Hermitage Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Hermitage, Pennsylvania.
- Location
- 500 Clarksville Road, Hermitage, Pennsylvania 16148
- CMS Provider Number
- 395231
- Inspections on file
- 32
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Hermitage Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with immobility and multiple sclerosis, requiring substantial staff assistance and a mechanical lift, did not consistently receive scheduled showers as outlined in their care plan. Documentation and staff interviews confirmed that showers were missed or replaced with bed baths without proper documentation or offering the resident a choice, contrary to facility policy and the resident's expressed preferences.
Hermitage Nursing and Rehabilitation failed to meet the required nurse aide (NA) to resident ratios on several occasions. The facility did not have enough NAs during the day, evening, and overnight shifts over a two-week period. The Nursing Home Administrator confirmed these staffing shortages.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day on five occasions, with care hours falling below the threshold on specific dates. This was confirmed by the Nursing Home Administrator.
Hermitage Nursing and Rehabilitation failed to meet the required nurse aide staffing ratios over a 14-day period, with shortages noted during day, evening, and overnight shifts. The facility consistently fell short of the mandated number of NAs per resident, as confirmed by staffing documents and the Nursing Home Administrator.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day for ten days within a two-week period. The nursing care hours per patient day (PPD) were below the minimum on several occasions, with the lowest being 2.81 PPD. This was confirmed by the Nursing Home Administrator.
The facility failed to store Schedule II-V medications in a permanently affixed compartment in the Unit 1 medication room. Controlled medications were kept in a removable locked box in the refrigerator, contrary to the facility's policy. A registered nurse confirmed the non-compliance during an interview.
The facility failed to notify the State LTC Ombudsman of emergency hospital transfers for four residents, as required by policy. These residents, with various serious medical conditions, were transferred multiple times without the necessary notifications. The Regional Clinician confirmed the facility's non-compliance during an interview.
The facility failed to provide written notice of its bed-hold policy to residents or their representatives within twenty-four hours of hospital transfers. This deficiency affected four residents with various medical conditions, and the lack of documentation was confirmed by the DON.
A facility failed to address a resident's care and treatment grievance in a timely manner. An employee received a letter of concern from the resident's family member but did not forward it for investigation, resulting in the grievance being unresolved. The Director of Nursing was unaware of the issue, confirming the facility's failure to follow its grievance policy.
Failure to Provide Scheduled Showers and Document Care for Dependent Resident
Penalty
Summary
Facility staff failed to provide scheduled showers to a resident who required substantial to maximal assistance with activities of daily living due to immobility and multiple sclerosis. According to the resident's care plan and facility policy, the resident was to receive showers on Wednesdays and Sundays during the evening shift, with full staff assistance and use of a mechanical lift. Documentation and interviews revealed that the resident did not consistently receive showers as scheduled, and there was no evidence that showers were offered or refused on several occasions. Instead, the resident was often given a bed bath without being offered a shower, despite expressing a preference for a shower over a bed bath. Review of clinical records, shower schedules, and staff interviews confirmed gaps in documentation and delivery of care. There was no documented evidence that the resident received or refused showers according to their care plan and preferences for a period of over a month. Facility leadership confirmed the lack of documentation and adherence to the resident's scheduled showers, which was not in accordance with facility policy or the resident's care plan.
Staffing Deficiencies at Hermitage Nursing and Rehabilitation
Penalty
Summary
Hermitage Nursing and Rehabilitation was found to be non-compliant with the Pennsylvania Long Term Care Licensure Regulations regarding nursing services. Specifically, the facility failed to meet the required nurse aide (NA) to resident ratios on multiple occasions between January 22, 2025, and February 4, 2025. During the day shift, the facility did not meet the minimum requirement of one NA per 10 residents on two days. On the evening shift, the facility failed to meet the minimum requirement of one NA per 11 residents on four days. Additionally, the overnight shift did not meet the minimum requirement of one NA per 15 residents on four days. The staffing shortages were confirmed through a review of the facility's nursing staffing documents and an interview with the Nursing Home Administrator. The administrator acknowledged that the facility did not meet the required NA ratios on the specified dates and shifts. The report does not provide any information about the impact of these staffing shortages on the residents or any specific incidents that occurred as a result of the deficiencies.
Plan Of Correction
No residents were found to be negatively affected by the deficient practice of regulation. The facility will maintain one Nurse Aide for ten residents on day shift, one nurse aide for eleven residents for evening shifts, and one nurse aide to fifteen residents for night shift to meet minimum state regulation, as required and calculated by PA DOH Minimum Staffing Ratios. 1. The Administrator and/or designee will have a staffing meeting each business day morning, for four weeks to ensure proper staff to resident ratios meet shift requirements according to current censuses. The Census will be reviewed each business day morning to ensure the staff to resident ratio. Every weekend the Director of Nursing and Assistant Director of Nursing alternate to assure compliance. 2. We are going to educate all Clinical Managers on the call off practice. Immediately notify scheduler/Director of Nursing and call staff with the provided phone numbers of employed staff. Failure to find coverage must notify Director of Nursing immediately. The facility will utilize administration staff that have a certified nurse aide certification to maintain the required ratios for the certified nursing assistants, in the event of unforeseen shortage of certified nursing assistants. 3. Daily staffing sheets completed Monday through Friday. Human Resources and Scheduler meet to discuss PPD and ratios. Scheduler, Director of Nursing, Administrator, and Human Resources meet to review staffing schedules five times a week. The Facility will utilize On-shift program to make the schedule accessible to staff to see open shifts and pick them up. 4. Director of Nursing and Assistant Director of Nursing oversees the admission process to determine the appropriate level of care regarding ratios and PPD. 5. Administrator or designees will continue to recruit potential employees by placing ads on Indeed and other recruiting mediums, networking within the community through Facebook and other social media. 6. Referral bonus will be offered to employees to encourage candidates to apply. 7. The Administrator or designee will review the staffing concerns monthly in the Quality Assurance and Performance Improvement meeting. The scheduler and nursing supervisor will be educated on the requirements of staff in order to meet mandatory resident to staff ratios. 8. Active recruitment of employees at local medical facilities that are closing will be documented. 9. All auditing of the above process will be completed by the Nursing Home Administrator and Director of Nursing, or designee and documented five times weekly at a minimum to achieve compliance.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day for five out of fourteen days reviewed. Specifically, on the dates of 1/25/25, 1/26/25, 1/27/25, 2/01/25, and 2/02/25, the facility's nursing staffing documents showed that the provided hours of care were below the required threshold, with recorded hours of 3.16, 2.93, 2.93, 3.06, and 3.11 respectively. This deficiency was confirmed during an interview with the Nursing Home Administrator on 2/07/25, who acknowledged that the facility did not meet the mandated minimum direct nursing care hours on the specified dates.
Plan Of Correction
No residents were found to be negatively affected by the deficient practice of regulation. The facility will maintain a minimum of 3.2 hours of direct resident care for each resident in a 24-hour period. The administrator, Director of Nursing, Assistant Director of Nursing, and scheduler will meet each business day, each morning, for four weeks to ensure the proper staffing is scheduled to meet required PPD according to the current censuses. Census will be reviewed in each morning meeting during the weekday to ensure the resident ratio and PPD is met. The facility will utilize open shifts on the OnShift mobile app available for all staff to access. The facility will utilize administrative staff that has Registered Nurse, Licensed Practical Nurse, and Certified Nursing Assistant to maintain 3.2 hours of direct patient care in the event of unforeseen staff shortage. Human Resources and Director of Nursing will continue to post ads on social media, Indeed, and community-based efforts to obtain staff. Offer a referral bonus to employees that recruit staff to apply and become hired. The administrator, Director of Nursing, and interdisciplinary team will meet monthly at the Quality Assurance Improvement Program meetings as needed. Scheduler and Nursing supervisors all will be educated on the requirements of staffing needs to meet mandatory minimum 3.2 hours of direct resident care for each resident in each 24-hour period. All the above processes will be completed by the administrator and Director of Nursing or designee and documented five times weekly at a minimum. Nursing supervisors are educated to notify the Director of Nursing and Assistant Director of Nursing as soon as possible of the staff shortage needs to cover needs as soon as possible. All admissions reviewed with Director of Nursing and Assistant Director of Nursing to ensure the ratio and PPD are being met prior to being admitted to the facility. Nursing schedule reviewed and audited each weekday for four weeks to ensure all shifts are properly covered. Director of Nursing and Assistant Director of Nursing alternate weekends with scheduler to audit. It is being audited before and after the schedule is out to ensure we meet regulations.
Nurse Aide Staffing Deficiency
Penalty
Summary
Hermitage Nursing and Rehabilitation failed to meet the required nurse aide (NA) staffing ratios as mandated by the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations. The facility was unable to provide the minimum number of NAs per resident during various shifts over a 14-day period. Specifically, the facility did not meet the required ratio of one NA per 10 residents during the day shift on five occasions, one NA per 11 residents during the evening shift on six occasions, and one NA per 15 residents during the overnight shift on four occasions. This deficiency was identified through a review of the facility's nursing staffing documents and confirmed by the Nursing Home Administrator during a telephone interview. The staffing shortages were documented on specific dates, with the facility consistently falling short of the required number of NAs needed to meet the resident census. For instance, on certain days, the facility had a census of 92 residents but only staffed 8.78 NAs instead of the required 9.20 during the day shift. Similar shortages were noted during the evening and overnight shifts, with the facility failing to meet the required NA ratios, thereby not complying with the state regulations. These findings indicate a pattern of insufficient staffing that persisted over the observed period.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. No residents were found to be negatively affected by the deficient practice of regulation. The facility will maintain 1 nurse aide for 10 residents on day shift, 1 nurse aide for 11 residents for evening shifts, and 1 nurse aide to 15 residents for night shift to meet minimum state regulation, as required and calculated by PA DOH Minimum Staffing Ratios. 1. The Administrator and/or designee will have a staffing meeting each business day morning, for four weeks to ensure the proper staff to resident ratios meet shift requirements according to current censuses. Census will be reviewed to ensure staff to resident ratio. 2. The facility will utilize administrative staff that have certified Nurse Aide certification to maintain the required ratios for the CNA, in the event of unforeseen shortage of CNA. 3. The Facility will utilize Open Shift program to make the schedule accessible to staff to see open shifts and pick them up. 4. Administrator or designees will continue to recruit potential employees by placing ads on Indeed and other recruiting mediums, networking within the community through Facebook and other social media. 5. Referral bonus will be offered to employees to encourage candidates to apply. 6. The Administrator or designee will review the staffing concerns in monthly QAPI meetings as needed. 7. Scheduler and Nursing Supervisors will be re-educated on requirements of staff in order to meet mandatory resident to staff ratios. 8. Nursing Supervisors will notify DON/ADON as soon as possible, of staff shortage needs in order to cover needs as possible. 9. Active recruitment of employees at local medical facilities that are closing will be documented. 10. All auditing of above process will be completed by NHA/DON, or designee, and documented 5 times weekly at a minimum.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day for ten out of fourteen days reviewed. The deficiency was identified through a review of the facility's nursing staffing documents for the period from November 20, 2024, to December 3, 2024. On specific dates, the facility's nursing care hours per patient day (PPD) fell below the required minimum, with the lowest being 2.81 PPD on December 1, 2024. This shortfall was confirmed by the Nursing Home Administrator during a telephone interview on December 13, 2024.
Plan Of Correction
No residents were found to be negatively affected by the deficient practice of regulation. The facility will maintain a minimum of 3.2 hours of direct resident care for each resident in each 24-hour period. 1. The Administrator and/or designee will have a staffing meeting each business day morning, for four weeks to ensure the proper staffing is scheduled to meet required PPD according to current censuses. Census will be reviewed to ensure staff to resident ratio and PPD. 2. The facility will utilize administrative staff that have RN, LPN licensure and/or CNA in good standing to maintain the required 3.2 hours of direct patient care, in the event of unforeseen staff shortage. 3. The Facility will utilize Open Shift program to make the schedule accessible to staff to see open shifts and pick them up. 4. Administrator or designees will continue to recruit potential employees by placing ads on Indeed and other recruiting mediums, networking within the community through Facebook and other social media. 5. Offer a referral bonus to employees that encourage candidates to apply. 6. The Administrator and his designees will review the staffing concerns in Monthly QAPI meetings as needed. 7. Scheduler and Nursing Supervisors will be educated on requirements of staffing needs in order to meet mandatory minimum of 3.2 hours of direct resident care for each resident in each 24-hour period. 8. Nursing Supervisors will notify DON/ADON as soon as possible, of staff shortage needs in order to cover needs as possible. 9. Active recruitment of potential employees of expected medical facility closings will be documented by Human Resource Director. 10. All auditing of above process will be completed by NHA/DON, or designee, and documented 5 times weekly at a minimum.
Improper Storage of Controlled Medications
Penalty
Summary
The facility failed to comply with regulations regarding the storage of Schedule II-V medications in one of its medication rooms. Specifically, the deficiency was identified in the Unit 1 medication room, where controlled medications were stored in a white locked box within the refrigerator door. However, this locked box was not permanently affixed to the refrigerator, allowing it to be removed entirely, which is against the facility's policy and regulatory requirements. This was confirmed during an interview with a registered nurse, who acknowledged that the controlled medications were not stored as required by the facility's policy dated 1/05/24.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman of emergency transfers for four residents, as required by their policy. The policy, dated January 5, 2024, mandates that the facility provide copies of notices for emergency transfers to the Ombudsman, when practicable, and maintain evidence of such notifications. However, upon review of clinical records and staff interviews, it was found that the facility did not send these notifications for Residents R18, R37, R56, and R88, who were transferred to the hospital on various occasions. Resident R18, diagnosed with stroke, dementia, and chronic kidney disease, was transferred to the hospital on February 11, 2024, without notification to the Ombudsman. Similarly, Resident R37, with Parkinson's disease and other conditions, was transferred multiple times without notification. Resident R56, with chronic kidney disease and high blood pressure, and Resident R88, with cancer and other serious conditions, were also transferred without the required notifications. The Regional Clinician confirmed these omissions during an interview, acknowledging the facility's failure to comply with the notification requirement.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents or their representatives within twenty-four hours of their transfer to a hospital. This deficiency was identified for four residents who were transferred to the hospital for various medical conditions, including stroke, dementia, chronic kidney disease, Parkinson's disease, high blood pressure, obstructive uropathy, cancer, and tracheostomy. The facility's policy requires that in the event of an emergency transfer, a written notice of the bed-hold policy should be provided to the resident or their representative within twenty-four hours. The clinical records for the residents in question lacked evidence that such notices were provided, as confirmed by the Director of Nursing during an interview. The residents involved had multiple hospital transfers, yet there was no documentation indicating compliance with the facility's policy regarding bed-hold notifications. This oversight was noted for residents who were transferred on several occasions, highlighting a systemic issue in adhering to the policy requirements.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to resolve a grievance related to the care and treatment of a resident, as reported by the resident's family member. The facility's Concerns-Grievances policy mandates that all grievances be investigated within 72 hours and the complainant be informed of the results within seven days. However, a letter of concern written by the resident's family member in February 2024 was received by an employee but was not forwarded to the appropriate staff for investigation and resolution. This resulted in the grievance not being addressed in a timely manner as per the facility's policy. Interviews with the resident's family member and the employee who received the letter confirmed that the grievance was not processed according to the established procedures. The Director of Nursing was unaware of the grievance and confirmed that the concerns were not addressed promptly. The facility's failure to follow its grievance policy led to the resident's care and treatment concerns being unresolved, violating the resident's rights and the facility's own policies.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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