Homeland Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Harrisburg, Pennsylvania.
- Location
- 1901 North Fifth Street, Harrisburg, Pennsylvania 17102
- CMS Provider Number
- 395475
- Inspections on file
- 20
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Homeland Center during CMS and state inspections, most recent first.
A resident with TBI and Parkinson’s became combative during PM incontinence care provided by two NAs. According to documentation and staff statements, the resident struck one NA in the face, either directly or by hitting a wet washcloth that then contacted the NA. In response, the NA immediately slapped the resident in the face with an open hand and made a verbal remark about the resident hitting her. The resident was later assessed with facial redness but no skin tears, bruising, pain, or change in baseline status. The facility’s investigation determined that the NA’s action constituted physical abuse in violation of facility policy prohibiting hitting or slapping residents.
A resident with dementia and osteoporosis suffered a hip fracture and facial laceration after staff failed to implement required fall prevention interventions, including proper bed positioning and placement of floor mats and alarms, as outlined in the care plan. Staff statements and documentation confirmed that the care plan was not fully followed, leading to the resident's fall and subsequent injuries.
A deficiency occurred when a resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in care that was not individualized or consistent with documented directives.
Two residents with significant cognitive and physical impairments did not receive consistent assistance with grooming, specifically shaving, as required by their care plans and facility policy. Despite documentation indicating personal hygiene was provided every shift and no refusals were recorded, both residents were repeatedly observed with visible facial hair. Staff interviews confirmed that shaving was only performed on shower days, and there was no evidence that additional grooming was offered or documented.
A staff member was observed using an ink pen to poke holes in medication blister packs and push pills into medication cups for two residents, contrary to facility policy requiring avoidance of direct contact with medications unless gloved. The staff member admitted to this practice and could not confirm that the pen did not touch the pills, and facility leadership confirmed this was not appropriate.
The facility failed to provide appropriate restorative nursing programs for two residents with limited mobility. One resident with a history of cerebrovascular accident and hemiplegia did not receive the passive range of motion program as documented, while another resident with muscle weakness and chronic pain did not receive the transfer and splint assistance programs. Documentation errors were noted, and the care plan for one resident was not updated to reflect the current program.
Two residents in an LTC facility had inaccurate assessments in their clinical records. One resident, using a CPAP machine, was incorrectly documented as not using a non-invasive mechanical ventilator. Another resident, with a pressure ulcer, had inaccurate MDS entries regarding nutrition interventions. The DON and RN Assessment Coordinator acknowledged these errors.
The facility failed to provide residents with access to grievance information and forms, as required by policy. Interviews with residents revealed they were unaware of how to file grievances, and observations confirmed the absence of posted grievance information. The facility's handbook also lacked details on filing grievances anonymously and the contact information of the grievance official. Interviews with the administration indicated that grievances were expected to be resolved verbally, with no formal grievance forms available.
Resident Physically Abused by NA During Combative Care Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be free from physical abuse. Facility policy on resident abuse, neglect, and exploitation, revised July 2023, defines physical abuse as including hitting, slapping, punching, biting, and kicking, and states that the facility will protect the health, welfare, and rights of each resident by prohibiting and preventing abuse. Despite this policy, a nurse aide (Employee 1) physically struck a resident during the provision of care. The resident involved had diagnoses including intracranial injury (TBI) and Parkinson’s disease. During evening care, the resident became combative while two nurse aides, Employee 1 and Employee 2, were providing incontinence care and transferring the resident to bed. According to clinical documentation and staff statements, the resident hit Employee 1 in the face, either directly with his hand or by striking a wet washcloth that then hit Employee 1. Employee 2 reported that immediately after being hit, Employee 1 responded by smacking the resident in the face with an open hand and verbally stating, “You think you’re just going to keep hitting me!” The resident was assessed following the incident and was noted to have redness to the right cheek, with no bruising or skin tears, no reported pain, stable vital signs, and no change from baseline mental status. Resident interview was not possible due to the resident’s diagnosis. In interviews with facility leadership, Employee 1 admitted that she slapped the resident, characterizing it as a reaction to being hit, although she later attempted to modify her account to say she pushed the resident’s arm away. The facility’s investigation concluded that Employee 1 was physically abusive when she chose to hit the resident in return for the resident’s actions, and that the resident’s behavior did not warrant this response, which was considered resident abuse.
Failure to Implement Fall Prevention Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was implemented for a resident with dementia and osteoporosis, resulting in actual harm. The resident's care plan included specific fall prevention interventions such as a tab alarm at all times in bed and chair, bilateral floor mattresses/alarming floor mats, and a low bed. However, on the day of the incident, these interventions were not properly implemented. The bed was not in the low position, and the fall mats were not placed on the floor as required by the care plan. Clinical documentation and staff witness statements revealed that the certified nurse assistant (CNA) assigned to the resident did not fully follow the care plan. Although the CNA reported placing the bed in the lowest position and setting up alarms and mats, a subsequent statement admitted to failing to put down the second fall mat. Other staff who responded to the incident found the bed elevated, fall mattresses propped against the wall, and alarms not connected. This failure to follow the care plan led to the resident rolling out of bed, sustaining a 4-5 cm laceration to the forehead and a mildly displaced fracture of the proximal left femoral metaphysis (hip fracture). The incident was unwitnessed and occurred after the CNA had left the room. The resident required emergency medical attention, including repair of the facial laceration and hospital admission for orthopedic evaluation. The facility's investigation confirmed that the care plan was not followed, which directly resulted in the resident's injuries.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when treatment and care were not provided in accordance with physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was individualized and aligned with the documented directives and wishes of the resident, as required by regulations.
Failure to Provide Adequate Personal Hygiene and Grooming for Dependent Residents
Penalty
Summary
The facility failed to maintain adequate personal hygiene and grooming for two residents who were dependent on staff for assistance with activities of daily living (ADLs). Both residents had significant medical conditions, including dementia, Parkinson's disease, hemiplegia, and generalized muscle weakness, which limited their ability to perform self-care. Facility policy required that residents unable to carry out ADLs receive necessary services to maintain good grooming and hygiene. Care plans for both residents specified that they were dependent on staff for grooming tasks such as shaving. However, repeated observations over several days showed that both residents had visible facial hair, indicating that shaving was not consistently provided. Staff interviews revealed that shaving was typically performed on shower days, and residents or their families could request additional grooming if needed. Documentation indicated that both residents received personal hygiene every shift, with no refusals of care recorded. Despite this, the presence of facial hair persisted across multiple observations, and there was no documentation to support that shaving was offered or refused outside of scheduled shower days. The DON confirmed that shaving should have been provided or at least offered and documented if refused, in accordance with facility policy.
Improper Medication Preparation Compromises Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during the preparation and administration of medications for two residents. Facility policy required staff to avoid touching tablets or capsules unless wearing gloves. During a medication pass, a staff member was observed using an ink pen to poke holes in the back of medication blister packs and then push pills through into medication cups, potentially allowing the pen to come into contact with the pills. The staff member acknowledged using the pen in this manner and was unsure if the pen had touched the medications. Facility leadership confirmed that this practice was not in accordance with policy.
Failure to Implement Restorative Nursing Programs for Residents
Penalty
Summary
The facility failed to ensure that residents with limited mobility received appropriate services and assistance to maintain or improve their mobility. Specifically, two residents, identified as Resident 30 and Resident 40, did not receive the necessary restorative nursing programs (RNP) as outlined in their care plans. Resident 30, who has a history of cerebrovascular accident, hemiplegia, and muscle weakness, was supposed to be on a passive range of motion (PROM) program to maintain functional mobility and prevent contractures. However, documentation revealed that the program was not implemented 25 times on the day shift and 11 times on the evening shift. Similarly, Resident 40, diagnosed with muscle weakness, chronic pain, and major depressive disorder, was supposed to be on a transfer program and a splint assistance program to prevent decline in functional mobility and contracture development. The documentation showed that the transfer program was not implemented 51 times on the day shift and 73 times on the evening shift, while the splint program was not implemented 44 times on the day shift and 81 times on the evening shift. Additionally, Resident 40's care plan did not reflect the current splint RNP program. The Director of Nursing acknowledged the documentation errors, which were initially attributed to refusals by the residents.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, leading to deficiencies in their clinical records. Resident 28, diagnosed with chronic kidney disease and heart failure, was observed using a CPAP machine daily. However, the Minimum Data Set (MDS) for Resident 28 inaccurately marked the use of a non-invasive mechanical ventilator as 'No,' despite progress notes indicating the CPAP was used throughout the night. The Director of Nursing (DON) was unaware of the CPAP usage, and a modification to the MDS was initiated to correct this oversight. Resident 66, diagnosed with dementia, a pressure ulcer, and hypertension, had physician orders for a diabetic supplement to support skin health. Despite this, the Quarterly MDS and subsequent assessments inaccurately marked 'No' for nutrition or hydration interventions to manage skin problems. The Registered Nurse Assessment Coordinator acknowledged the coding errors, and the DON expressed an expectation for accurate MDS coding. These inaccuracies in resident assessments were identified as deficiencies during the survey.
Failure to Provide Grievance Information and Access in LTC Facility
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal by not posting the required grievance information and not providing access to grievance forms. The facility's policy, titled 'Resident and Family Grievances,' was reviewed and found lacking in providing the contact information of the grievance official, including their name, business address, and phone number. Observations across all resident areas confirmed the absence of posted grievance information and the identification of the Grievance Official. Interviews with three residents revealed that they were unaware of how to file a grievance or where to find grievance forms or information, despite attending monthly Resident Council meetings. Additionally, the facility's Skilled Nursing Resident Handbook did not include information on filing grievances anonymously or the contact details of the grievance official. Interviews with the Nursing Home Administrator and Director of Nursing indicated that no grievance forms were available, and grievances were expected to be resolved verbally through staff. The facility's grievance log showed only one grievance filed in the past six months, suggesting a lack of formal grievance processes.
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.
Trusted by long-term care providers and associations.
