Homewood Living Plum Creek, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Hanover, Pennsylvania.
- Location
- 425 Westminster Avenue, Hanover, Pennsylvania 17331
- CMS Provider Number
- 395898
- Inspections on file
- 18
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Homewood Living Plum Creek, Inc during CMS and state inspections, most recent first.
A resident with C-diff and sepsis was placed on contact precautions, requiring staff to wear gloves and a gown when entering the room. A housekeeper entered the room wearing only gloves and a mask, not a gown, and did not perform hand hygiene after leaving the room before continuing to clean other areas. This failure to follow infection control protocols was confirmed through observation and staff interview.
The facility failed to implement proper infection control practices for two residents on droplet precautions. A nurse aide did not wear eye protection when entering a resident's room, and another aide improperly disposed of a face shield outside a resident's room. The DON acknowledged these lapses, which violated the facility's infection control policy.
A facility failed to accommodate the needs of a resident with dementia by turning off her call light without addressing her request for restroom assistance. Additionally, another resident with vision impairments had her call bell out of reach, contrary to her care plan. The DON confirmed these deficiencies.
A facility failed to ensure accurate resident assessment when a resident's MDS inaccurately indicated treatment for PTSD, despite no medical record or care plan supporting this. The DON confirmed the error, noting the resident had no PTSD history.
A resident with CHF and edema had a physician order for Tubi grips to be applied twice daily, but observations revealed they were not in place despite visible edema. The Treatment Administration Record inaccurately indicated compliance with the order. Interviews revealed the resident had not worn the Tubi grips for over a month due to weight loss and improved edema, and the order was changed to 'as needed'. The DON acknowledged the documentation error.
A facility failed to limit PRN orders for antipsychotic medications to 14 days, as required by policy. A resident with dementia, major depressive disorder, and anxiety disorder had a PRN order for Seroquel without a stop date, which was not reviewed within the mandated timeframe. The DON acknowledged the oversight, confirming non-compliance with the regulation.
The facility failed to include the facility name in the daily nurse staffing postings, as observed on two separate occasions. This omission was confirmed through staff interviews, and a corrected posting was later provided by the DON.
The facility failed to maintain its automatic sprinkler system, affecting one of seven smoke compartments. Observations revealed missing escutcheons on sprinkler heads in the Care South Country Kitchen and outside a resident room, confirmed by the Administrator.
Failure to Follow Contact Precaution Protocols for Resident with C-diff
Penalty
Summary
The facility failed to ensure that staff implemented infection control policies for a resident on contact precautions. Facility policy required staff and visitors to wear gloves and a disposable gown when entering the room of a resident on contact precautions. A resident with diagnoses of Clostridioides difficile (C-diff) and sepsis was placed on contact precautions per physician order and care plan. On observation, a housekeeper entered the resident's room wearing only disposable gloves and a surgical mask, but not a protective gown, despite signage on the door indicating the requirement for both gloves and gown. After leaving the resident's room, the housekeeper removed her gloves and put on a new pair without washing her hands, then proceeded to clean the hallway and other resident rooms. The housekeeper stated she was aware of the contact precautions but believed only gloves and a mask were required. The deficiency was identified through observation, policy review, and staff interview, confirming that infection control protocols were not followed as required for residents on contact precautions.
Infection Control Lapses in Droplet Precautions
Penalty
Summary
The facility failed to implement proper infection control practices for two residents on droplet precautions. The facility's infection control policy, last reviewed in April 2024, outlines the need to prevent and control the spread of communicable diseases and establish guidelines for transmission-based precautions. However, observations revealed that these guidelines were not followed. Specifically, a nurse aide did not wear eye protection when entering the room of a resident diagnosed with influenza, congestive heart failure, and chronic kidney disease. Another nurse aide improperly disposed of a face shield outside the room of a resident with similar diagnoses, contrary to the facility's policy that requires PPE disposal bins to be inside the resident's room. The Director of Nursing acknowledged during an interview that the PPE disposal bin should have been inside the resident's room and that staff should wear PPE appropriately. The facility's failure to adhere to its infection control policy was observed during the delivery of lunch trays to the residents, highlighting lapses in the implementation of droplet precautions. These deficiencies were noted under the regulations 28 Pa Code 201.18(b)(1) Management and 28 Pa Code 211.12(d)(1)(5) Nursing Services.
Plan Of Correction
Preparation and evaluation of the enclosed plan of correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or concluded set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provision of Federal and State law. F-0880 Infection Prevention and Control 1. Resident #46 - Re-Education provided to the staff member on proper donning of PPE for Droplet precautions by Infection Preventionist. Resident #68 - Re-Education provided to the staff member on proper doffing of PPE for Droplet precautions by Infection Preventionist. 2. All resident rooms on precautions were checked to ensure PPE donning and doffing set up was done per facility policy and staff were following the correct procedures. No other discrepancies found. Donning and Doffing was reviewed with staff by Infection Preventionist on 1/23/25. 3. Policy on Infection Control will be reviewed and revised as necessary by DON. Re-education will be provided to the Healthcare staff on Infection Control and proper donning and doffing of PPE via Relias with education completed by 2/21/25. 4. QA Coordinator will audit for proper donning and doffing of PPE. 5 donning or doffing audits will be done weekly X2 weeks, bi-weekly x2 weeks then monthly x2. Any immediate concern will be brought to DON for immediate attention and re-education. Audits will be reviewed at QA Meetings. All Corrective actions will be completed by 2/25/25.
Failure to Accommodate Resident Needs and Ensure Call Bell Accessibility
Penalty
Summary
The facility failed to reasonably accommodate the needs of Resident 4, who had dementia, major depressive disorder, and anxiety disorder. On January 21, 2025, Resident 4 activated her call light to request assistance to use the restroom. A Registered Nurse (Employee 1) entered the room to administer medication, was informed by Resident 4 of her need, and turned off the call light without ensuring the need was met. Employee 1 claimed to have notified a Nurse Aide (Employee 3) via communication devices, but Employee 3 was occupied with an emergent situation and delayed in assisting Resident 4. The Director of Nursing (DON) confirmed the delay and the inappropriate deactivation of the call light before Resident 4's needs were addressed. Additionally, the facility did not ensure call bell accessibility for Resident 87, who had macular degeneration, age-related nuclear cataract, and hypertension. During an observation, Resident 87 was found eating breakfast in bed with her call bell out of reach on a recliner. Her care plan, which included an intervention to keep frequently used items within reach due to a history of falls, was not followed. The DON acknowledged that the call bell should have been within Resident 87's reach.
Plan Of Correction
Preparation and evaluation of the enclosed plan of correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or concluded set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provision of Federal and State law. F-0558- Reasonable Accommodations Needs/Preferences 1. Resident #4 - DON provided education that in the future, the aide should notify her team leader that she was in another emergent situation so another person could respond to the residents' needs. Resident #87 re-education given to the aide to ensure the call light was always within reach for resident. 2. All other resident rooms were checked on both units on 1/23/2024 and all call lights were within reach and no other concerns were identified with residents receiving services with reasonable accommodations of resident needs and preferences. 3. Policy for Call Lights- Answering has been reviewed and revised by the DON. Education provided via Relias computer education system to Healthcare staff on the revised policy to include not turning off the call light until the resident needs have been met, call lights should be within reach at all times and the importance of residents receiving services with reasonable accommodations of resident needs and preferences. This education will be completed by 2/21/2025. 4. Audits will be completed by the QA coordinator monitoring for residents receiving services with reasonable accommodations of resident needs and preferences/call lights within reach/call lights turned off when resident needs met. Audits will be done weekly X2 weeks, bi-weekly x2 weeks then monthly x2. Any immediate concern will be brought to DON for immediate attention and re-education. Audits will be reviewed at QA Meetings. All corrective actions will be completed by 2/25/25.
Inaccurate Resident Assessment in MDS
Penalty
Summary
The facility failed to ensure that the resident assessment accurately reflected the resident's status for one of the residents reviewed. Specifically, the clinical record review and staff interview revealed that a resident, diagnosed with cerebral infarction and gastro-esophageal reflux disease, was inaccurately assessed in the Minimum Data Set (MDS) as having been treated for Post Traumatic Stress Disorder (PTSD) in the previous seven days. However, the resident's electronic medical record did not show any treatment for PTSD, nor was there a care plan addressing PTSD. The Director of Nursing confirmed that the MDS was marked in error and that the resident did not have a history of PTSD.
Plan Of Correction
Preparation and evaluation of the enclosed plan of correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or concluded set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provision of Federal and State law. F-0641- Accuracy of Assessments 1. Resident #49 MDS was modified on 1/22/25 removing that the resident had been treated for PTSD in section I6100. DON did a written education for the LPNAC that entered this incorrectly. 2. All assessments completed in the past 14 days were audited for accuracy in section 16100 with no other errors identified. 3. Policies for Resident Assessments and comprehensive Assessments has been reviewed and will be revised as needed by the DON. Re-education provided to the MDS team by the DON on 1/31/2025 on accuracy of assessments per the RAI manual. Ongoing MDS training courses will be scheduled for the MDS team as offered and appropriate. 4. MDS's completed by the LPNAC will be audited by RNAC for accuracy. Audits will be completed on random sections of the MDS completed by the LPNAC. 5 assessments will be audited bi-weekly X2, then monthly x3 in coordination with residents MDS schedule. MDS will be modified if any errors identified. Any error identified will be brought to DON attention immediately. Audits will be reviewed at QA Meetings. All corrective actions will be completed by 2/25/25.
Failure to Implement Resident-Directed Care and Treatment
Penalty
Summary
The facility failed to implement resident-directed care and treatment consistent with the physician orders and care plan for a resident diagnosed with congestive heart failure, localized edema, and muscle weakness. The resident had a physician order for Tubi grips to be applied to the bilateral lower extremities twice a day to manage edema, starting from September 20, 2024. However, observations on January 21 and 22, 2025, revealed that the resident was not wearing the Tubi grips, despite having visible edema in the lower extremities. The Treatment Administration Record inaccurately indicated that the Tubi grips were in place on these dates. Interviews with the resident and the Director of Nursing revealed that the resident had not worn the Tubi grips for over a month due to significant weight loss and improvement in edema. The Director of Nursing confirmed that the physician order was changed to 'as needed' on January 22, 2025, but acknowledged that the order should not have been signed off as if the Tubi grips were in place when they were not. This discrepancy highlights a failure in accurately documenting and implementing the resident's care plan as per the physician's orders.
Plan Of Correction
Preparation and evaluation of the enclosed plan of correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or concluded set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provision of Federal and State law. F-0684-Quality of Care 1. Resident 41's Physician orders/eTAR was reviewed and discussed with physician and resident. Physician changed order to PRN on 1/22/25. 2. All Resident treatment orders were reviewed to ensure the facility had implemented resident-directed care and treatment consistent with Physician's orders. No other discrepancies were identified. 3. Policies on Care Plans-Comprehensive Person-Centered and Nursing Documentation were reviewed and will have necessary revisions made by DON. Re-education provided to the Licensed nurses via Relias. Re-education to include reviewing the policies-Nursing Documentation and Care Plans-Comprehensive Person-Centered with a focus to include that residents receive any treatment ordered by the physician or the physician must be updated per policy of refusals or unnecessary treatment. Education will be completed by 2/21/25. 4. Treatments and Resident observations will be audited by QA Coordinator to ensure they are following the resident care plan and physician orders. Monitoring will include nurse observation to ensure treatment or appliance is in place. 5. Audits will be done weekly X2 weeks, bi-weekly x2 weeks then monthly x2. Any immediate concern will be brought to DON for immediate attention and re-education. Audits will be reviewed at QA Meetings. All corrective actions will be completed by 2/25/25.
Failure to Limit PRN Antipsychotic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that PRN orders for antipsychotic medications were limited to 14 days, as required by their policy and regulations. Specifically, Resident 4 had a PRN order for Seroquel, an antipsychotic medication, which was prescribed without a stop date, starting on December 31, 2024. This order was not renewed or evaluated for appropriateness within the 14-day period, as mandated by the facility's policy. The Director of Nursing acknowledged the oversight during an interview, confirming that the facility should comply with the regulation requiring a 14-day stop date for PRN antipsychotic medications. Resident 4's clinical record indicated diagnoses of dementia, major depressive disorder, and anxiety disorder, which are conditions that may require careful management of medications. Despite an assessment by a practitioner on January 13, 2025, which included a plan to continue medications as recommended by psychiatric services, the PRN order for Seroquel was not updated or reviewed within the required timeframe. This oversight was identified during a survey, highlighting a deficiency in the facility's adherence to its own policy and regulatory requirements.
Plan Of Correction
Preparation and evaluation of the enclosed plan of correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or concluded set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provision of Federal and State law. F-0758- Free from Unnecessary Psychotropic meds/PRN use 1. Resident #4 PRN order for antipsychotic medication was reviewed with physician and discontinued on 1/23/25. 2. All PRN psychotropic orders were reviewed to ensure the order had an appropriate stop date per regulatory compliance. No other discrepancies found. 3. Policies for Psychotropic and Anti-psychotic Medications reviewed and any necessary revisions made by DON. Re-education to all Licensed Nurses on Psychotropic Medication use including every PRN order having a 14 day stop date will be provided via Relias to be completed by 2/21/2025. 4. QA Coordinator will review all new PRN psychotropic orders for a 14 day stop date. Audits will be done weekly X2 weeks, bi-weekly x2 weeks then monthly x2. Any immediate concern will be brought to DON for immediate attention and re-education. Audits will be reviewed at QA Meetings. All corrective actions will be completed by 2/25/25.
Omission of Facility Name in Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to include all required data in the daily nurse staffing postings, specifically omitting the facility name. This deficiency was identified during observations of the Daily Nursing Staff Postings on January 21, 2025, at 10:27 AM, and on January 22, 2025, at 9:35 AM. The absence of the facility name in the postings was confirmed through staff interviews. Subsequently, the Director of Nursing provided a corrected copy of the posting via email on January 22, 2025, at 4:03 PM.
Sprinkler System Deficiency Due to Missing Escutcheons
Penalty
Summary
The facility failed to maintain the hardware components of its automatic sprinkler protection system, affecting one of seven smoke compartments. During an observation on January 7, 2025, at 11:15 AM, it was noted that the sprinkler head closest to the corridor door in the Care South Country Kitchen was missing an escutcheon. This deficiency was confirmed through an interview with the Administrator at the same time. Additionally, another observation at 11:33 AM on the same day revealed that the sprinkler head located in the corridor outside Resident Room C-148 was also missing an escutcheon, which was again confirmed by the Administrator.
Plan Of Correction
The enclosed plan of correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or concluded set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provision of Federal and State law. 1. What systematic changes will be put in place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored. The sprinkler head escutcheon was placed onto the sprinkler heads located closest to the corridor door, within the Care South Country Kitchen and in the corridor outside Resident Room C-148 on 1.7.2025. Maintenance Director completed a full inspection and did not identify any further sprinkler/escutcheon concerns. Education was provided on 1.7.25 - 1.17.25 by NHA and Maintenance Director on the proper maintenance and importance of the sprinkler system specifically the escutcheons being intact at all times. 2. What quality assurance program will be put into place, and the dates when corrective actions will be complete. Action plan #455 was initiated. Audits will be done monthly X3 then quarterly by the Maintenance Director. The Maintenance Director will then report the findings to the QA Committee quarterly to ensure compliance with this regulation. The corrective action will be completed by 2.7.25.
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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