Independence Rehab And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 600 W Cheltenham Avenue, Philadelphia, Pennsylvania 19126
- CMS Provider Number
- 395330
- Inspections on file
- 34
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 41 (1 serious)
Citation history
Health deficiencies cited at Independence Rehab And Nursing during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a documented history of alcohol and substance abuse repeatedly obtained and ingested alcohol-based hand sanitizer despite facility policies intended to prevent avoidable accidents. On multiple occasions, nursing staff and a psychologist observed the resident drinking or possessing cups of hand sanitizer, sometimes with ice, and removed the product; however, there was at least one incident where the MD was not notified and no specific monitoring or supervision interventions were documented. Although the care plan was later updated to address the resident’s behavior and provide education and psychosocial interventions, the resident continued to have access to hand sanitizer while ambulating freely throughout the building, and staff did not determine how the resident was obtaining it. The DON and NHA acknowledged that the resident had ingested or been found with hand sanitizer on three separate occasions while still having access to the product, resulting in an Immediate Jeopardy finding related to environmental hazards and inadequate supervision.
A resident with multiple comorbidities, cognitive intactness, and a history of falls and behavioral incidents was involved in repeated verbal and physical altercations, left an ER without being seen, and was subsequently identified as an elopement risk by facility assessment. Although the care plan addressed issues such as skin integrity, ADL decline, medication reactions, falls, nutrition, behavioral concerns, and smoking-related behaviors, it did not include a problem or interventions for wandering or elopement risk even after the resident was scored as at risk. A social worker later reported being unaware of the resident’s elopement risk status and that the care plan had not been updated to reflect this, demonstrating the facility’s failure to implement and revise the care plan for elopement risk and escalating behaviors.
A resident with multiple comorbidities, mobility limitations, and a documented elopement risk score was allowed to leave on day passes without documented elopement interventions or adherence to LOA policy. Facility policies required elopement risk assessment, individualized interventions, monitoring, and specific LOA procedures, but staff limited LOA documentation to sign-out at the front desk and did not consistently obtain physician orders for each LOA. The resident left twice with a family member; after the second departure, the resident did not return, and attempts to contact the resident and a prior shelter were unsuccessful. The MD stated he would not authorize independent LOA for an elopement-risk resident, the DON acknowledged minimal LOA documentation practices, and the social worker reported being unaware of the resident’s elopement risk or the facility’s elopement and LOA policies.
Surveyors found that the facility did not consistently honor resident food preferences or provide acceptable substitutions, resulting in several residents receiving meals they disliked, could not eat, or found inedible. One resident with cancer, worried about weight loss, reported not receiving ordered double portions or regular nutritional supplements. Another resident described receiving burnt pizza and undercooked chicken without replacement items, while others reported repeatedly being served foods they had previously refused and feeling hungry as a result.
The facility did not follow its abuse, neglect, and exploitation policy requiring prompt reporting of all alleged violations to the state agency. Two residents reported separate incidents of alleged verbal abuse: in one case, a staff member allegedly threatened to have a resident removed from the facility after the resident accused her of disclosing his mental health diagnosis; in another, a nurse aide allegedly threatened a resident with death if she continued to ring her call bell. The DON and Administrator confirmed these allegations were not reported to the Department of Health or entered into the Event Reporting System, despite policy requirements.
A resident with dementia, psychosis, epilepsy, HTN, and COPD, and documented moderate cognitive impairment, became physically aggressive and struck a dietary aide. After being informed, a dietary supervisor confronted the resident in a hallway near the kitchen. Multiple statements indicated the resident raised fists and swung at the supervisor; the supervisor admitted swinging back and hitting the resident in the face. Witness accounts from another resident, an activity aide, and an RN supervisor confirmed that the supervisor struck the resident during the altercation, with one witness reporting the supervisor saying, “you messing with the wrong one” while hitting the resident. Surveyors concluded that the staff member’s act of striking the cognitively impaired resident constituted abuse and resulted in actual harm.
A resident who reported that a dresser fell on their shoulder and complained of arm pain had no corresponding documentation, nursing assessment, vital signs, or physician notification in the clinical record, and an LPN stated they were told by a manager not to document the event. In addition, one resident with psychosis did not receive ordered morning haloperidol because it was not available on the cart or in the medication room and needed to be reordered, and another resident with chronic back pain and sciatica did not receive ordered oxycodone because it had not been delivered from the pharmacy and a new prescription was required.
The facility failed to maintain safe room temperatures, adequate lighting, functioning water, and sanitary conditions on two nursing units. On one unit, multiple rooms had temperatures in the low 50s–60s°F, residents reported feeling cold, restroom lights in several rooms did not work, a sink had been shut off at the valve, and rust and discoloration were observed around a toilet and on nearby flooring. The same unit had empty hand sanitizer dispensers and a room with a strong cigarette smoke odor linked to a noncompliant smoker, where a lighter was found. On another unit, two rooms had no working cold water at the bathroom faucets; a resident reported having informed staff, and the maintenance director admitted knowing about one room’s lack of cold water for weeks without repairing it.
A resident with multiple diagnoses, including kidney failure, osteoporosis, psychosis, and PTSD, had an ongoing physician order for fortified cereal once daily with breakfast for added kcal and protein. During an observation of medication administration, a staff member documented that the fortified cereal was provided and/or consumed without actually seeing it on the breakfast tray or observing the resident eat it, instead relying on the assumption that dietary usually sends it. This resulted in inaccurate clinical documentation of the resident’s ordered nutritional intervention.
A resident who was cognitively intact and admitted for short-term rehab expressed a desire to be discharged and live with family, but the facility did not initiate or document a discharge plan as required by policy. Although the social worker was aware of the resident's wishes and therapy notes indicated a plan for home discharge, there was no evidence of coordinated discharge planning or required notifications.
A medication labeling error occurred when a resident's Potassium Chloride order for 20 MEQ/15ML was mislabeled by the pharmacy as 20 MEQ/7.5 ML, resulting in incorrect dosage instructions. The DON confirmed the discrepancy between the physician's order and the medication label.
A resident with a history of verbal aggression physically assaulted another resident, resulting in a closed head injury and a fractured finger. Despite previous incidents and threats, the facility failed to prevent the altercation, leading to significant harm.
The facility failed to provide suitable and nourishing snacks for eight residents who wanted to eat at non-traditional times. Despite being able to express their nutritional needs, these residents were not routinely offered bedtime snacks, as confirmed by clinical records and resident interviews. Observations showed that while bulk snacks were available for the 7-3 shift, there was uncertainty about their availability during the 3-11 shift. Meeting minutes also revealed prior resident concerns about snack availability.
The facility failed to follow professional standards for food service safety by not using the correct test strips to measure chlorine concentration in the dishwashing process. Dietary staff did not conduct a test load of dishes or use appropriate sanitizer testing strips, leading to improper sanitation practices.
The facility failed to create comprehensive care plans for two residents. One resident, diagnosed with physical aggression, paranoia, and insomnia, was involved in altercations without a care plan addressing these behaviors. Another resident, requiring oxygen therapy for shortness of breath due to anemia and leukemia, also lacked a care plan for their respiratory needs. The absence of these care plans was confirmed by the ADON.
A facility failed to maintain therapeutic levels of Depakote for a resident with epilepsy by not conducting routine testing and incorrectly decreasing the dosage. Additionally, a recommended increase in Risperdal was not communicated to the physician. The NHA and DON could not provide documentation or rationale for these actions.
Two residents with limited range of motion did not receive the necessary restorative care to maintain or improve their mobility. One resident with multiple diagnoses, including paraplegia and muscle contractures, was not provided with the documented passive range of motion exercises and splinting. Another resident with a history of stroke and hemiplegia did not receive the recommended splint and brace program. Observations and staff interviews confirmed the lack of care and documentation for both residents.
A resident with a history of self-harm was found with razors left in their bathroom by a nursing assistant, despite care plan interventions to prevent access to harmful items. The facility's DON confirmed the oversight.
The facility failed to ensure proper medication management for two residents. One resident was prescribed medications for insomnia without a diagnosis, while another received Lorazepam without documented rationale for extended use and Depakote without adequate indication. Blood level monitoring for Depakote was also insufficient.
A resident with obesity and high risk for pressure sores did not receive ordered blood tests to assess albumin and thyroid function. The facility failed to document the completion of these tests, as confirmed by an LPN during an interview.
A facility failed to maintain enhanced barrier precautions for a resident requiring enteral nutrition. Despite a care plan and signage indicating the need for gowns and gloves during high-contact activities, a nurse aide provided incontinence care wearing only gloves. The aide acknowledged awareness of the precautions but did not follow them, resulting in a deficiency.
A resident, who was cognitively intact and had anxiety and depression, missed doses of Trazodone without being informed by the physician about the medication change or alternative treatment options. The resident experienced poor sleep and there was no documentation indicating that the resident was allowed to participate in decisions regarding their care and treatment.
The facility failed to ensure food was stored, prepared, distributed, and served according to professional standards. Observations included dirty corridors, improperly stored food items, and maintenance issues in the food service areas. These deficiencies were confirmed by the Food Service Director.
The facility failed to implement a complete drug regimen review process for four residents, as required by their policy. Reviews and recommendations by the consultant pharmacist were inconsistently documented, and there was no evidence of follow-up actions or acknowledgment by the physician, as revealed in an interview with the DON.
The facility failed to ensure complete and accurate documentation of TB testing for three residents. The MAR showed discrepancies such as residents being marked as absent or refusing the test, yet negative results were recorded. The DON confirmed these discrepancies and was unsure how the results were documented without the tests being administered.
The facility failed to maintain complete and accurate dialysis communication records for a resident with End-Stage Renal Disease, missing critical information on multiple occasions. An interview with a Registered Nurse confirmed the lack of communication with the dialysis center.
The facility failed to maintain sufficient dietary personnel, resulting in late meal service. Observations revealed a backlog of dirty dishes and delayed lunch tray preparation. Interviews with residents confirmed the late delivery of lunch trays, with some still waiting well past the scheduled time. The delay was due to one aide calling off and another arriving three hours late.
The facility failed to maintain an effective infection control program in the laundry room. Two Laundry Aides were observed processing and folding clean linens in a manner that allowed the linens to come into contact with their personal clothing and one aide's beard, which was confirmed by the employees during an interview.
Repeated Hand Sanitizer Ingestion Due to Inadequate Hazard Control and Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free of accident hazards and to provide adequate supervision for a resident with known alcohol abuse and cognitive impairment, resulting in repeated ingestion of alcohol-based hand sanitizer. The facility’s Accident & Injury Prevention and Response Policy stated that residents were to be protected from avoidable accidents and injuries through proactive assessment, environmental safety, staff training, and timely response. The Safety Data Sheet for the ProCure Alcohol Gel Hand Sanitizer 70% identified the product as containing 70–75% ethyl alcohol and directed that a physician or poison control center be contacted immediately if ingested. Despite this information, the resident, who had a BIMS score of 10 indicating moderately impaired cognition and documented diagnoses including alcohol abuse, bipolar disorder, COPD, heart failure, and dementia, was able to obtain and ingest hand sanitizer on multiple occasions. The resident’s history included prior discharge from another LTC facility for alcohol abuse, insurance issues, and behavioral issues, and psychologist notes over several months documented alcohol and cocaine abuse, as well as the resident’s statements that they currently drink, do not plan to stop, and had drunk at a previous nursing home. On one date in January, a nurse observed the resident drinking hand sanitizer during rounds, removed the substance, completed an assessment, and documented stable vital signs. However, the clinical record did not show that the physician was notified of this ingestion or that any interventions were implemented to monitor or supervise the resident specifically related to hand sanitizer consumption. This lack of notification and absence of documented follow-up interventions occurred despite the known hazardous nature of the product and the resident’s substance use history. In late February, the unit manager documented finding the resident drinking a cup of hand sanitizer, discarding the cup, educating the resident on the dangers of ingestion, and notifying the physician and responsible party. A care plan was then documented indicating that the resident drinks hand sanitizer, with interventions focused on administering medications, analyzing triggers, assessing coping skills and support systems, providing re-education, and encouraging the resident to discuss feelings. Nevertheless, on a subsequent date in March, a nurse again observed the resident in their room with a bottle of hand sanitizer and a cup containing hand sanitizer, and both items were removed. A psychologist note also recorded that the resident was observed drinking hand sanitizer from a cup, with no further documentation of additional interventions to prevent recurrence. Staff interviews confirmed that the resident walked throughout the building unrestricted, could obtain more sanitizer without staff knowledge, and that the unit manager did not ask where the resident had obtained the sanitizer. The DON and NHA acknowledged that the resident drank or was observed with hand sanitizer in a cup on three separate occasions, had a history of alcohol abuse, and continued to have access to hand sanitizer in the facility, leading surveyors to identify an Immediate Jeopardy situation related to hazardous substance access and inadequate supervision.
Removal Plan
- Audit Resident R1's personal environment to ensure no hazardous substances are in the resident's possession or within reach.
- Update Resident R1's care plan to include history of alcohol and substance use.
- Initiate facility-wide staff in-service on signs and symptoms of alcohol/substance consumption and the requirement to report to a direct supervisor; supervisor to notify physician and family in the event of consumption.
- Notify and in-service staff regarding Resident R1's behaviors and educate staff to monitor when Resident R1 comes into view.
- Remove all alcohol-based hand sanitizer products potentially accessible to Resident R1 from units, including removing refills from wall dispensers, removing the dispensers, and removing other self-standing bottles.
- Provide staff with pocket hand sanitizers; ensure no hand sanitizer is available in the facility aside from these pocket sanitizers.
- Educate staff to keep pocket sanitizers on their person at all times.
- Conduct an audit to identify all residents with a history of alcohol and substance abuse; update care plans to include this history and appropriate interventions.
- Audit units every shift for audits.
- Continue audits and report results to QAPI.
Failure to Develop and Revise Care Plan for Elopement Risk and Escalating Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to implement interventions and revise the care plan after a resident was identified as an elopement risk and exhibited escalating behavioral issues. The resident was cognitively intact, required assistance with transfers and ambulation, and had multiple diagnoses including coronary artery disease, hypertension, diabetes mellitus, CVA, malnutrition, generalized weakness, and a history of falls. The resident’s medication regimen included antiplatelet agents, hypoglycemics including insulin, and anticoagulant therapy. The care plan initially addressed areas such as impaired skin integrity risk, ADL decline, adverse medication reactions, fall risk, oral/dental issues, nutritional concerns, and discharge planning, but did not include a problem or interventions for wandering or elopement risk. Events leading to the deficiency included multiple behavioral incidents and a documented elopement-related event. On one date, the resident was involved in a verbal altercation in which another resident ran toward and punched him; no visible injuries were noted, and notifications were made. The following day, after a room transfer, the resident was involved in another verbal altercation with a new roommate and was then moved to a different nursing unit. Later, the resident went to the ER and left without being seen, returning to the facility on the same morning. Following this, an elopement risk evaluation identified the resident as at risk for elopement, with a score above the facility’s threshold for elopement risk, based on a history of attempting to leave without informing staff, wandering behavior, and recent admission with incomplete adjustment to the facility. Despite the new elopement assessment and ongoing behavioral concerns, the care plan was not updated to include elopement or wandering. Subsequent nursing documentation noted that the resident was found smoking in his room and verbally threatened another resident, and later remained on a Leave of Absence with unsuccessful follow-up phone contact. Behavioral concerns and smoking-related behaviors were added to the care plan after an incident in which the resident punched another resident, and a self-determination focus was added regarding the resident’s choice not to follow smoking rules. However, there was still no care plan developed for wandering or elopement risk. The social worker later reported being unaware that the resident had been identified as an elopement risk and not knowing that the care plan had been updated to reflect that status, confirming the lack of care plan revision specific to elopement risk.
Failure to Supervise Elopement-Risk Resident on Leave of Absence
Penalty
Summary
The facility failed to provide adequate supervision and implement elopement interventions for a resident identified as being at risk for elopement. Facility policies required residents to be assessed for elopement risk upon admission, routinely, and with significant changes, and for residents identified as at risk to have individualized care plan interventions and close monitoring. The Elopement Prevention Policy also required staff to document exit-seeking behaviors, promptly report attempts to leave, and remain with the resident while notifying the charge nurse if a resident attempted to leave. The Leave of Absence (LOA) Policy required staff to ensure clinical stability, obtain a signed LOA form, document departure and return times, and complete a nursing assessment upon return, with additional steps if a resident did not return as expected. Resident R1 was admitted with multiple diagnoses including coronary artery disease, hypertension, diabetes mellitus, CVA, malnutrition, generalized weakness, and a history of falls, and required partial to moderate assistance with transfers and ambulation, and total assistance for car transfers. An initial elopement risk evaluation at admission scored the resident at 0, but a subsequent evaluation on January 20, 2026, scored the resident at 2.0, indicating elopement risk based on a history of attempting to leave without informing staff, wandering behavior, and recent admission with incomplete adjustment to the facility. Despite this identified risk, the record did not show implementation of specific elopement-related interventions or restrictions on unsupervised departures. Nursing notes and the LOA log showed that the resident left the facility on a LOA on February 3, 2026, and returned the same day without incident, and left again on February 4, 2026, accompanied by a brother and did not return. Social services documented that the resident left around 11:00 a.m. on February 4 and did not return as expected, and attempts to contact the resident and a prior shelter were unsuccessful. The Medical Director stated he does not write blanket LOA orders, that an order should be written each time a resident leaves, and that a resident identified as an elopement risk should not leave without staff supervision. The DON reported that LOA/day pass documentation was limited to signing out, with no requirement for formal documentation, education, or medication reconciliation, and the Social Worker stated she was unaware the resident was an elopement risk and was unfamiliar with the facility’s elopement and LOA policies. These actions and inactions resulted in the resident at known elopement risk leaving the facility and not returning, without appropriate supervision or adherence to policy requirements.
Failure to Honor Food Preferences and Provide Adequate, Acceptable Meals
Penalty
Summary
Surveyors identified that the facility failed to honor resident food preferences and provide requested nutritional items for multiple residents. One resident reported frequently receiving foods she had previously stated she does not like. Another resident stated she often receives foods she dislikes but eats them because she is very hungry; observation of her lunch plate showed she had eaten all of the ham, broccoli, and mashed potatoes despite reporting that she really does not like ham. Review of this resident’s meal ticket showed no notation for double portions, although she reported that she had spoken to the dietitian and was supposed to receive double portions. A further interview with this same resident revealed she does not like the food served and is not eating well. This resident also reported a recent cancer diagnosis and expressed concern about losing weight, stating she was supposed to receive a nutritional supplement with meals but had only received it once over more than a week. Another resident reported often receiving foods he cannot eat and showed a photo of a burnt piece of pizza that he described as inedible; he stated he sent it back and did not receive a replacement and was told nothing else would be sent, leading him to order food from outside. He also reported receiving chicken with blood in it, which he refused to eat due to concern, and again stated he was not given a substitute. Another resident reported not getting enough to eat and often feeling hungry, stating she continues to receive foods she had indicated she does not eat, such as scrambled eggs. These findings were cited under 28 Pa. Code 211.6(a) Dietary services, 201.14(a) Responsibility of licensee, and 201.18(b)(3) Management.
Failure to Report Allegations of Verbal Abuse to State Authorities
Penalty
Summary
The facility failed to ensure that all allegations of suspected abuse were reported immediately to the state agency as required by its abuse, neglect, and exploitation policy. The policy required reporting all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes: immediately, but not later than two hours after the allegation is made if the events involve abuse or result in serious bodily injury, or not later than 24 hours if the events do not involve abuse and do not result in serious bodily injury. Review of the Pennsylvania Department of Health (DOH) Event Reporting System (ERS) and facility documentation showed that two of three allegations of suspected abuse were not reported to DOH or entered into the ERS. One unreported allegation involved a grievance submitted for Resident R10 on February 7, 2026, describing an ongoing alleged incident of verbal abuse, most recently occurring on February 6, 2026, by Employee E10. The allegation stated that Employee E10 threatened to have the resident removed from the facility because the resident accused her of disclosing his mental health diagnosis. Another unreported allegation involved Resident R2, who, along with her daughter, reported to the DON that on February 3, 2026, a nurse aide wearing black scrubs threatened her to stop ringing her call bell or she would "end up dead." The DON recalled the conversation and noted that the black scrubs suggested the aide was likely from an agency, but confirmed that this allegation was also not reported to DOH or entered into the ERS. Review of the DOH ERS confirmed no reported events for either resident.
Staff-to-Resident Physical Abuse During Altercation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse when a staff member struck the resident in the face during an altercation. Facility policy titled “Freedom from Abuse Neglect and Exploitation,” revised in September 2025, required the facility to provide a safe environment and protect residents from verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Despite this policy, a dietary supervisor engaged in a physical confrontation with a resident and admitted to hitting the resident after the resident attempted to swing at him. The resident involved, identified as having diagnoses including epilepsy, hypertension, COPD, dementia, and unspecified psychosis, had a comprehensive MDS dated November 19, 2025, indicating moderate cognitive impairment. On the date of the incident, information submitted by the facility stated that the resident was physically aggressive toward staff, attacked and hit a dietary employee in an elevator, and later attacked another employee who then “took a swing” at the resident. The facility’s investigation documented that the dietary aide reported being approached and punched in the face by the resident while in the elevator, and that he informed the dietary supervisor of this event. According to the dietary supervisor’s written and verbal statements, after being notified that the resident had hit the dietary aide, he went to locate the resident and attempted to calm the situation. He reported that the resident became aggressive, that he asked the resident to stop multiple times, and that when he tried to exit the situation the resident took a swing at him. The dietary supervisor stated that he then swung back and hit the resident. A resident witness reported seeing the resident put hands up to fight and observed the dietary supervisor hit the resident back after being struck. An activity aide reported seeing the resident with fists balled up and observed the dietary supervisor hit the resident on the side of the face, though she did not see the resident hit the supervisor. The nursing supervisor’s statement indicated she saw the resident punch the dietary supervisor, after which the dietary supervisor began hitting the resident and said, “you messing with the wrong one,” while punching the resident in the face. Based on these documents and interviews, surveyors determined that a staff member striking a resident with moderate cognitive impairment constituted abuse and caused actual harm, compromising the resident’s right to be free from abuse.
Failure to Assess Injury Complaint and Ensure Availability of Ordered Medications
Penalty
Summary
The deficiency involves failures in assessment and medication administration for three residents. One resident with epilepsy, depression, PTSD, adjustment disorder, anxiety, hypertension, and diabetes reported that a drawer or dresser fell on their right shoulder while they were sitting on the bed and that their arm hurt. The clinical record contained no documentation that this alleged event occurred, no nursing assessment of the shoulder/arm area over time, and no documentation of vital signs or physician notification related to the incident. A licensed nurse confirmed that the resident had reported that a dresser fell on their shoulder and stated that the manager on duty, the Human Resources Manager, instructed him not to document anything about the event in the clinical record. The deficiency also includes failures to administer medications as ordered for two other residents. One resident with kidney failure, osteoporosis, psychosis, and PTSD had a physician’s order for 1–2 mg of haloperidol to be given in the morning for psychosis and schizophrenia; during a medication pass, the LPN could not locate the haloperidol on the cart or in the medication room and reported that the medication could not be administered because the resident had no more doses left and it needed to be reordered from the pharmacy. Another resident with lumbago with sciatica, hypertension, and epilepsy had a physician’s order for 15 mg oxycodone to be given by mouth every 10 hours for pain related to lumbago with sciatica; during a medication pass, the LPN informed the resident, who stated they were in a lot of pain and needed their pain medication, that the oxycodone was not available because it had not been delivered by the pharmacy and a prescription from the physician was needed.
Failure to Maintain Safe Temperatures, Functioning Utilities, and Sanitary Conditions
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment on multiple nursing units, as required by its own policy and regulatory standards. On the first-floor unit, surveyors measured room temperatures as low as 52°F, 57°F, 61°F, 62°F, and 66.5°F in several resident rooms, while residents reported feeling cold. One resident was observed lying in bed wrapped in multiple blankets and stated that it had been cold in the room for the past three months and that they felt cold. Another resident in a different room also reported feeling cold. In addition, all rooms from 111–116 had non-functioning restroom lights, and the sink water in one room had been turned off at the valve until the Maintenance Director reopened it during the survey. The survey also identified environmental and sanitation issues on the same unit. In one resident room, the restroom had rusted metal edges on the wall with rust flaking off, rust discoloration around the toilet and toilet valves, and brown rust discoloration on the floor tile behind the toilet. The hallway on the unit had two hand sanitizer dispensers, both of which were empty. In another room, there was a strong smell of cigarette smoke near one bed; the resident occupying that bed denied smoking, but the Unit Manager confirmed a strong smoking odor and reported that the resident was a smoker with a contract not to smoke and was noncompliant. A lighter was found during a search of the room. On a separate date, during a tour of the fourth-floor nursing unit, surveyors found that one resident room had no working cold water when the bathroom faucet was turned on. Another room on the same unit also had no working cold water when the bathroom faucet was tested. A resident reported that she had told staff about the issue but could not recall to whom she had reported it. The Director of Maintenance stated he had been aware since December 10, 2025, that one of these rooms did not have working cold water after he went to fix the toilet there and acknowledged that he had known about the problem and had not had time to fix it. He also reported that he was notified of the lack of cold water in the other room only after the surveyor’s observation.
Inaccurate Documentation of Prescribed Fortified Cereal Intake
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record regarding a prescribed fortified cereal at breakfast for one resident. The resident had physician orders, dated August 25, 2022 and monthly thereafter, for fortified cereal once daily with breakfast to provide additional calories and protein. The resident’s diagnoses included kidney failure, osteoporosis, psychosis, and post-traumatic stress disorder. During a medication administration observation on January 6, 2026 at 10:11 a.m., a staff member (Employee E11) was observed documenting in the clinical record with her initials indicating that the resident had received and/or consumed the fortified cereal. When questioned, Employee E11 acknowledged that she had not actually seen the fortified cereal on the resident’s breakfast tray and had not observed the resident consuming it. She stated that dietary “usually” sends the fortified cereal up, indicating that her documentation was based on assumption rather than direct observation or confirmation. This resulted in an inaccurate entry in the resident’s clinical record regarding the provision and consumption of the ordered fortified cereal.
Failure to Initiate and Document Discharge Planning for Resident Requesting Discharge
Penalty
Summary
The facility failed to initiate and document a discharge plan for a resident who requested to be discharged. According to facility policy, residents may not be discharged unless specific criteria are met, and the facility must provide written notice, physician documentation, and coordinate discharge planning with social services, nursing, MDS, and therapy. The policy also requires that the discharge notice include the reason for discharge, effective date, appeal rights, and discharge location, as well as the development of a post-discharge plan of care. In this case, the resident, who was cognitively intact and admitted for short-term rehabilitation due to cellulitis of the lower limb, expressed a desire to leave the facility and live with family. The resident had communicated this wish to the social worker for several weeks, but no discharge plan was documented or initiated. Review of the clinical record showed that while the social worker was aware of the resident's wishes and had attempted to contact the resident's daughter, there was no evidence of a coordinated discharge plan or documentation of the required notifications. The care plan did not mention discharge planning, and the nursing home administrator confirmed that no steps had been taken to facilitate the resident's discharge. Physical therapy notes indicated the resident was expected to return home with family support and identified potential barriers, but these were not addressed in a formal discharge plan. The deficiency was identified through review of facility policy, clinical records, and staff and resident interviews.
Medication Labeling Error for Potassium Chloride
Penalty
Summary
The facility failed to ensure that a medication label was accurate for a resident. Review of the resident's physician orders showed an order for Potassium Chloride Liquid 20 MEQ/15ML to be given once daily via PEG-tube for hypokalemia. However, observation of the medication label revealed it was incorrectly labeled as Potassium Chloride Liquid 20 MEQ/7.5 ML. An interview with the DON confirmed that the pharmacy had mislabeled the medication, instructing administration of 7.5 ML instead of the ordered 15 ML.
Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident, identified as R112, from physical abuse by another resident, R46, who had a known history of verbal aggression towards R112. This failure resulted in actual harm to R112, who sustained a closed head injury and a fractured right finger. R46, who was alert and oriented, had a history of verbal altercations with R112, including an incident where R46 threatened R112. Despite these known issues, the facility did not take adequate measures to prevent further incidents. On the day of the incident, R112 was found bleeding from the head and reported being hit by R46 with a cane. The facility's investigation confirmed that R46 was the perpetrator, as witnessed by R112's roommate. R112 was subsequently treated at the hospital for a closed head injury and a fractured finger. The facility's failure to address the ongoing aggression from R46 towards R112 led to this incident of physical abuse, resulting in significant harm to R112.
Failure to Provide Nourishing Snacks at Non-Traditional Times
Penalty
Summary
The facility failed to ensure that suitable and nourishing snacks were provided for eight out of nine residents who wanted to eat at non-traditional times, outside of the scheduled meal service schedule. The residents involved were able to verbally express their nutritional preferences and needs, and clinical record reviews confirmed that they were cognitively intact, except for one resident who was moderately cognitively impaired. During a group meeting, the residents expressed that they were not being routinely offered nourishing snacks at bedtime, which was corroborated by the lack of consistent documentation indicating that staff members were completing this task. Observations revealed that bulk snacks were provided by the dietary department at 6:00 a.m. for use during the 7-3 shift, but there was uncertainty among nursing staff about whether the 3-11 shift was routinely offering bedtime snacks. Additionally, a review of food committee meeting minutes indicated that a resident had previously voiced concerns about not being offered between meals and bedtime snacks as care planned. This deficiency was identified through clinical record reviews, interviews with residents and staff, and reviews of policies and procedures.
Improper Dishwashing Practices and Testing in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the operation and monitoring of their dishwashing process. During an initial tour of the main kitchen, it was observed that dietary staff were not conducting a test load of dishes nor utilizing the appropriate sanitizer testing strips to verify the concentration of the final rinse water. The dish machine, which operates as a low temperature machine relying on chemical sanitation, was not being properly monitored for effective sanitation. Further investigation revealed that the Dietary Assistant was using incorrect test strips, specifically QAC QR test strips, which are not suitable for measuring chlorine concentration in the sanitizing solution. The test strips did not change color, indicating a failure to measure the necessary parts per million (ppm) of chlorine. The Food Service Director confirmed that chlorine test strips should have been used and acknowledged that proper sanitation practices were not followed, leading to a deficiency in food safety standards.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident R46, who was diagnosed with physical aggression, paranoia, insomnia, and was taking antipsychotic medication for psychosis. Despite being alert and oriented, Resident R46 was involved in multiple altercations, including a verbal altercation on May 2, 2024, and a physical altercation on October 12, 2024, which resulted in injuries to another resident. The facility's documentation and psychiatric notes highlighted the resident's aggressive and paranoid behaviors, yet no care plan was established to address these issues. Additionally, the facility did not create a care plan for Resident R170, who required oxygen therapy due to shortness of breath associated with anemia and acute myeloblastic leukemia. Although a physician's order for oxygen was noted, there was no corresponding care plan to manage the resident's respiratory needs. The Assistant Director of Nursing confirmed the absence of a care plan for Resident R170's oxygen use, indicating a lapse in addressing the resident's medical requirements.
Failure to Maintain Therapeutic Medication Levels and Communicate Dosage Changes
Penalty
Summary
The facility failed to provide treatment and services in accordance with professional standards of practice by not conducting routine testing to verify therapeutic levels of a seizure medication for a resident diagnosed with epilepsy. The resident, who was alert, oriented, and capable of making independent decisions, was initially prescribed Depakote at a daily total of 750 mg. However, due to an error, the dose was decreased to 500 mg daily without proper clarification or documentation. This error persisted for two weeks before the dose was corrected. Additionally, the facility did not perform routine Depakote level testing after the initial admission test, which was against the facility's policy and the psychiatrist's recommendation for biannual testing. Furthermore, the facility failed to inform the physician of a recommended increase in the resident's Risperdal dosage, which was suggested due to increased paranoia and aggression. The psychiatrist confirmed that the Depakote dose should not have been changed and that the Risperdal increase was not communicated to the physician. The Nursing Home Administrator and Director of Nursing were unable to provide documentation or answers regarding the facility's policy for testing Depakote levels or the rationale behind the medication changes, highlighting a lack of adherence to established protocols.
Failure to Provide Restorative Care for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve the range of motion for two residents, leading to deficiencies in their care. Resident R7, who has multiple diagnoses including paraplegia, multiple sclerosis, and muscle contractures, was observed with his left arm in a fixed position on his chest. Despite having a restorative nursing program in place, which included passive range of motion exercises and splinting, there was no documented evidence that these interventions were provided. The Assistant Director of Nursing confirmed the lack of documentation for the restorative nursing program and splinting for Resident R7. Similarly, Resident R37, who has a history of cerebrovascular accident and hemiplegia, was not receiving the recommended restorative nursing program. The occupational therapy discharge summary recommended a splint and brace program, but there was no documentation that this was reinstated or provided. Observations revealed that Resident R37's left upper and lower extremities were limp, and interviews confirmed that the resident was not receiving the necessary splinting care. The Assistant Director of Nursing also confirmed the absence of documentation for the restorative nursing program for Resident R37. The lack of documented evidence and the observations made during the survey indicate that the facility did not ensure that residents with limited range of motion received the necessary treatment and services. This failure to provide appropriate care and maintain documentation led to deficiencies in the care of Residents R7 and R37, as confirmed by staff interviews and clinical record reviews.
Resident Access to Hazardous Items Due to Staff Oversight
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident on the third floor. A resident, who was admitted with a history of opioid dependence, homicidal ideations, and a previous suicide attempt, was found holding two razors in the doorway of their room. The resident's care plan included specific interventions to prevent self-harm, such as removing harmful items from the room and maintaining hourly checks. However, during an observation, the resident was found with razors that had been accidentally left in the bathroom by a nursing assistant. Interviews with the resident and the nursing assistant confirmed that the razors were inadvertently left accessible to the resident, which was against the care interventions in place. The Director of Nursing and the facility administrator acknowledged the oversight and confirmed that the resident should not have had access to such hazardous items, given their history and care plan requirements.
Medication Management Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure that medications were administered with adequate indications for use and monitoring for two residents. Resident R46 was prescribed Melatonin and Trazodone for insomnia, despite not having a diagnosis of insomnia. This indicates a lack of proper assessment and documentation for the necessity of these medications. Additionally, Resident R83, who had severe cognitive impairment and diagnoses of anxiety disorder, psychotic disorder, and schizophrenia, was receiving Lorazepam as needed for anxiety without documented rationale for its continued use beyond 14 days. There was also no documentation indicating the duration for which the antianxiety medication was to be used. Furthermore, Resident R83 was prescribed Depakote sprinkles for behavior without adequate indication for its use, as the medication is typically used for bipolar disorder, epilepsy, or migraine headaches. A valproic acid blood level test showed a result below the normal range, yet there was no documentation that this was reviewed with the physician to ensure proper monitoring and effectiveness of the drug. Interviews with staff confirmed the lack of documentation for the rationale and monitoring of these medications, highlighting deficiencies in medication management and oversight.
Failure to Conduct Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain necessary laboratory studies as ordered by the physician for a resident identified as R158. The resident, who has a diagnosis of obesity and is at high risk for pressure sore development, required blood tests to assess albumin and thyroid function. These tests were ordered by the physician to evaluate nutritional deficiencies and the resident's metabolism. However, a review of the clinical records for November 13 and 15, 2024, showed no documentation that these tests were completed. This deficiency was confirmed during an interview with a licensed nurse, Employee E17, who acknowledged the failure to follow the physician's orders for the laboratory testing on the specified dates.
Failure to Maintain Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain enhanced barrier precautions for a resident, identified as Resident R15, who was under care for multiple conditions including Parkinson's disease, dyskinesia, anxiety, bipolar disorder, muscle wasting, and dysphasia. Resident R15 required enteral nutrition through a gastrostomy tube, and the care plan included goals to keep the tube insertion site free from infection. Enhanced barrier precautions, as outlined by the CDC, require the use of gowns and gloves during high-contact care activities to prevent the spread of multi-drug resistant organisms. On December 18, 2024, an observation revealed that a nurse aide, Employee E6, was providing incontinence care to Resident R15 while only wearing gloves, without the required gown. This was despite the presence of a sign outside the resident's room indicating the need for enhanced barrier precautions, including the use of gowns and gloves for specific high-contact activities. Employee E6 confirmed awareness of the enhanced barrier precautions but did not adhere to the proper procedure, leading to the deficiency noted in the report.
Failure to Inform Resident of Medication Change
Penalty
Summary
The facility failed to ensure that a resident was informed of and allowed to participate in decisions regarding their care and treatment. Resident R1, who was cognitively intact and had diagnoses of anxiety and depression, reported missing doses of Trazodone, a medication used to help with sleep. The resident was told by nursing staff that the medication was discontinued by the physician but was not given an explanation. The resident experienced poor sleep during the days the medication was not provided and was not informed by the physician about the medication change or alternative treatment options. Review of Resident R1's physician orders revealed that Trazodone was prescribed and later discontinued without documented evidence explaining the reason for the discontinuation. The medication was re-started a few days later, but there was no documentation in the resident's clinical record indicating that the resident was informed of the medication change or allowed to participate in decisions regarding their care and treatment. This lack of communication and documentation led to the deficiency noted in the report.
Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial tour of the Food Service Department, several deficiencies were observed. The corridor between the receiving door and the kitchen was very dusty and dirty with visible dirt and debris on the floor. In the dry storage room, a pan rack had a reddish substance splashed over it, and the floor was littered with paper, straws, packets, and dust. Additionally, there was less than the required 18 inches between boxes on the top shelf and the ceiling and sprinkler heads. In the walk-in cooler, an undated container of garlic was found, along with a brown substance on the floor near the door and patches of light-colored growth on the ceiling. The reach-in freezer contained tilapia filets in an open box with the inner plastic liner exposed to the air, and the second reach-in freezer had an open box of biscuits with the inner plastic liner exposed, along with a build-up of dark sticky and dusty substance on the outside vent. The prep sink had a steady stream of water running even when the knobs were shut tight. These observations were confirmed by the Food Service Director during the tour. The facility's policy on food storage, which was updated in February 2023, states that all foods should be stored wrapped or in covered containers, labeled and dated, and arranged to prevent cross-contamination. The facility failed to adhere to these standards, resulting in the identified deficiencies. The findings indicate a lack of proper maintenance and cleanliness in the food service areas, which could potentially lead to cross-contamination and food safety issues.
Failure to Implement Complete Drug Regimen Review Process
Penalty
Summary
The facility failed to implement a complete drug regimen review process for four of 36 residents reviewed. The Consultant Pharmacist Services Provider Requirements Policy mandates monthly medication regimen reviews (MRR) for each skilled nursing resident, with communication of potential or actual problems to the responsible prescriber, medical director, and director of nursing. However, the review of clinical records and facility documentation revealed that for Resident R131, R123, R37, and R42, the facility did not consistently document the pharmacist's recommendations or ensure follow-up actions were taken. Specifically, Resident R37 had no review available for February 2024, and Resident R42 had no pharmacy progress notes available at all. Additionally, there was no documentation to confirm whether the recommendations made by the consultant pharmacist were acknowledged by the physician and implemented or not, as revealed in an interview with the Director of Nursing on March 28, 2024, at 10:18 a.m. Resident R131, admitted with multiple sclerosis and anxiety disorder, had pharmacy progress notes indicating recommendations made from November 2023 to February 2024. Resident R123, with diagnoses including asthma, COPD, type 2 diabetes, and dementia, had pharmacy progress notes with recommendations made in February and March 2024. Resident R37, with multiple diagnoses including type II diabetes, repeated falls, and bipolar disorder, had pharmacy progress notes from November 2023 to January 2024 but lacked a review for February 2024. Resident R42, with cardiovascular disease, COPD, and other conditions, had no pharmacy progress notes available for review. The lack of documentation and follow-up on the pharmacist's recommendations indicates a failure to adhere to the facility's policy and regulatory requirements for pharmacy services and nursing services as per 28 Pa. Code 211.9 (k) and 28 Pa. Code 211.12 (d)(1)(3)(5).
Incomplete and Inaccurate Documentation of TB Testing
Penalty
Summary
The facility failed to ensure complete and accurate documentation related to tuberculosis (TB) testing for three residents. Resident R480, who was admitted with chronic kidney disease, had an order for a TB skin test to be administered within the first 24 hours of admission. However, the Medication Administration Record (MAR) indicated that the resident was absent from home without medication, which was confirmed to be incorrect as the resident was newly admitted and present in the facility. Similarly, the second step of the TB test was also marked as not administered, yet the result was recorded as negative. The Director of Nursing (DON) confirmed the discrepancies and was unsure how the test results were recorded without the test being administered. Resident R479, admitted with chronic subdural hemorrhage, had a similar issue where the MAR indicated the TB test was refused, yet a negative result was recorded. The DON confirmed the refusal code and was unsure how the test result was documented. Resident R134, admitted with type 2 diabetes mellitus, also had discrepancies in the MAR, showing the resident as absent and refusing the TB test, yet a negative result was recorded. The DON confirmed these discrepancies and was unsure how the results were documented without the tests being administered.
Incomplete Dialysis Communication Records
Penalty
Summary
The facility failed to maintain complete and accurate records related to dialysis communication for a resident with End-Stage Renal Disease (ESRD). The resident, admitted on an unspecified date, had a physician's order for dialysis treatment at an outpatient facility on Mondays, Wednesdays, and Fridays. However, the Hemodialysis Communication Record for the resident was found to be incomplete on multiple occasions. Specifically, on March 1 and March 4, 2024, the records lacked information on pre-weight, post-weight, pre-blood pressure, post-blood pressure, and temperature. Additionally, on March 6, 2024, the records were missing details on the access site, bruit, thrill, acute problems since the last appointment, medication changes, and new orders or significant social changes in condition during dialysis. An interview with the Unit Manager of the First Floor, a Registered Nurse, confirmed the lack of communication with the dialysis center. This deficiency was identified during a review of the resident's clinical records and staff interviews, indicating a failure to ensure proper documentation and communication regarding the resident's dialysis care. The facility's non-compliance with maintaining accurate and complete clinical records was cited under multiple Pennsylvania codes, including management, clinical records, resident care policies, and nursing services.
Insufficient Dietary Personnel Leading to Late Meal Service
Penalty
Summary
The facility failed to maintain sufficient dietary personnel to complete essential job functions, resulting in meals being served late. Observations in the main kitchen revealed stacks of dirty dishes and tray delivery carts full of trays with dirty dishware that still needed to be processed. This backlog delayed the preparation and delivery of lunch trays. Interviews with residents confirmed that lunch trays were delivered much later than usual, with some residents still waiting for their meals well past the scheduled delivery time. The lunch tray cart for the third floor, which was scheduled to be delivered at 12:30 p.m., was not delivered until 1:20 p.m. The Food Service Director confirmed that the delay was due to one aide calling off and another arriving three hours late, which put the dietary staff behind schedule. A review of the Dietary Department schedule and time clock punch report corroborated this, showing that one employee did not punch in at all and another punched in three hours late. This staffing issue directly contributed to the late meal service, affecting multiple residents who expressed their dissatisfaction with the delay.
Infection Control Deficiency in Laundry Room
Penalty
Summary
The facility failed to maintain an effective infection control program in the laundry room. During an observation, two Laundry Aides, Employees E15 and E16, were seen processing and folding clean linens in a manner that allowed the linens to come into contact with their personal clothing and Employee E15's beard. This practice was confirmed by the employees during an interview, acknowledging that the linens should have been folded without touching their clothing to prevent contamination and maintain infection control.
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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