Ivory Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Norristown, Pennsylvania.
- Location
- 2004 Old Arch Road, Norristown, Pennsylvania 19401
- CMS Provider Number
- 395446
- Inspections on file
- 27
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Ivory Wellness Center during CMS and state inspections, most recent first.
During non-emergent room remodeling, multiple residents were relocated from their rooms to a second-floor lounge and required to remain there for extended periods, reportedly up to 8–12 hours, without routine access to their rooms or beds. Residents stated they were told they could not stay in their rooms while work was done and reported limited access to rest, privacy, normal routines, and the ability to lie down, remaining in wheelchairs for prolonged periods. The administrator and DON confirmed the relocation was for dust and construction safety concerns and that residents were not offered alternative areas to rest upon request, and chart review showed no documentation that scheduled bed rest periods consistent with resident preferences were discussed or arranged.
A resident with a history of substance abuse and mental health diagnoses was subjected to searches of her person and belongings, including the use of drug-sniffing dogs, without documented voluntary consent or understanding of the reason for the search. Facility staff confirmed that the resident had not signed the required drug policy or consent forms, resulting in a violation of resident rights and dignity.
The facility failed to adhere to professional standards for food storage and safety. Observations revealed food items stored on the floor, undated and moldy produce, and improper storage practices in the kitchen. The reach-in freezer was overpacked, and the prep area had cleanliness issues, including fruit flies and greasy surfaces. These deficiencies were confirmed by the Food Service Director.
The facility did not maintain a homelike environment in a nursing unit where a resident's closet rod was broken, resulting in clothes being piled messily. Two residents confirmed the rod had been broken for a while, and the DON verified the issue during an observation.
The facility failed to conduct monthly medication regimen reviews by a licensed pharmacist for several residents and did not ensure timely physician review of pharmacist recommendations. Missing documentation and delayed actions were noted for multiple residents, impacting medication management and care quality.
The facility failed to follow its menu, leading to substitutions and lack of variety. On two occasions, the kitchen ran out of listed items, serving alternatives instead. Residents expressed dissatisfaction with repetitive menus and unaddressed requests. The menu review confirmed the lack of variety, with repeated pork meals.
The facility failed to provide palatable and warm food, as evidenced by a test tray showing cold temperatures for breakfast items and multiple residents reporting dissatisfaction with the taste and temperature of meals. Observations included tough waffles and congealed gravy, contributing to the unappetizing presentation.
The facility failed to maintain an effective QAPI program, as required by policy, to address and resolve quality deficiencies identified in previous State surveys. There was no documented evidence of action plans or resolutions for these deficiencies, and interviews confirmed the absence of QAPI activities since the new administration took over.
The facility did not have a comprehensive Water Management Program to prevent Legionella and other waterborne pathogens. The existing policy lacked an assessment of the building's water systems, and there was no documented program based on national standards. The Maintenance Director confirmed the absence of such a program, though a company was recently hired to develop one.
A resident with dementia and Alzheimer's was transferred to a mental health hospital without documented justification. Despite a history of aggressive behavior, the resident was calm on the day of transfer. Staff interviews confirmed no acute events or changes in status, and the facility was unwilling to continue one-to-one supervision, leading to a deficiency in management and nursing services.
A facility failed to notify a resident's representative in writing about the bed hold policy during a hospital transfer. The resident, with dementia and Alzheimer's, was transferred without proper documentation or communication of the bed hold duration. The form was incorrectly signed by a nurse instead of the resident or representative, and the Director of Nursing confirmed the lack of proper notification.
A facility failed to develop a comprehensive care plan for a resident with a history of sexually inappropriate behaviors. Despite a physician order for 1:1 supervision, the care plan did not specifically address these behaviors. This was confirmed through record reviews and an interview with the DON.
The facility failed to ensure safe and timely medication administration for two residents. One resident did not receive insulin as scheduled with breakfast, while another resident was given medication in the hallway and left unsupervised, leading to the resident discarding the pills. These actions were inconsistent with the facility's medication administration policies.
A resident with a history of substance abuse and behavioral issues was able to leave the facility unsupervised due to inadequate supervision and compromised security measures. Despite having a care plan that included a Wander Guard bracelet and close monitoring, the resident knew the exit code and left the building to smoke. Staff interviews revealed that the exit code had been shared among residents, leading to a lapse in security. The facility's management confirmed the code was changed after the incident.
A facility failed to administer oxygen as ordered for a resident with COPD. The resident was observed receiving oxygen at 3.5 LPM instead of the prescribed 4 LPM. The Unit Manager confirmed the discrepancy, acknowledging the oxygen level should have been set at 4 LPM, which constitutes a deficiency in respiratory care.
The facility did not complete annual performance reviews for three nurse aides, as required. Employees hired in 1998, 2003, and 2017 lacked performance reviews in their files. The NHA and DON were unsure if reviews had been conducted, and none were provided during the survey.
The facility failed to properly monitor and document behaviors for two residents with mental health conditions, despite care plans and psychiatric recommendations. The eMAR notes lacked details on observed behaviors and staff interventions, leading to a deficiency in behavioral health care.
A resident who does not eat pork was served a meal containing pork and was not offered an alternative. The menu was posted in a location inaccessible to some residents, preventing them from making informed meal choices.
The facility's kitchen was found to be unsanitary, with overripe bananas attracting fruit flies in the dry storage area and sticky teriyaki sauce above the prep sink. The Food Service Director confirmed the presence of pests, indicating a failure in maintaining a pest-free environment.
The facility failed to notify the Ombudsman of emergency transfers for three residents and did not inform a resident's representative of a transfer to a mental health hospital. One resident was transferred without documented reason or change in condition, and the Ombudsman was not notified of transfers following falls and abnormal lab results.
The facility failed to maintain proper food holding temperatures due to broken steam tables and a malfunctioning griddle, leading to food items being served below the required 135 degrees Fahrenheit. This violation of food safety standards was confirmed by the Food Service Director and Cook during a lunchtime meal service.
The facility failed to maintain essential dietary equipment in safe operating condition, with broken steam tables and a non-functional griddle leading to inadequate food holding temperatures. Additionally, a lack of refrigeration storage resulted in the use of paper cups for juice service.
The facility failed to serve food and drink at palatable temperatures, as reported by three residents. One resident missed lunch due to cold food, and a test tray confirmed that food items were served below acceptable temperatures. The Food Service Director acknowledged the issue.
The facility failed to notify the Office of the State Long-Term Care Ombudsman of emergency transfers for six residents, as required. The transfers involved residents with conditions such as wound evaluation, pain and numbness, abdominal pain, lethargy, and abnormal lab results. The Nursing Home Administrator confirmed the lack of notification, which is a deficiency in compliance with regulatory requirements.
A resident with limited mobility and left-sided weakness fell from bed during care due to incorrect handling by a nursing assistant, resulting in a head injury requiring sutures. The resident's care plan required substantial assistance, which was not properly followed, leading to the incident.
A resident with multiple health conditions, including cerebral infarction and morbid obesity, required two-person assistance for bed mobility. However, a nursing assistant attempted to provide care alone, resulting in the resident falling from the bed and sustaining a forehead laceration requiring sutures. The incident occurred with the bed in its highest position, and the resident reported ongoing soreness and headaches.
A resident reported missing personal items, but the facility failed to resolve the grievance promptly. Despite evidence of purchase and delivery to the facility, the Nursing Home Administrator cited a lack of petty cash funds as the reason for not reimbursing the resident, leaving the grievance unresolved.
A resident with left-sided weakness fell from a bed during care, resulting in a forehead injury requiring sutures. The nursing assistant rolled the resident incorrectly, leading to the fall. The facility failed to report this incident to the State Survey Agency within the required timeframe, constituting a neglect violation.
A resident with multiple health conditions required substantial assistance for daily activities. The facility failed to update the care plan to include an enabler bar for bed mobility after the resident was moved to LTC. This oversight led to a fall and head injury, as confirmed by the DON.
A facility failed to provide necessary mobility equipment for a resident with left-sided weakness and limited mobility due to a cerebral infarction. The resident required substantial assistance for daily activities and had an enabler bar installed on their bed in the short-term unit. However, upon transfer to the LTC unit, the enabler bar was not reinstalled, leading to a deficiency in care.
A resident with severe cognitive impairment was physically restrained by a nurse during an altercation, contrary to the facility's restraint policy. The incident involved the nurse grabbing the resident's arms and holding them against a wall, leading to both falling to the floor, with the nurse restraining the resident's arms while straddling them.
A resident with severe cognitive impairment and multiple diagnoses exhibited behavior problems, and the facility failed to provide appropriate behavioral management. Despite having training protocols for managing catastrophic reactions, the staff did not apply these during the incident. The staff development coordinator confirmed that the necessary training was not utilized, and the licensed nurse's annual training was overdue.
Failure to Accommodate Resident Rest Preferences During Non-Emergent Room Remodeling
Penalty
Summary
Surveyors found that the facility failed to reasonably accommodate residents' needs and preferences for scheduled rest periods in their beds during non-emergent room remodeling. On the survey date, construction was observed in rooms 123-127, and residents assigned to the first floor were relocated to a second-floor lounge area. Four of five reviewed residents were observed seated in the second-floor lounge and reported being required to remain there for extended periods, approximately 8–12 hours, without routine access to their rooms or beds. They stated they were told they could not remain in their rooms while work was being completed. These residents reported limited access to rest, privacy, and normal routines, including the ability to lie down, and stated they remained seated in wheelchairs for prolonged periods. The Nursing Home Administrator and DON confirmed that residents were moved due to concerns about dust particles and construction safety, and that the remodeling was not emergent. They further confirmed that residents were not offered alternative areas to rest upon request. Clinical record review for the four affected residents showed no documented evidence that scheduled rest periods in bed, consistent with resident preference, were discussed or arranged.
Failure to Obtain Resident Consent for Searches Related to Drug Policy
Penalty
Summary
A deficiency was identified when the facility failed to ensure that searches of a resident or their personal belongings were only conducted with the resident's voluntary agreement and understanding of the reason for the search. Facility policy required resident consent for searches, but documentation and interviews revealed that a resident with a history of substance abuse, depression, insomnia, and anxiety was subjected to searches, including the use of drug-sniffing dogs, without documented consent. The Director of Nursing and the physician confirmed that the resident had not signed the facility's Drug Use Policy or consented to searches, as she routinely refused to sign such documents. The resident was found in possession of a pill, which she admitted to hiding after a nurse left her medication unattended. Staff interviews indicated ongoing concerns about the resident's behavior, including allegations of selling medication to other residents and substance abuse. Despite these concerns, the facility's actions included conducting searches and involving law enforcement without documented resident consent, as required by both facility policy and state regulations. A grievance was filed by the resident, alleging harassment by facility leadership in their efforts to locate drugs. The clinical record and staff interviews confirmed that searches were performed and that the resident was not informed or did not agree to these actions. This failure to obtain voluntary agreement and ensure the resident understood the reason for the search resulted in a violation of resident rights and dignity as outlined in state code.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. During a tour of the main kitchen, it was observed that a food order received in the morning was not yet put away, resulting in items such as frozen French fries, waffles, tomatoes, and apple juice cups being stored directly on the kitchen floor. In the dry storage area, a reach-in refrigerator contained undated sheet cakes, a moldy cucumber, and a box of cream cheese portions with a dark liquid dripping over it. Additionally, undated pork loins and chicken thighs were found, and a box of bananas was stored on a milk crate, which upon removal, caused a swarm of fruit flies to scatter. Further observations revealed several issues with food storage and cleanliness. An open bag of sugar was not stored in an airtight container, and dented cans of sweet potatoes were not placed in a designated damaged goods area. The reach-in freezer was overpacked, limiting air circulation, and contained an open, undated container of hot dogs. The bottom of the freezer had significant food and debris buildup. The walk-in refrigerator had undated pineapples, and the prep sink area had a shelf with sticky teriyaki sauce and dark drippings on the wall. The shelf and microwave were greasy, and fruit flies were present. The condiment cart was missing a wheel and was propped up by a small bin. These observations were confirmed by the Food Service Director during the kitchen tour.
Failure to Maintain a Homelike Environment Due to Broken Closet Rod
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in one of its nursing units, specifically in room [ROOM NUMBER]-B. During observations, it was noted that the closet for Resident R15 had clothes thrown in a messy pile due to a broken closet rod, which prevented staff from hanging the clothes properly. Interviews with alert and oriented residents R17 and R69 confirmed that the closet rod had been broken for some time. The Director of Nursing, Employee E2, also confirmed the broken rod and the disorganized state of the resident's clothes during an observation.
Failure to Conduct Timely Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews were conducted by a licensed pharmacist for several residents, as required by their policy. Specifically, there was no documented evidence of a complete medication regimen review for Residents R88, R6, and R40 for certain months in 2024. Additionally, Resident R28's records showed missing pharmacy reviews for multiple months. The Director of Nursing, who was newly hired in August 2024, was unable to retrieve data from the consultant pharmacist prior to September 2024, indicating a lapse in the facility's documentation and review process. Furthermore, the facility did not ensure timely review and action upon pharmacist recommendations. For instance, a recommendation made on June 29, 2024, for Resident R40 regarding a possible dose reduction of an antidepressant was not reviewed by the physician until August 26, 2024. Similarly, for Resident R21, a pharmacist's recommendation from July 28, 2024, requesting a rationale for the continuation of Amitriptyline was not addressed in the resident's clinical record, and the physician's response was delayed until August 26, 2024, without any follow-up from psychology or psychiatry. These deficiencies highlight the facility's failure to adhere to its own policies regarding medication regimen reviews and timely physician responses to pharmacist recommendations. The lack of documentation and delayed actions could potentially impact the residents' medication management and overall care quality, as evidenced by the specific cases of Residents R88, R28, R6, R40, and R21.
Menu Adherence and Variety Deficiency
Penalty
Summary
The facility failed to adhere to its Spring/Summer Menu 2024 Week 1, as observed during a survey. On October 28, 2024, the breakfast menu listed apple cinnamon oatmeal and French toast, but the kitchen did not have apple cinnamon oatmeal available and served cream of wheat instead. Additionally, toward the end of the breakfast service, 5-6 residents received waffles instead of French toast due to a shortage. The surveyor's test tray also contained waffles instead of the listed French toast. During lunch on the same day, residents on the second floor did not receive the yellow cake with topping as indicated on the menu, nor any other dessert. On October 29, 2024, the facility ran out of Southern Style Fried Chicken during lunch service for the 2nd floor residents and substituted chicken patties instead. Interviews with residents revealed dissatisfaction with the menu variety and the facility's responsiveness to their requests. Resident R18 mentioned that the menus are repetitive and that the facility does not consider residents' requests during meetings. Resident R85 expressed concerns about the lack of variety and the frequent serving of pork. Resident R19 reported that the facility often runs out of food and does not serve the items listed on the menu, also noting the repetitiveness and excessive pork in meals. The menu review confirmed the repetitiveness, with pork meals scheduled for both October 28 and October 30, 2024.
Facility Fails to Serve Palatable and Warm Food
Penalty
Summary
The facility failed to ensure that food was palatable and served at appetizing temperatures, as evidenced by a test tray conducted on the second-floor nursing unit during breakfast service. The test tray revealed that the waffles were 108.7 degrees Fahrenheit, bacon was 86.7 degrees Fahrenheit, and the hard-boiled egg was 97.3 degrees Fahrenheit, all of which were considered cold and unappetizing. Additionally, the waffles were described as tough and chewy, making them difficult to eat. Multiple residents expressed dissatisfaction with the food, stating that it was often served cold and did not taste good. Several residents, including those with schizoaffective disorder, major depressive disorder, and anxiety disorder, reported that the food was unappetizing and frequently cold. One resident, with a BIMS score indicating moderate cognitive impairment, complained about the poor taste and temperature of the food. Another resident, who was cognitively intact, also reported that the food was consistently cold and unpalatable. Observations further revealed that a resident was scraping congealed gravy off their pork, indicating the food's unappetizing presentation.
Failure to Maintain Effective QAPI Program
Penalty
Summary
The facility failed to maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program as required. The facility's policy on QAPI indicates that the program should be based on the collection of information from data, self-assessment, and feedback systems, which is then evaluated and monitored by the QAPI Committee. The policy further states that the QAPI process should focus on identifying problematic systems and processes that could contribute to avoidable negative outcomes related to resident care, quality of life, safety, choice, or autonomy, and make efforts to correct or mitigate these outcomes. However, a review of the facility's QAPI documents revealed no documented evidence that deficient practices identified during previous State surveys were addressed using the QAPI process. There was no documentation showing that action plans were developed and implemented to correct the identified quality deficiencies, nor was there evidence that these deficiencies were resolved. An interview with the Nursing Home Administrator confirmed the absence of QAPI documentation from the previous administration for any previously identified quality deficiencies. Additionally, an employee revealed that since the new company took over, no QAPI activities were conducted for deficiencies identified during previous State surveys, including those with plans of correction that required QAPI involvement.
Failure to Implement Water Management Program
Penalty
Summary
The facility failed to develop and implement a comprehensive Water Management Program aimed at preventing, detecting, and controlling waterborne contaminants, such as Legionella, which causes Legionnaire's Disease. The facility's policy, titled 'Legionella Water Management Program,' was last revised in September 2022, but it lacked a crucial assessment component. This assessment should have included a detailed description of the building's water systems, using text and flow diagrams, to identify potential growth and spread areas for Legionella and other opportunistic waterborne pathogens. Upon reviewing facility documents, it was found that there was no documented water management program based on nationally accepted standards. Additionally, there was no evidence of a conducted assessment to map out the water systems. An interview with the Maintenance Director, Employee E19, confirmed the absence of a documented water management program, although a company had recently been hired to create one.
Unjustified Resident Transfer to Mental Health Hospital
Penalty
Summary
The facility failed to ensure that a resident's transfer to a mental health hospital was necessary and did not document the basis for the transfer in the resident's medical record. The resident, who was moderately cognitively impaired with diagnoses including dementia and Alzheimer's Disease, was on one-to-one supervision and had no documented behavioral issues leading up to the transfer. Despite a history of aggressive behavior, the resident was described as calm and without negative behaviors on the day of the transfer. Interviews with staff, including the unit manager, nurse aide, and Director of Nursing (DON), confirmed the absence of documentation or indication for the transfer. The DON acknowledged that there were no acute events or changes in the resident's status that would warrant the transfer, and the facility was unwilling to continue providing one-to-one supervision. The lack of documentation and justification for the transfer constitutes a deficiency in the facility's management and nursing services.
Failure to Provide Bed Hold Notice During Resident Transfer
Penalty
Summary
The facility failed to provide appropriate bed hold notice to a resident's representative during a facility-initiated transfer to a hospital. Resident R55, who was moderately cognitively impaired with diagnoses including dementia, Alzheimer's Disease, and encephalopathy, was transferred to a mental health hospital. Despite the transfer, there was no documentation in the resident's clinical record indicating that the resident's representative was notified in writing about the duration of the bed hold policy. Upon review, it was found that the Bed Hold and In-House Transfer Policy form for Resident R55 lacked the specified duration for the bed hold and was improperly signed by a registered nurse instead of the resident or their representative. The Director of Nursing confirmed the absence of documentation showing that the bed hold policy was communicated to the resident or their representative at the time of transfer. This deficiency was identified during a survey, highlighting a lapse in the facility's management and nursing services.
Failure to Address Resident's Inappropriate Behaviors in Care Plan
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident with a history of sexually inappropriate behaviors. The resident, identified as R63, had a physician order for 1:1 supervision every shift due to these behaviors. However, the comprehensive care plan dated August 8, 2019, did not specifically address the resident's sexually inappropriate behavior with other female residents. This deficiency was confirmed through a review of the clinical record, past survey history, and an interview with the Director of Nursing, who acknowledged the omission in the care plan.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure safe and timely medication administration for two residents, as observed during a survey. For one resident, who has diagnoses including paraplegia, type one diabetes, and anxiety, there was a physician order for Insulin Lispro to be administered at specific times with meals. However, during an interview, the resident reported not receiving the insulin with breakfast as scheduled. The nurse confirmed the medication was late, which was inconsistent with the facility's policy requiring medications to be administered within a specific timeframe relative to meal times. Another resident, diagnosed with dorsalgia, hypertension, type two diabetes, and major depressive disorder, was observed receiving medication inappropriately. The resident, who has been assessed to have behavioral problems, was given a cup of medication pills in the hallway and left to take them unsupervised. The resident later threw the pills on the bed, claiming they were incorrect. The nurse confirmed that the medication was handed to the resident in the hallway, which is against the facility's policy for medication administration.
Resident Elopement Due to Inadequate Supervision and Security
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for a resident, identified as R306, who was able to gain access to an exit door. Resident R306, who has a history of substance abuse and opioid-seeking behaviors, was admitted with several medical conditions including cellulitis, sepsis, anemia, and a history of stroke. The resident's care plan noted a risk for unusual behaviors and elopement, with interventions such as the use of a Wander Guard bracelet and close monitoring of the resident's whereabouts. Despite these measures, the resident was able to leave the facility unsupervised to smoke, as noted in a behavior progress note. The resident was seen smoking outside and later denied the incident, indicating a lapse in supervision and security measures. Interviews with staff revealed that the resident knew the security code to exit the building, which had been shared among residents. The facility's policy on incidents and accidents emphasizes the need for prompt responses and preventative measures, yet the resident's ability to exit the building undetected suggests these were not effectively implemented. The facility's management, including the Nursing Home Administrator and Director of Nursing, confirmed that the exit code had been compromised and subsequently changed. However, the incident on October 27, 2024, where the resident left the building after 11:00 p.m., was not known to the administrator, highlighting a communication gap and failure in monitoring procedures.
Failure to Administer Correct Oxygen Level
Penalty
Summary
The facility failed to administer oxygen as ordered by the physician for a resident receiving oxygen therapy. The facility's policy on oxygen administration, revised on April 1, 2015, requires checking the physician's order for the correct liter flow and method of administration, and changing all oxygen tubing weekly. Resident R61, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Acute Pulmonary Edema, Hypertension, and Morbid Obesity, was observed to have an oxygen order of 4 liters per minute (LPM) via nasal cannula continuously for shortness of breath/COPD. During an observation on October 28, 2024, it was noted that Resident R61 was receiving oxygen at 3.5 LPM instead of the ordered 4 LPM. The Unit Manager, Employee E11, confirmed the discrepancy in the oxygen level and acknowledged that it should have been set at 4 LPM. This failure to administer the correct oxygen level as per the physician's order constitutes a deficiency in providing appropriate respiratory care for the resident.
Failure to Conduct Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance reviews for nurse aide staff as required, affecting three of five nurse aide personnel files reviewed. Employees E14, E16, and E18, who were hired on June 22, 2003, January 17, 2017, and January 12, 1998, respectively, did not have their annual performance reviews available for review at the time of the survey. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed uncertainty about whether performance reviews had been conducted for these employees. Despite follow-up efforts, no performance reviews were provided during the survey.
Failure to Document Behavioral Health Interventions
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of behaviors for two residents, leading to a deficiency in behavioral health care and services. Resident R40, diagnosed with schizophrenia, exhibited behaviors such as aggression towards staff, use of profanity, and refusal to use assistive devices. Despite recommendations from a psychiatry note to monitor and document these behaviors for effective psychotropic medication management, the electronic Medication Administration Records (eMAR) lacked detailed information about the observed behaviors and staff interventions on multiple occasions. Similarly, Resident R6, who had dementia and an anxiety disorder, displayed behaviors including wandering, loud outbursts, and refusal of care. The care plan required staff to document these behaviors to assist with medication management, but the eMAR notes also failed to provide specifics about the behaviors or interventions taken. The Director of Nursing confirmed that nursing staff should document behavioral episodes, indicating a lapse in adherence to this protocol.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to accommodate a resident's dietary preferences, specifically a preference to not eat pork. A nutrition note dated September 17, 2024, documented that Resident R11 does not eat pork. However, on October 28, 2024, the lunch menu included roast pork with gravy, and the resident was served this meal without being offered the alternate option of baked chicken with brown gravy. During an interview on the same day, Resident R11 stated that he was unable to eat his lunch. Observations confirmed that the resident did not eat the meal served. Additionally, it was noted that the menu was posted at the elevators, which some residents could not access, limiting their ability to make meal choices.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen, leading to a pest issue. During a tour of the main kitchen with the Food Service Director, it was observed that a box of bananas in the dry storage area was extremely overripe and deteriorating, with liquid drippings beneath the box. This condition attracted a swarm of fruit flies, which scattered throughout the dry storage room when the box was moved. Additionally, a container of teriyaki sauce with sticky drippings was found above the prep sink, where fruit flies were also present. The Food Service Director confirmed that the bananas were the source of the fruit flies and acknowledged the presence of the pests above the prep sink.
Failure to Notify Ombudsman and Resident Representatives of Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers to the hospital for four residents. Specifically, for Residents R65, R54, and R94, there was no documentation available to indicate that the Ombudsman was informed of their transfers. Resident R65 and R54 were transferred to a local hospital following falls, while Resident R94 was transferred due to abnormal lab results. The Nursing Home Administrator confirmed that the Ombudsman was not notified of these transfers as required. Additionally, the facility did not notify a resident's representative of a transfer to a mental health hospital. Resident R55, who was moderately cognitively impaired with diagnoses including dementia and Alzheimer's Disease, was transferred without any documented reason or change in condition that would warrant such a transfer. The Director of Nursing confirmed that there was no documentation explaining the transfer, and the resident's representative was not informed at the time of the transfer.
Failure to Maintain Proper Food Holding Temperatures
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. During a review of the facility's food safety practices, it was found that the steam tables in the main kitchen were broken, which compromised the ability to maintain proper holding temperatures for Time/Temperature Control for Safety (TCS) foods. Observations during a lunchtime meal service revealed that dietary staff were using a tray line meal system to plate resident meal trays in the main kitchen before delivering them to residents' rooms. However, the steam tables were not in use due to being broken, and a flat top griddle was being used instead, which was also malfunctioning and not producing heat. Temperature checks conducted with the Food Service Director revealed that several food items, including chicken, mashed potatoes, gravy, rice, pureed ziti, and pureed vegetables, were not maintained at the required holding temperature of 135 degrees Fahrenheit. The Food Service Director and the Cook confirmed that the food items were not kept at appropriate temperatures due to the broken equipment. This failure to maintain proper food temperatures is a violation of the facility's policy and the 2022 Food Code, which requires TCS foods to be held at 135 degrees Fahrenheit or above to prevent the growth of pathogens and ensure food safety.
Failure to Maintain Safe Operating Condition of Dietary Equipment
Penalty
Summary
The facility failed to ensure that essential mechanical dietary equipment was in safe operating condition, specifically the steam tables in the main kitchen. The steam tables had been intermittently malfunctioning since June 2024 and completely stopped working by early August 2024. During a survey on September 10, 2024, it was observed that dietary staff were using alternative methods to keep food warm, such as placing pans of food directly on stove top gas burners and using a flat top griddle, which was also broken and not producing heat. As a result, the holding temperatures of various food items, including chicken, mashed potatoes, and pureed vegetables, were below the required 135 degrees Fahrenheit for food safety. Additionally, the facility faced issues with refrigeration storage, as one of the refrigerators was down, limiting the ability to store enough pre-packaged juice cups. This led to the use of paper cups for serving juice. Interviews with the Food Service Director and the Cook confirmed the equipment failures and the inability to maintain appropriate food holding temperatures, highlighting the facility's failure to maintain essential dietary equipment in safe operating condition.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to provide food and drink at palatable temperatures for three residents, as determined through observations and interviews. Resident R2 reported that coffee and food were served cold, while Resident R3 stated that the food was cold and not palatable, leading to a missed lunch. Resident R4 also confirmed that food was consistently served cold. A test tray conducted during lunchtime with the Food Service Director revealed that the temperatures of the food items were below acceptable levels, with rice at 114°F, baked chicken at 111.8°F, pureed ziti at 96.3°F, pureed vegetable at 96.6°F, and mashed potatoes at 100°F. The Food Service Director confirmed that these temperatures were not palatable.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers for six residents. The deficiency was identified through a review of facility documentation, clinical records, and staff interviews. The Transfer Log, received on September 10, 2024, listed residents transferred to the hospital from March 1, 2024, through September 9, 2024. Specific cases included Resident R7, who was transferred for wound evaluation, and Resident R8, who experienced pain and numbness in the left arm. Resident R4 had abdominal pain and a distended abdomen, while Resident R9 was lethargic and unable to swallow food or medicine. Residents R10 and R11 were transferred due to abnormal lab results. Despite these transfers, there was no evidence that the Ombudsman was notified as required. The Nursing Home Administrator confirmed the lack of notification during an interview on September 10, 2024. This failure to notify the Ombudsman of emergency transfers constitutes a deficiency in compliance with the regulatory requirements outlined in 28 Pa. Code 201.14(a) and 28 Pa. Code 201.18(b)(2).
Neglect Leads to Resident Injury During Care
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in actual harm. Resident R1, who was admitted with conditions including cerebral infarction, left-sided weakness, and limited mobility, required substantial assistance for movement and was dependent on staff for personal care. Despite these needs, during a care session, the resident fell from the bed while being washed by a nursing assistant. The fall occurred because the nursing assistant rolled the resident away from her, contrary to the correct technique, and the bed was in its highest position. This resulted in the resident sustaining a head injury that required five sutures. The incident was confirmed through interviews with the resident, who reported falling during care and sustaining injuries, and with the nursing assistant, who admitted to using an incorrect technique. The Director of Nursing and the Assistant Director of Nursing also confirmed the nursing assistant's error. The resident's care plan indicated the need for total assistance and the use of mechanical aids for transfers, highlighting the neglect in failing to adhere to these requirements during care, leading to the resident's fall and subsequent injury.
Resident Injury Due to Inadequate Assistance During Bed Mobility
Penalty
Summary
The facility failed to provide adequate assistance to a resident, identified as Resident R1, during bed mobility, resulting in actual harm. Resident R1, who was admitted with multiple diagnoses including cerebral infarction, deep vein thrombosis, and morbid obesity, required substantial assistance for bed mobility due to left-sided weakness and other impairments. The resident's care plan specified the need for assistance from two staff members for all bed mobility activities. However, during a morning care session, a nursing assistant attempted to roll the resident alone, resulting in the resident falling from the bed. The incident occurred while the bed was in its highest position, and the resident sustained a laceration on the forehead, requiring five sutures. The resident reported ongoing soreness and headaches following the fall. The nursing assistant confirmed that she was providing care alone when the resident fell. This failure to adhere to the care plan's requirement for two-person assistance during bed mobility directly led to the resident's fall and subsequent injury.
Failure to Resolve Resident Grievance Regarding Missing Items
Penalty
Summary
The facility failed to promptly resolve a grievance submitted by a resident, identified as Resident R2, regarding missing personal items. Resident R2, who was admitted with chronic obstructive pulmonary disease, high blood pressure, and major depression, reported a grievance on May 29, 2024, about a missing pair of dark brown boots and brown pumps. The facility initially responded on May 31, 2024, stating that the items were not found on the resident's inventory sheet, and the resident was informed of this outcome. However, the grievance process was not completed as required. Two weeks prior to an interview conducted on July 29, 2024, the Grievance Officer received receipts for the missing shoes, which confirmed they were purchased online in 2021 and delivered to the facility. Despite this evidence, the Nursing Home Administrator admitted to not having the funds in petty cash to reimburse the resident, leaving the grievance unresolved. This inaction violated the facility's policy on grievance management, which mandates prompt efforts to resolve residents' concerns.
Failure to Report Resident Injury and Neglect
Penalty
Summary
The facility failed to report a serious injury sustained by a resident, identified as Resident R1, who was admitted with a diagnosis of cerebral infarction affecting left-sided weakness. The resident required substantial assistance for mobility and was dependent on staff for movement from lying to sitting positions. On July 12, 2024, while a nursing assistant, Employee E3, was providing morning care, the resident fell from the bed, which was at its highest position, resulting in a forehead injury that required five sutures. The nursing assistant admitted to rolling the resident away from her, contrary to her training, which led to the fall. The incident was not reported to the State Survey Agency within the required timeframe, as confirmed by the Nursing Home Administrator during an interview on July 29, 2024. This failure to report the incident constitutes a violation of neglect under the facility's regulatory obligations. The deficiency was identified during a review of clinical records and staff interviews, highlighting the facility's lapse in adhering to mandatory reporting protocols.
Failure to Implement Comprehensive Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan in a timely manner for a resident admitted with multiple diagnoses, including cerebral infarction, deep vein thrombosis, and bipolar disorder. The resident required substantial assistance for activities of daily living due to left-sided weakness and limited mobility. Although an initial care plan was developed, it was not updated to include the use of an enabler bar for bed mobility when the resident was moved to long-term care. This oversight was confirmed by the Therapy Director and the Director of Nursing. The deficiency was further highlighted when the resident fell from the bed during care, resulting in a head injury that required emergency medical attention and sutures. The Director of Nursing confirmed that the care plan for paired care was not implemented at the time of the fall, indicating a failure in executing the necessary interventions to ensure the resident's safety and well-being.
Failure to Provide Necessary Mobility Equipment for Resident
Penalty
Summary
The facility failed to provide necessary equipment to assist with mobility for a resident diagnosed with a cerebral infarction, resulting in left-sided weakness and limited mobility. The resident, who was admitted with conditions including deep vein thrombosis, high blood pressure, and morbid obesity, required substantial assistance for daily activities such as toileting, bathing, and dressing. The resident's care plan, developed in May 2024, indicated the need for a mechanical aid and assistance from two staff members for transfers due to the resident's limited mobility. Upon discharge from the short-term unit, an enabler bar was placed on the resident's bed to aid in bed mobility. However, when the resident was transferred to the long-term care unit, the enabler bar was not reinstalled on the bed, as confirmed by the Therapy Director and the Director of Nursing. This oversight resulted in the resident not receiving the necessary equipment to assist with mobility, as required by their care plan.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by an incident involving a resident with severe cognitive impairment and multiple medical diagnoses, including Anoxic Brain Damage and Vascular Dementia. The resident, who was admitted with a BIMS score indicating severe cognitive impairment, was involved in an altercation with a licensed nurse. The incident occurred when the resident wanted to go out to smoke and was redirected by the nurse, leading to a physical confrontation. The nurse grabbed the resident's arms and held them against the wall, resulting in both the nurse and the resident falling to the floor, with the nurse restraining the resident's arms while straddling them. The facility's policy on Restraint Management emphasizes that restraints should only be used when necessary to treat a medical symptom and not for staff convenience. However, the review of security camera footage and staff statements revealed that the nurse's actions were not in line with this policy. The footage showed the nurse physically restraining the resident without evidence of a medical necessity, as the resident was attempting to free themselves from the nurse's grasp. This incident highlights a failure to adhere to the facility's policy and regulatory requirements regarding the use of physical restraints.
Failure to Manage Resident's Behavioral Issues
Penalty
Summary
The facility failed to provide appropriate behavioral management for a resident with severe cognitive impairment and multiple diagnoses, including Anoxic Brain Damage and Vascular Dementia. The resident exhibited behavior problems, and the facility did not effectively de-escalate the inappropriate behavior. The facility's training materials on preventing and managing catastrophic reactions were not applied during the incident, despite the resident's known condition and the potential for catastrophic reactions. The staff development coordinator confirmed that the staff, including a licensed nurse, had received training on behavior management and de-escalation, but this training was not utilized during the incident. The licensed nurse's most recent training was conducted in January 2023, and it was confirmed that the annual in-service training should have been completed by January 2024. The facility has a protocol for handling catastrophic reactions, including a 'code cat' alert, but it was not properly implemented in this case.
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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