Hamilton Arms Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lancaster, Pennsylvania.
- Location
- 336 South West End Avenue, Lancaster, Pennsylvania 17603
- CMS Provider Number
- 395224
- Inspections on file
- 20
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Hamilton Arms Center during CMS and state inspections, most recent first.
A resident with Alzheimer's disease and dementia, whose son was designated as financial and healthcare POA, was switched to a new health insurance plan by facility staff after the original plan was discontinued. The Business Manager enrolled the resident in a different plan to maintain coverage but did not notify the POA, who later learned of the change from the insurance company and questioned the facility. The Administrator confirmed that the insurance change was made without informing the resident's appointed representative, resulting in a failure to honor the resident's right to representative notification.
A resident with CHF and significantly elevated BNP levels had multiple physician and NP orders for cardiology follow-up, with documentation that referrals were placed and the need for cardiology evaluation was discussed with facility staff. Despite nursing notes indicating calls to the cardiology office and messages left to schedule an appointment, there was no documentation that the consult was ever completed. The DON later reported that a cardiology visit had been scheduled but missed due to the resident being sick and could not provide supporting documentation, demonstrating a failure to carry out and document the ordered cardiology follow-up.
A resident with left-sided hemiplegia, requiring total assist for bed mobility, was left inadequately supervised during care by a CNA. The resident rolled out of bed and sustained a nondisplaced right ankle fracture, as confirmed by hospital evaluation. Facility staff and the DON confirmed that insufficient supervision during care led to the resident's fall and injury.
Two residents were inaccurately assessed as receiving anticoagulant medications in their MDS assessments, despite no evidence in their clinical records or physician orders to support this. These errors were confirmed by facility leadership through record review and staff interviews.
A resident with a pressure ulcer did not have required wound assessments, measurements, or treatment interventions documented in the clinical record, despite facility policy. Instead, staff relied on hospice documentation for monitoring and treatment, and the DON confirmed that this information was not entered into the facility's records.
Surveyors found that medications were not properly labeled and stored, including a medication refrigerator with unrecorded and elevated temperatures and an opened Lantus insulin pen on a medication cart that was not dated. Staff confirmed that these practices did not follow facility policy or regulatory requirements.
Five residents had personal refrigerators in their rooms without any temperature monitoring, cleaning logs, or evidence of maintenance according to food safety standards. The facility lacked a written policy and had not provided education to residents or families about safe food storage or refrigerator upkeep.
The facility did not follow physician orders for blood sugar checks and hypoglycemia management for two residents with diabetes and end stage kidney disease, and failed to complete required blood pressure monitoring for a resident with multiple cardiac conditions. Documentation was missing for physician notifications, timely interventions, and reassessments as required by orders.
The facility did not meet the required nurse aide staffing ratios, failing to provide the minimum number of nurse aides per residents during specific day and night shifts. The NHA confirmed the non-compliance during an interview.
The facility did not meet the required LPN to resident ratio on one day during the review period. On a specific day shift, the facility lacked the mandated minimum of one LPN per 25 residents. This was confirmed by the NHA during an interview.
The facility did not meet the required minimum nursing care hours for residents on two days, providing 3.13 and 3.07 direct care nursing hours per resident instead of the mandated 3.20 hours. This was confirmed by the NHA.
The facility did not effectively implement Enhanced Barrier Precautions (EBP) on two nursing floors. Observations revealed that resident rooms with EBP signage lacked available PPE. Interviews with staff, including an Infection Preventionist and the Nursing Home Administrator, indicated a lack of awareness and knowledge about PPE use and availability for EBP residents.
The facility did not provide necessary Medicare and Medicaid coverage notifications to residents. A resident did not receive a Notification of Medicare Non-Coverage (NOMNC), and three residents did not receive Advanced Beneficiary Notices of Non-Coverage (ABN). This was confirmed through documentation review and an interview with the Nursing Home Administrator.
A resident reported rough handling by CNAs, causing pain and anxiety. Although a grievance form was completed, the facility did not conduct an abuse investigation or report the allegation to the State Agency. The Nursing Home Administrator acknowledged the oversight.
A resident reported rough handling by CNAs, causing pain and anxiety. Although a grievance form was completed, the facility did not conduct an abuse investigation or report the allegation to the State Agency, as confirmed by the Nursing Home Administrator.
The facility failed to accurately complete MDS assessments for two residents. One resident's MDS inaccurately reported significant weight loss prior to admission, while another resident's MDS did not reflect hospice services despite a physician's order. These inaccuracies were confirmed by the Nursing Home Administrator and DON.
A resident with frequent constipation had multiple physician's orders for various medications, but the facility failed to clarify when each should be administered. Additionally, recommendations from a GI consult were not communicated to the attending physician, leading to a deficiency in care.
A resident did not receive timely dental services, including an annual exam and necessary care, despite authorization for such services. The resident reported missing fillings and issues with food getting stuck in their teeth. The DON confirmed the lack of a completed dental exam.
A resident expressed frustration over inadequate discharge preparation, lacking details on necessary durable medical equipment and follow-up care. The clinical record review showed missing information on primary care physician contacts, home health agency, and equipment arrangements, leading to a deficiency in ensuring a safe transfer.
Failure to Notify Resident Representative of Insurance Coverage Change
Penalty
Summary
The facility failed to honor a resident's right to have their appointed representative notified of changes affecting their care and finances when it changed the resident's health insurance coverage without informing the resident's power of attorney (POA). The resident had diagnoses including Alzheimer's disease and dementia, conditions that affect memory, thinking, and social abilities. The resident's profile and POA documents identified the resident's son as both financial and healthcare POA. The facility received a notification from the resident's insurance company indicating that the resident's current insurance plan was no longer offered, and subsequently enrolled the resident in a new health insurance plan. The Business Manager reported that the facility made the insurance change to ensure the resident would continue to have coverage, and confirmed that the new insurance coverage began on January 26, 2026, though the exact date of the change was not known. The Business Manager also stated that the resident's son, as POA, was notified of the change by the insurance company and then questioned the facility about why he had not been informed. The Nursing Home Administrator confirmed that the facility enrolled the resident in a different health insurance plan without notifying the POA. This sequence of actions and omissions resulted in the facility failing to ensure the resident's appointed representative was notified of the insurance coverage change.
Failure to Complete Ordered Cardiology Follow-Up for Resident With CHF
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for cardiology follow-up for a resident with congestive heart failure (CHF) and elevated BNP levels. Physician progress notes dated November 7, 2025, documented that the resident had CHF with BNP levels in the 1000s and that a cardiology follow-up was due, with a referral placed and discussed with the facility and scheduler. A physician order dated November 6, 2025, directed a cardiology follow-up, but there was no documented evidence that this consult was completed. The resident continued to experience shortness of breath and required supplemental O2, and a new medication was ordered while CHF remained the primary assessment. On December 8, 2025, nursing progress notes documented a new NP order for cardiology follow-up for CHF, and a corresponding physician order for cardiology follow-up was entered the same day. Physician progress notes on December 10, 2025, again stated that the resident needed cardiology follow-up and that this need had been discussed with the facility for scheduling. Nursing notes on December 11, 2025, indicated that cardiology had been called twice and messages left to schedule an appointment, with staff awaiting a return call. However, there was no documented evidence that the cardiology consult ordered on December 8, 2025, and referenced on December 11, 2025, was ever completed. During an interview, the DON stated that a cardiology consult had been scheduled but the resident could not attend due to illness and was unable to provide documentation of this, resulting in a failure to ensure that the cardiology follow-up orders were followed.
Failure to Provide Adequate Supervision During Care Resulting in Resident Fracture
Penalty
Summary
A resident with a history of cerebral infarction and left-sided hemiplegia required total assistance from one staff member for bed mobility and care, as documented in the care plan and Minimum Data Set. During care, a CNA rolled the resident onto their side to change them, removed the brief, and placed it on the floor. While the CNA was momentarily distracted, the resident rolled out of bed and fell to the floor. The resident was found lying on their left arm in a semi-prone position on the right side of the bed, with visible injuries including a bump on the forehead, a bruise on the left arm, and complaints of right ankle pain. Subsequent assessment and hospital evaluation revealed the resident sustained a nondisplaced fracture of the right ankle, with X-rays indicating possible fractures of the distal fibula and tibia, as well as severe diffuse osteopenia. Facility documentation and staff interviews confirmed that the resident did not receive adequate supervision during care, which resulted in actual harm. The Director of Nursing acknowledged that staff failed to provide the necessary supervision, leading to the resident's fall and injury.
Inaccurate MDS Assessments for Medication Administration
Penalty
Summary
The facility failed to ensure accurate assessments for two residents during the review period. For one resident, the Minimum Data Set (MDS) assessment indicated that the resident was receiving an anticoagulant under Section N0415, but a review of physician orders showed no evidence that the resident was actually receiving this medication. This discrepancy was confirmed by the Director of Nursing. Similarly, another resident's admission MDS assessment indicated receipt of an anticoagulant under Section N0410, but the clinical record did not support this, and the Nursing Home Administrator confirmed the MDS was coded incorrectly. These findings were based on clinical record reviews and staff interviews, demonstrating that the facility did not accurately document medication administration in the MDS assessments for these two residents.
Failure to Document Pressure Ulcer Assessment and Treatment in Clinical Record
Penalty
Summary
The facility failed to ensure that the clinical record accurately reflected the assessment and treatment of a pressure ulcer for one resident. According to facility policy, nursing staff are required to assess and document significant risk factors for pressure ulcers, as well as provide a full assessment of any pressure sores, including location, stage, measurements, and the presence of exudates or necrotic tissue. For a resident with a physician order for wound care to the buttocks, the clinical record showed an initial skin observation assessment noting an open area on the coccyx. However, subsequent facility documentation did not include required wound assessments, measurements, or treatment interventions. Instead, the facility relied solely on hospice documentation for monitoring and treatment of the pressure ulcer, without entering this information into the resident's clinical record. The DON confirmed that the facility did not document the wound and treatments in the clinical record, as required by policy.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Surveyors identified deficiencies in the facility's medication labeling and storage practices. In the second-floor low side medication room, the medication refrigerator was observed to be at 50 degrees Fahrenheit, which is above the recommended storage temperature for most medications. Additionally, the Medication Storage Monthly Temperature Log for this refrigerator had multiple days in September where temperatures were not recorded, and the temperatures that were logged consistently showed the highest allowable reading of 46 degrees Fahrenheit. These findings indicate a failure to monitor and maintain appropriate storage conditions for medications as required by facility policy and professional standards. Further, on the second-floor high side, a medication cart was found to contain an opened Lantus insulin pen that was not dated. Staff interviews confirmed that opened medications are required to be dated upon first use, and that this procedure was not followed. The Nursing Home Administrator and DON acknowledged that the medication refrigerator log was incomplete, the high temperature was not addressed, and the opened insulin pen was not properly dated, all of which are contrary to facility policy and regulatory requirements.
Failure to Monitor and Maintain Personal Refrigerators for Food Safety
Penalty
Summary
Surveyors observed that five residents had personal refrigerators in their rooms, and there was no evidence of temperature logs or monitoring for these refrigerators. Additionally, there was no documentation or indication that the refrigerators were being cleaned or maintained according to professional food safety standards. An interview with the Nursing Home Administrator confirmed that the facility did not have a written policy regarding personal refrigerators, and no education had been provided to residents or their families about safe food storage, refrigerator cleaning, or temperature monitoring. These findings indicate that the facility failed to ensure food stored in personal refrigerators was maintained in accordance with professional standards for food safety, as required by regulation.
Failure to Follow Physician Orders for Blood Sugar and Blood Pressure Monitoring
Penalty
Summary
The facility failed to follow physician's orders for blood sugar monitoring and management for two residents and for blood pressure monitoring for one resident. For one resident with end stage kidney disease and diabetes mellitus, there were multiple instances where blood sugar readings were below the physician-ordered threshold, but there was no documented evidence that the physician was notified, that a rapidly absorbed glucose was provided, or that blood sugar was rechecked within the required timeframe. Similarly, another resident with end stage kidney disease and diabetes mellitus had several low blood sugar readings, but documentation did not show that the physician was notified or that the hypoglycemic protocol was followed as ordered, including timely reassessment after intervention. Additionally, a resident with a history of stroke, coronary artery disease, heart failure, hypertension, diabetes mellitus, and high cholesterol had physician's orders for blood pressure checks twice daily. However, the medication administration record showed missing documentation for required blood pressure checks on several occasions. Interviews with the Director of Nursing confirmed that the required monitoring and notifications were not completed as ordered for these residents.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide staffing ratios as per the regulation effective July 1, 2023. Specifically, the facility did not maintain a minimum of one nurse aide per 12 residents during the day and evening shifts, and one nurse aide per 20 residents overnight. During the period from January 11 to January 25, 2025, the facility was found to be non-compliant on January 19, 2025, for the day shift, and on January 22, 2025, for the night shift. The Nursing Home Administrator (NHA) confirmed during an interview on February 4, 2025, that the facility did not meet the minimum required staffing ratios on the identified dates.
Plan Of Correction
1. The facility failed to maintain nurse aide ratios on multiple days and shifts. 2. Facility will need to maintain a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening and 1 nurse aide per 15 residents overnight. Calculation of shift ratios will be completed and reviewed daily for accuracy by the scheduler or designee. 3. The scheduler and nursing supervisors will be educated on these ratios. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. 4. Daily audits will be conducted for 1 month. Audits will be conducted by the scheduler or designee. Results of audits will be reviewed by the QAPI committee. 5. Date Certain is 4-4-25.
Failure to Meet LPN to Resident Ratio
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratio on one of the fourteen days reviewed. Specifically, on January 18, 2025, during the day shift from 7:00 a.m. to 3:00 p.m., the facility did not have the mandated minimum of one LPN per 25 residents. This deficiency was confirmed during an interview with the Nursing Home Administrator (NHA) on February 4, 2025, at 1:45 p.m., who acknowledged the shortfall in meeting the staffing requirements on the specified day.
Plan Of Correction
1. The facility failed to maintain LPN ratio on January 18th, 2025. 2. The facility will need to maintain a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight. Calculation of shift ratios will be completed and reviewed daily for accuracy by the scheduler or designee. 3. The scheduler and nursing supervisors will be educated on these ratios. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. 4. Daily audits will be conducted for 1 month. Audits will be conducted by the scheduler or designee. Results of audits will be reviewed by the QAPI committee. 5. Date certain is 4-4-25.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum general nursing care hours for residents on two specific days. On January 18, 2025, the facility provided 3.13 direct care nursing hours per resident, and on January 22, 2025, it provided 3.07 direct care nursing hours per resident. These figures were below the mandated minimum of 3.20 hours of general nursing care per resident. This deficiency was confirmed during an interview with the Nursing Home Administrator (NHA) on February 4, 2025.
Plan Of Correction
1. The facility failed to maintain a minimum of 3.2 hours of direct resident care for each resident on multiple days and shifts. 2. Facility will need to maintain a PPD of 3.2 hours. Calculation of the PPD will be completed and reviewed daily for accuracy by the scheduler or designee. 3. The scheduler and nursing supervisor will be educated on the daily PPD. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. 4. Daily audits will be conducted for 1 month. Audits will be conducted by the scheduler or designee. Results of audits will be reviewed by the QAPI committee. 5. Date certain is 4-4-25.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish effective Enhanced Barrier Precautions (EBP) on two nursing floors, as observed by surveyors. On the second-floor nursing unit, a resident room had signage indicating the resident was on EBP, but there was no evidence of Personal Protective Equipment (PPE) availability. An interview with Employee E3 revealed a lack of awareness regarding the appropriate PPE for EBP residents and where to obtain it. Similarly, on the first-floor nursing unit, a resident room also lacked visible PPE despite EBP signage. Licensed Employee E4 was similarly unaware of the necessary PPE and its location. The Infection Preventionist, Licensed Employee E5, stated that staff had been educated on PPE use for EBP residents. The Nursing Home Administrator confirmed that staff should be knowledgeable about PPE location and use for EBP residents.
Failure to Provide Required Coverage Notifications
Penalty
Summary
The facility failed to provide necessary notifications regarding Medicare and Medicaid coverage to residents, as required by regulations. Specifically, a Notification of Medicare Non-Coverage (NOMNC) was not provided to one resident, and Advanced Beneficiary Notices of Non-Coverage (ABN) were not provided to three residents. This deficiency was identified through a review of facility documentation and confirmed during an interview with the Nursing Home Administrator. The lack of these notifications means that residents were not informed about their coverage status and potential financial liabilities for services not covered by Medicare or Medicaid.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who expressed concerns about the care provided by the nursing staff. The resident, who uses a cane and rollator for ambulation and has no family support except for a significant other, reported that the CNAs were rough during repositioning, causing pain and anxiety. This information was documented during a meeting with the social services department and physical therapy. Despite the completion of a grievance form by Social Services, no abuse investigation was conducted, and the allegation was not reported to the State Agency. The Nursing Home Administrator confirmed that an investigation and report should have been made.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident who expressed concerns about the care received. The resident, who ambulates with a cane and rollator, reported that the CNAs were rough during repositioning, causing pain and anxiousness. This concern was documented during a meeting with the social services department and physical therapy. Despite the grievance form being completed by Social Services, no abuse investigation was conducted, and the allegation was not reported to the State Agency. The Nursing Home Administrator confirmed that an investigation should have been conducted and reported, indicating a lapse in the facility's management of abuse allegations.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents. For Resident 13, the Admission Nutrition Evaluation indicated a history of weight loss, but the MDS inaccurately reported a significant weight loss prior to admission, which was confirmed as incorrect by the Nursing Home Administrator. Resident 57's clinical record included a physician's order for hospice care, but the quarterly MDS failed to reflect that the resident was receiving hospice services, as confirmed by the Nursing Home Administrator and Director of Nursing.
Failure to Clarify and Implement Physician's Orders for Constipation Management
Penalty
Summary
The facility failed to clarify and implement physician's orders for a resident experiencing frequent constipation. The resident had multiple physician's orders for constipation management, including Colace, Dulcolax suppository, Polyethylene Glycol Powder, and Senna Plus. However, there was no order for Milk of Magnesia, which was referenced in the Dulcolax order, nor was there clarification on when each medication should be administered. Additionally, a gastrointestinal consult recommended a specific regimen involving Senna and Dulcolax, but these recommendations were not communicated to the resident's attending physician. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the oversight in clarifying the physician's orders and implementing the GI consult recommendations. The clinical records did not show any action taken to address the GI consult's recommendations, leading to a deficiency in providing appropriate treatment and care according to the resident's needs and physician's orders.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services for a resident, as evidenced by the lack of an annual dental exam and necessary dental care. The resident expressed concerns about missing fillings and the desire to have teeth pulled due to food getting stuck in the holes in their teeth. Despite authorization from the resident's responsible party for Direct Mobile Dental Services to perform an annual dental exam, x-rays, and cleanings in May 2023, there was no evidence in the clinical record that these services were provided. The Director of Nursing confirmed the absence of a completed dental exam for the resident.
Inadequate Discharge Preparation for Resident
Penalty
Summary
The facility failed to adequately prepare Resident R3 for a safe transfer or discharge from the nursing home. Resident R3, who was scheduled for discharge to home, expressed frustration and concern over the lack of information regarding necessary durable medical equipment such as a wheelchair, bedside commode, and hospital bed. The resident's clinical record indicated a Medicare cut letter stating that skilled nursing services would terminate on July 12, 2024, but the discharge planning summary assessment lacked essential details. The clinical record review revealed that the discharge summary did not include appointment or contact information for the primary care physician, nor did it provide details about the home health agency or durable equipment agency. Additionally, there were no documented discharge planning details regarding follow-up appointments, home health agency contacts, or durable medical equipment arrangements. An interview with the Director of Nursing confirmed these deficiencies, highlighting the facility's failure to ensure appropriate transfer and discharge preparation for Resident R3.
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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