residents on EBP.
Failure to Provide Adequate Supervision and Care
Penalty
Summary
The facility failed to ensure that Resident 2 received adequate supervision and care as per her care plan. The quarterly Minimum Data Set (MDS) assessment indicated that Resident 2 was cognitively intact and required extensive assistance from staff for daily care. Despite this, Nurse Aide 1 provided incontinence care to Resident 2 alone, contrary to the care plan that required an extensive assist of two. Later, Resident 2 was found with a bruise on her forehead and complained of severe pain, which led to the discovery of a right hip fracture. The resident was subsequently sent to the emergency room and admitted to the hospital for surgery. Interviews with staff and the Director of Nursing confirmed that the care plan was not followed, and Resident 2 did not receive the required assistance. The resident's inability to get back into bed on her own after falling out of bed further highlighted the lack of adequate supervision. The facility's failure to adhere to the care-planned interventions resulted in significant harm to Resident 2, as evidenced by the hip fracture and subsequent hospitalization.
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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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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