Havencrest Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Monongahela, Pennsylvania.
- Location
- 1277 Country Club Road, Monongahela, Pennsylvania 15063
- CMS Provider Number
- 395633
- Inspections on file
- 28
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Havencrest Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia, Alzheimer’s disease, muscle weakness, syncope, cognitive communication deficits, non-ambulatory status, unsteady gait, and a history of falls was sent alone to a cardiology appointment despite facility policy requiring staff accompaniment for cognitively impaired residents needing ADL assistance. The resident’s confusion and dependence on staff were documented in clinical and psychiatric evaluations, yet no staff member accompanied the resident to the outside appointment, and the cardiology office reported the resident could not be seen due to confusion. The DON confirmed the resident was sent without needed staff assistance, resulting in a failure to provide appropriate treatment and care according to orders, preferences, and goals.
The facility failed to fully investigate an incident in which a resident with multiple chronic conditions was left on a bedpan for about two hours after being placed there by an LPN during an understaffed overnight shift. The LPN reported asking an NA to monitor the call light and remove the bedpan, but later could not locate the NA when rounds began, and the resident was found still on the bedpan by the LPN and an RN, with no injuries noted. The NA stated she stayed past her shift but was unaware the resident had been placed on a bedpan. The facility’s abuse/neglect investigation policy required interviews with the reporter and other residents cared for by the involved staff, but the DON and NHA acknowledged there was no written proof that such resident interviews or a complete investigation were conducted.
The facility did not have a qualified individual designated as the Infection Control Preventionist (ICP), with the DON performing both the DON and ICP roles. Although an LPN was recently assigned to infection control, the interim DON continued to act as the ICP, resulting in noncompliance with requirements for infection prevention and control program oversight.
The facility did not have a qualified individual officially designated and onsite to manage the infection prevention and control program, as required. Although an LPN was recently assigned to infection control, the Interim DON had been fulfilling the role at the time of the survey, and this was confirmed by the DON during staff interviews.
The facility failed to properly store, label, and date food products and did not ensure adequate chemical sanitation levels in the main kitchen, creating the potential for foodborne illness. Observations revealed issues such as an unverified milk cooler temperature, a scoop inside a sugar container, undated cereal bowls, and inadequate sanitizer levels in the three-compartment sink.
The facility failed to ensure a safe environment in the Back Hall Nursing Unit by not securing the Utility Room, which contained a full sharps container without a lid. This was confirmed by an RN and further acknowledged by the Nursing Home Administrator and the DON.
The facility failed to provide culturally competent, trauma-informed care for two residents with PTSD, as their care plans lacked goals and interventions related to their condition. Additionally, there were no assessments for trauma-informed care in their evaluations. This deficiency was acknowledged by the Nursing Home Administrator and the DON.
The facility failed to properly store and dispose of medications and biologicals, as evidenced by undated and expired items found in the medication room and on the Long Hall medication cart. Additionally, the medication cart was left unlocked and unattended. These deficiencies were confirmed by staff and acknowledged by the Nursing Home Administrator and the DON.
The facility failed to disinfect a glucometer between uses on multiple residents, as required by policy and manufacturer instructions. Staff members, including an LPN and an RN, used the glucometer on several residents without cleaning it, and it was observed to be visibly soiled at one point. Interviews confirmed the non-compliance with disinfection protocols, posing a risk of cross-contamination.
The facility did not provide required Abuse and Neglect Prevention training for two staff members, a Nurse Aide and a Therapy Employee, as per the facility's policy. This deficiency was confirmed by the Assistant Business Office Manager and the Nursing Home Administrator.
The facility failed to provide mandatory infection control training for four staff members, as required by its infection prevention and control program. Documentation showed that a nurse aide, a registered nurse, and a therapy employee did not receive the necessary in-service education within the specified time frames. This was confirmed by the Assistant Business Office Manager, the Nursing Home Administrator, and the DON.
The facility failed to provide the required 12 hours of in-service education for two nurse aides within 12 months of their hire date anniversary. Employee E8 received only 6 hours, and Employee E9 received 3.75 hours of training. This deficiency was confirmed by the Assistant Business Office Manager and the Nursing Home Administrator.
The facility failed to provide training on Resident Rights for four staff members, as required by policy. Documentation showed that a Nurse Aide, a Registered Nurse, and a Therapy Employee did not receive the necessary training within the specified time frames after their hire dates. This was confirmed by interviews with the Assistant Business Office Manager, the Nursing Home Administrator, and the DON.
The facility failed to provide effective communication training for two staff members, NA Employee E8 and NA Employee E9, as required by the facility's Staff Development Program policy. This deficiency was confirmed through a review of training records and interviews with facility management.
The facility did not provide mandatory QAPI training to four staff members, as required by their Staff Development Program policy. Documentation showed that a NA, an RN, and a therapy employee did not receive QAPI in-service education within the specified time frames after their hire dates. This was confirmed by the Assistant Business Office Manager, the Nursing Home Administrator, and the DON.
The facility failed to provide required behavioral health training for three staff members, as per the facility's Staff Development Program policy. Documentation showed that a Nurse Aide and a Therapy Employee did not receive behavioral health in-service education within the specified timeframes. Interviews confirmed the absence of documented training, violating state codes on staff development and management.
Failure to Accompany Cognitively Impaired Resident to Cardiology Appointment
Penalty
Summary
The facility failed to provide appropriate treatment and care by not following its own policy for accompanying residents to outside medical appointments. The facility’s Transportation, Resident Appointments policy stated that a member of the nursing staff or Social Services would accompany a resident to an appointment when the resident could not go alone due to factors such as elopement risk, poor judgment, wandering behaviors, cognitive impairment, or need for assistance with ADLs. Resident R33’s clinical record showed diagnoses of dementia, Alzheimer’s disease, muscle weakness, and syncope, with a Minimum Data Set indicating ongoing cognitive impairment and dependence on staff for ADLs. A psychiatric evaluation further documented confusion, memory impairment, cognitive communication deficit, non-ambulatory status, muscle weakness, unsteady gait, and a history of falling. Despite these documented conditions that met the facility’s criteria for requiring staff accompaniment, the Appointment Calendar showed that Resident R33 was sent alone to a cardiology appointment on 1/28/26 at 7:30 a.m. A nurse progress note later recorded that staff from the cardiologist’s office reported the resident needed staff sent with her due to confusion and could not be seen. In an interview, the Director of Nursing confirmed that the resident was sent to the cardiology appointment without facility staff assistance and that the facility failed to provide needed care and services during the transfer to the outside appointment.
Failure to Fully Investigate Incident Involving Prolonged Time on Bedpan
Penalty
Summary
The facility failed to fully investigate a potential incident of abuse or neglect involving one resident, as required by its Abuse Investigation and Reporting policy. The policy, reviewed on 10/8/25, required that all reports of abuse, neglect, exploitation, mistreatment, or injuries of unknown origin be promptly reported and thoroughly investigated, including interviewing the person reporting the incident and other residents who received care from the accused employee. The resident involved, who had diagnoses including high blood pressure, depression, and chronic pain, was re-admitted to the facility on an unspecified date. Facility records showed that on 1/1/26, the resident was placed on a bedpan by an LPN, who then asked an NA to watch for the call light and remove the bedpan. The NA’s shift ended at 4:00 a.m., and during subsequent rounds the LPN and an RN found the resident still on the bedpan, approximately two hours later; no injuries were noted on assessment. During interviews, the DON acknowledged there was no written proof that residents were interviewed about the care and services they received on the night shift when the incident occurred. The NA stated she was asked to stay past her shift, which ended at 3:00 a.m., and that she remained until 3:30 a.m., but reported she was unaware the resident had been placed on a bedpan. The LPN reported that a major snowstorm had caused multiple call-offs, leaving only an RN, the LPN, and one NA to cover the overnight shift, and that she and the RN assisted the NA with resident care, including placing the resident on the bedpan. The LPN also stated she could not locate the NA at 4:00 a.m. when rounds began and described prior derogatory remarks from the NA that led to hard feelings between them. An attempt to interview the RN by telephone was unsuccessful. The Nursing Home Administrator confirmed that the incident involving the resident was not fully investigated and that resident statements regarding their care by staff during the night shift were not obtained, in violation of 28 Pa. Code 201.149(a) and 201.18(e)(1).
Failure to Designate Qualified Infection Control Preventionist
Penalty
Summary
The facility failed to designate a qualified individual onsite to serve as the Infection Control Preventionist (ICP), as required by regulations. The Director of Nursing (DON) was also acting as the ICP since September 8, 2025, in addition to her primary responsibilities. Review of job descriptions confirmed that the DON is responsible for the overall operation of the Nursing Department, while the ICP is tasked with planning and directing the infection control program. During staff interviews, it was confirmed that although a Licensed Practical Nurse (LPN) had recently been put in place for infection control, the interim DON continued to act as the Infection Control Nurse at the time of the survey. This resulted in the facility not having a designated, qualified individual responsible for implementing infection prevention and control programs and activities.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified individual onsite to be responsible for implementing the infection prevention and control program. Review of the Infection Preventionist job description showed that the role requires planning, organizing, developing, coordinating, and directing the infection control program in accordance with federal, state, and local regulations. During staff interviews, it was revealed that a Licensed Practical Nurse was recently assigned to infection control, but the Interim DON had been acting as the Infection Control Nurse at the time of the survey. The DON confirmed that there was no qualified individual officially designated and present onsite to oversee infection prevention and control activities, as required by regulations.
Deficiency in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to its own policies regarding food storage and sanitation, which created the potential for foodborne illness. During an observation in the main kitchen, it was noted that the milk cooler's temperature was recorded at 41 degrees, but there was no thermometer inside the cooler to verify the accuracy of the milk's temperature. Additionally, a large plastic container used for sugar storage had a scoop lying inside, contrary to the facility's policy that requires containers to have tight-fitting lids and no scoops inside. Furthermore, a tray containing 21 bowls of dried cereal was found undated, which is against the facility's labeling and dating requirements. The facility also failed to maintain appropriate chemical sanitation levels for dishware and utensils. The three-compartment sink was checked in the presence of the Dietary Manager, Employee E1, and it was found that the sanitizer strip did not indicate a sanitizer level adequate to meet the required 200 ppm as per the manufacturer's recommendations. These observations were confirmed by the Dietary Manager, highlighting the facility's failure to properly store, label, and date food, as well as to ensure that chemical sanitation levels were adequate, thereby creating the potential for foodborne illness.
Failure to Secure Sharps Container in Utility Room
Penalty
Summary
The facility failed to provide a safe environment for residents in the Back Hall Nursing Unit. During an observation, it was noted that the Utility Room door lacked a locking mechanism, and within the room, a full sharps container without a lid was present on a small table. This situation was confirmed by Registered Nurse Employee E5, who acknowledged that the utility room was designated as a Sharps Room and that the unsecured sharps container posed a safety risk to residents. Further confirmation of the facility's failure to maintain a safe environment was provided by the Nursing Home Administrator and the Director of Nursing during an interview.
Failure to Provide Culturally Competent, Trauma-Informed Care
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for two residents, as required by professional standards of practice. Resident R13, who has diagnoses including anxiety, depression, bipolar disorder, and PTSD, did not have goals and interventions related to PTSD included in their plan of care. Additionally, there was no assessment for trauma-informed care or PTSD in Resident R13's evaluations. Similarly, Resident R26, diagnosed with anxiety, depression, schizophrenia, and PTSD, also lacked goals and interventions related to PTSD in their plan of care, and their evaluations did not reveal an assessment for trauma-informed care or PTSD. During an interview, the Nursing Home Administrator and the Director of Nursing acknowledged the facility's failure to provide culturally competent, trauma-informed care for these residents. This deficiency was identified through a review of the facility's policy, clinical records, and staff interviews, indicating a lack of adherence to the facility's policy on behavioral assessment, intervention, and monitoring, which aims to maintain the highest practicable physical, mental, and psychosocial well-being of residents.
Improper Storage and Disposal of Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored and disposed of, as evidenced by observations in the medication room and on the Long Hall medication cart. During an inspection, an opened and undated vial of Aplisol was found in the medication room, along with vacutainers and a catheter securement device that were past their expiration dates. Additionally, opened sterile dressing kits were observed. These findings were confirmed by a registered nurse during the inspection. Further observations revealed that the Long Hall medication cart contained a partially used and undated Lantus injection pen, two bottles of prednisolone 1% suspension eye drops, and a bottle of Isopto Tears ophthalmic solution, all of which were partially used and undated. The medication cart was also found unlocked and unattended, which was confirmed by a registered nurse who admitted to leaving it unsecured while attending to a resident. The Nursing Home Administrator and the Director of Nursing acknowledged the facility's failure to properly store and dispose of medications and biologicals.
Failure to Disinfect Glucometer Between Uses
Penalty
Summary
The facility failed to prevent potential cross-contamination during glucometer usage for five of six residents. The facility policy required that glucometers be disinfected after each use, as per the manufacturer's instructions. However, observations revealed that staff members, including an LPN and an RN, did not disinfect the glucometer between uses on different residents. Specifically, the glucometer was used on multiple residents consecutively without disinfection, and at one point, it was visibly soiled with brown spots before being used on another resident. Interviews with staff confirmed the failure to adhere to the disinfection protocol. The Infection Preventionist and the Nursing Home Administrator acknowledged that glucometers should be cleaned between each resident to prevent cross-contamination. The report highlights that the facility did not comply with its own policies and the manufacturer's instructions, leading to a potential risk of cross-contamination among residents.
Failure to Provide Abuse and Neglect Prevention Training
Penalty
Summary
The facility failed to provide mandatory training on Abuse and Neglect Prevention for two staff members, Employee E8 and Employee E12. According to the facility's policy, all personnel are required to participate in initial orientation and regularly scheduled in-service training classes. However, a review of the facility's documents and training records revealed that Nurse Aide Employee E8, hired on 9/10/88, did not receive the required training between 9/10/23 and 9/10/24. Similarly, Therapy Employee E12, hired on 10/10/16, lacked documented training within the period from 10/10/23 to 10/10/24. This deficiency was confirmed during interviews with the Assistant Business Office Manager and the Nursing Home Administrator, along with the Director of Nursing, who acknowledged the oversight in training these staff members.
Infection Control Training Deficiency
Penalty
Summary
The facility failed to provide mandatory infection control training as part of its infection prevention and control program for four out of ten staff members. The facility policy requires all personnel to participate in initial orientation and regularly scheduled in-service training classes. However, documentation revealed that Nurse Aide Employee E6, Nurse Aide Employee E9, Registered Nurse Employee E11, and Therapy Employee E12 did not receive the required infection control in-service education within the specified time frames after their hire dates. This deficiency was confirmed during interviews with the Assistant Business Office Manager, the Nursing Home Administrator, and the Director of Nursing.
Inadequate In-Service Education for Nurse Aides
Penalty
Summary
The facility failed to provide the required 12 hours of in-service education within 12 months of their hire date anniversary for two nurse aides, Employees E8 and E9. According to the facility's Staff Development Program policy, all personnel must participate in initial orientation and regularly scheduled in-service training classes. However, Employee E8, hired on 9/10/88, received only 6 hours of in-service education between 9/10/23 and 9/10/24. Similarly, Employee E9, hired on 10/30/21, received only 3.75 hours of in-service education between 10/30/23 and 10/30/24. This deficiency was confirmed during interviews with the Assistant Business Office Manager and the Nursing Home Administrator, who acknowledged the lack of documentation for the required training hours.
Failure to Provide Resident Rights Training
Penalty
Summary
The facility failed to provide training on Resident Rights for four out of ten staff members, as determined by a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on March 4, 2024, mandates that all personnel participate in initial orientation and regularly scheduled in-service training classes. However, documentation revealed that Nurse Aide Employee E7, Nurse Aide Employee E9, Registered Nurse Employee E11, and Therapy Employee E12 did not have documented training on Resident Rights within the specified time frames after their hire dates. This deficiency was confirmed during interviews with the Assistant Business Office Manager, the Nursing Home Administrator, and the Director of Nursing.
Failure to Provide Effective Communication Training
Penalty
Summary
The facility failed to provide training on effective communication for two of ten staff members, specifically Nurse Aide (NA) Employee E8 and NA Employee E9. According to the facility's Staff Development Program policy, all personnel are required to participate in initial orientation and regularly scheduled in-service training classes. However, a review of the facility's documents and training records revealed that NA Employee E8, hired on 9/10/88, did not receive effective communication in-service education between 9/10/23 and 9/10/24. Similarly, NA Employee E9, hired on 10/30/21, lacked documented training on effective communication between 10/30/23 and 10/30/24. This deficiency was confirmed during interviews with the Assistant Business Office Manager, the Nursing Home Administrator, and the Director of Nursing.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program for four out of ten staff members, as required by their Staff Development Program policy. The policy mandates that all personnel participate in initial orientation and regularly scheduled in-service training classes. However, documentation revealed that Nurse Aide Employee E8, Nurse Aide Employee E9, Registered Nurse Employee E11, and Therapy Employee E12 did not receive QAPI in-service education within the specified time frames after their respective hire dates. This deficiency was confirmed during interviews with the Assistant Business Office Manager, the Nursing Home Administrator, and the Director of Nursing.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide required behavioral health training for three out of ten staff members, as determined by a review of facility policy, personnel in-service training records, and staff interviews. The facility's Staff Development Program policy, last reviewed on March 4, 2024, mandates that all personnel participate in initial orientation and regularly scheduled in-service training classes. However, documentation revealed that Nurse Aide Employee E8, hired on September 10, 1988, did not receive behavioral health in-service education between September 10, 2023, and September 10, 2024. Similarly, Nurse Aide Employee E9, hired on October 30, 2021, and Therapy Employee E12, hired on October 10, 2016, also lacked documented behavioral health training within their respective timeframes. Interviews conducted on February 20, 2025, with the Assistant Business Office Manager and later with the Nursing Home Administrator and the Director of Nursing confirmed the absence of documented behavioral health training for these staff members. This deficiency is in violation of 28 Pa Code: 201.14 (a) Responsibility of licensee, 28 Pa Code: 201.18 (b)(1) Management, and 28 Pa Code: 201.20 (a)(c) Staff development.
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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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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