Ivy Hill Post Acute Nursing & Rehabilitation Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 1401 Ivy Hill Road, Philadelphia, Pennsylvania 19150
- CMS Provider Number
- 395525
- Inspections on file
- 29
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Ivy Hill Post Acute Nursing & Rehabilitation Llc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia with behavioral disturbance, and an anxiety disorder had an active order and care plan interventions for lorazepam (Ativan) gel to be given TID for generalized anxiety. During observation, an RN/LPN confirmed the order but reported the medication was on hold and could not locate it in the med cart. Review of treatment records over two months showed numerous missed doses documented as not available or on hold, despite standing instructions to call the pharmacy every 30 days for delivery. The DON reported the family paid out of pocket for the medication, acknowledged discrepancies in timely refills and intermittent signing by nursing staff, and could not identify when the medication was last obtained and administered.
The facility failed to provide a safe and homelike environment, with residents lacking access to locked drawers for personal belongings and experiencing maintenance issues like broken beds and heating units. Observations revealed unmaintained windowsills, thick dust, and soiled ceiling tiles, confirmed by the Maintenance Director and resident council.
A resident with a history of bipolar disorder and moderate cognitive impairment engaged in inappropriate sexual behaviors towards other residents, despite being on one-to-one supervision. The facility failed to adequately supervise the resident and document incidents, resulting in a deficiency in resident safety and care.
The facility failed to conduct criminal background checks for two volunteers and did not implement its abuse policy, resulting in unreported incidents involving a resident with a history of inappropriate sexual behavior. Despite staff reports, the administration was unaware of these incidents, highlighting a lapse in policy enforcement and resident protection.
The facility did not update the PASRR applications to include new mental health diagnoses for three residents. A resident's PASRR did not reflect a mental disorder and anxiety disorder obtained after the initial assessment. Another resident's PASRR failed to include a mood disorder diagnosed later, and a third resident's PASRR did not update a schizophrenia diagnosis. The social worker confirmed that updates were not made unless residents were targets for level 2, violating resident care policies.
The facility did not provide required training on abuse, neglect, and exploitation to two volunteers, despite policy mandates for all staff, including volunteers, to receive such training. Interviews confirmed that the volunteer Pastor and his wife, who have been conducting religious activities at the facility for years, were not trained, and the Human Services Director was not responsible for volunteer training.
A resident, who is a retired pharmacist, was not assessed by the interdisciplinary care team for the ability to self-administer medications, despite expressing interest and being cognitively intact. The facility's policy requires such an assessment to ensure safety and resident rights, but no care plan was developed, leading to a deficiency.
The facility failed to document and resolve grievances related to missing personal belongings for residents. A resident reported missing money, and another resident's family reported missing clothing, both of which were not properly documented or resolved. The facility did not provide a locked drawer for personal items as promised and failed to communicate the grievance process effectively. Staff confirmed the lack of a clear process for tracking clothing when families handled laundry, contributing to unresolved grievances.
The facility failed to assess and document the use of restraints for two residents. One resident was found with a locked seatbelt in a wheelchair without a physician's order, and another had their bed against the wall, restricting movement, without proper assessment or care planning. These actions indicate a lack of proper evaluation and documentation regarding restraint use.
The facility failed to develop comprehensive care plans for residents, leading to deficiencies in addressing their specific needs. A resident with a history of substance-seeking behavior experienced an overdose, and the care plan was not promptly revised. Another resident, who was incontinent and required assistance, lacked a toileting care plan. Additionally, a cognitively intact resident wishing to self-administer medications did not have a care plan to support this request.
A resident with a history of Traumatic Brain Injury and other conditions was found self-administering medications without proper authorization, due to concerns about missed doses. The facility's policy requires licensed staff to administer medications, but the resident stored pills in a bedside container, leading to a deficiency in supervision.
A resident with severe cognitive impairment was not provided with necessary postural support during meals, leading to unsafe positioning. The resident was only assessed for adapted equipment after a delay. Additionally, the facility failed to collect adequate biochemical data to assess the resident's nutritional status, despite a diagnosis of hypothyroidism and a prescription for Levothyroxine.
A facility failed to provide respiratory care according to professional standards for a resident with sepsis, COPD, and hypertension. The resident was observed receiving oxygen without a physician's order, and the oxygen tubing was not dated. Staff interviews confirmed these deficiencies, indicating non-compliance with the facility's oxygen therapy policy.
A resident with low back pain and opioid dependency did not receive accurate pain level assessments as required by physician orders. Despite being prescribed Oxycodone, the MAR showed no documented pain levels for March, and staff interviews confirmed the assessments were not completed. The resident reported severe pain, and the DON acknowledged the lapse in nursing services.
A facility failed to provide trauma-informed care for a resident with PTSD, as required by their policy. The resident, with a history of sexual trauma and aggressive behavior, was not assessed or treated for PTSD, despite being admitted to a psychiatric hospital for related issues. The Director of Nursing confirmed the oversight, acknowledging the absence of PTSD in the resident's care plan.
The facility failed to follow pharmacy recommendations for two residents' medication regimens. A resident on Atorvastatin did not receive recommended lipid studies, and another on Midodrine lacked a blood pressure limit in their order. The DON confirmed these oversights.
A facility failed to document the rationale and duration for a PRN order of Lorazepam for a resident, as required by regulations. The order was indefinite, and the clinical record lacked documentation from the prescribing practitioner. This deficiency was identified during a review of clinical records and staff interviews.
A resident with renal failure and traumatic brain injury, requiring medications via peg-tube, received them orally due to a nurse's misunderstanding. The nurse, instructed during a morning meeting, administered medications orally, contrary to physician orders. The DON confirmed the error, highlighting a significant medication administration issue.
A facility failed to timely update a resident's care plan to reflect a change in code status from full code to DNR/DNI, resulting in a discrepancy between the care plan and physician orders. The resident had a complex medical history and the change occurred during hospitalization. Difficulty in contacting the resident's out-of-country representative delayed confirmation of the code status, and a temporary verbal agreement was made until a signed POLST form could be obtained.
A resident with a language barrier was unable to communicate his needs for assistance with daily activities due to the facility's failure to assess and provide appropriate communication support. The care plan noted the language issue but lacked measures for interpreter services, and there were no documented family contacts. The Speech/Language Pathologist confirmed the lack of assessment and use of assistive devices to evaluate the resident's communication abilities.
A facility failed to follow a physician's order for a resident's tube feeding. The resident was prescribed Jevity 1.5 via PEG tube, 237 ml bolus, six times a day, but a nurse administered an extra half container due to the resident's complaints of hunger. The dietician was unaware of this additional feeding, which was not reflected in the resident's care plan or caloric intake calculations.
A resident's need for corrective lenses was not addressed after their glasses were broken during an argument. Despite the facility's policy requiring immediate notification to the vision service provider for repairs, no documentation was found indicating such action was taken. The resident was observed without glasses and unable to read a picture board, confirming the lack of corrective lenses since the incident.
A resident with decreased functional abilities did not receive necessary physical therapy services due to being classified as custodial care, despite a physical therapy evaluation indicating a need for skilled services. The facility did not inform the resident or their family about the lack of services or provide options for receiving them.
A resident with a complex medical history, including Guillain-Barre Syndrome and hyponatremia, was placed on a 1200 ml daily fluid restriction. Despite recommendations for lab monitoring, no lab work was conducted since admission, leading to a deficiency in care. The issue was confirmed by the DON, highlighting a significant oversight in the resident's care plan.
A resident with a history of mental health issues, including major depressive disorder and previous suicide attempts, was not provided with necessary behavioral health services at the facility. Despite repeated requests for non-pharmacological support, such as a grief support group, the facility did not arrange these services. Clinical notes and interviews revealed the resident's ongoing struggles with depression, self-harm, and aggression, yet the facility failed to demonstrate efforts to provide the requested support.
The facility failed to properly store and label medications in two medication rooms. An opened tube of Santyl Collagenase was found unlabeled in a treatment cart on the second floor, and an opened vial of Tuberculin lacked a date opened in the third-floor medication room. Staff confirmed these deficiencies, indicating non-compliance with storage and labeling policies.
A resident experienced significant weight loss and difficulty eating due to unresolved dental issues. Despite evaluations by an outside dental group recommending extractions and dentures, the procedures were not completed, and no schedule was documented. The resident's diet was supplemented with soft foods, but the lack of dental care persisted.
A facility failed to maintain proper infection control during tube feeding and medication administration. A nurse provided tube feeding with only one gloved hand and placed equipment on a dirty table. Another nurse handled medications without changing gloves or sanitizing hands, and stacked medication cups improperly, risking contamination.
The facility failed to maintain mechanical dietary equipment in safe operating condition. The dish machine was not dispensing sanitizer during the final rinse cycle due to malfunctioning equipment, preventing proper cleaning and sanitizing of kitchenware. Additionally, the three-compartment sink operation was compromised as staff were unable to test sanitizer concentration due to a malfunctioning device, resulting in insufficient sanitization levels. Interviews confirmed the issues with the equipment.
Failure to Ensure Availability and Administration of Ordered Antianxiety Medication
Penalty
Summary
The facility failed to ensure that an ordered antianxiety medication (lorazepam gel/Ativan gel) was available and administered as prescribed for one resident. The resident had multiple diagnoses including COPD, depression, dementia with behavioral disturbance, anxiety disorder, hypomagnesemia, and dysphagia, and was care planned for verbal/physical agitation, resistiveness to care, and behavioral symptoms related to dementia and anxiety. The care plan interventions included administering medications per physician orders, specifically Depakote, lorazepam, and Rexulti. The resident had an active order for lorazepam gel 0.5 mg/ml, 1 ml topically three times daily for generalized anxiety disorder. During an observation, the resident, who had a BIMS score of 0 indicating severe cognitive impairment, was in bed requesting potato chips. After receiving chips, the resident refused an oral medication despite the nurse’s third attempt. When asked about the lorazepam gel order, the nurse confirmed the order existed but stated it was on hold and was unaware of the reason. The nurse checked the medication cart and there was no lorazepam gel available. Record review showed a current order with instructions that the pharmacy should be called every 30 days for Ativan gel, that the pharmacy would deliver to the facility, and that the medication should not be signed out unless the facility called. The Treatment Administration Records for March showed 71 possible administrations of Ativan gel, with 28 entries marked as NA (Not Available) and 4 entries marked as 5 (Hold/see nurses notes). For February, there were 84 possible administrations, with 24 entries marked NA and 15 entries marked as 5 (Hold/see nurses notes). The DON reported that the resident’s family had been paying out of pocket for the Ativan gel because it was not covered by insurance, confirmed discrepancies with the medication not being filled timely and being signed out intermittently by nursing staff, and stated that any nurse could call for a refill when the medication was not available. The DON also confirmed that the last date the medication was obtained and administered to the resident was unknown.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed across three nursing units. On multiple occasions, residents were found without access to locked drawers to secure their personal belongings, leading to grievances such as the one filed by a resident regarding missing money. Additionally, the facility did not address maintenance issues, such as broken heating units and beds, which affected residents' comfort and safety. For instance, a resident was observed lying in a fetal position due to a broken bed and non-functional heating unit, which was confirmed by a Certified Nursing Assistant. Further observations revealed significant housekeeping and maintenance lapses, including unmaintained and leaking windowsills, thick dust, dried clumps of patching plaster, and multiple soiled ceiling tiles in resident rooms and common areas like the dining room. These conditions were confirmed by the Maintenance Director, who acknowledged the lack of locked drawers and the presence of soiled ceiling tiles. The resident council meeting also highlighted the absence of locks on drawers, indicating a widespread issue affecting multiple residents.
Failure to Protect Residents from Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to protect three residents from inappropriate sexual behaviors by another resident, leading to a deficiency in resident safety and care. The resident in question, who has a history of bipolar disorder and moderate cognitive impairment, was observed engaging in inappropriate sexual behaviors towards other residents. Despite being placed on one-to-one supervision, the resident was able to move unsupervised throughout the facility, entering other residents' rooms and common areas, and engaging in inappropriate conduct. Interviews with staff and volunteers revealed multiple instances where the resident was caught inappropriately touching other residents, including removing a resident's underwear and touching another resident's breast. These incidents were reported to the facility's management, including the Director of Nursing and Nursing Home Administrator, but there was no documented evidence of these reports in the residents' clinical records. Additionally, the facility's documentation of the resident's whereabouts and supervision was incomplete, with no evidence of regular checks being conducted as required. The facility's failure to adequately supervise the resident and document incidents of inappropriate behavior resulted in a lack of protection for the affected residents. The nursing staff assignments did not explicitly include duties to supervise the resident, and there was no documentation of corrective actions taken to address the resident's behavior. This deficiency highlights a significant lapse in the facility's responsibility to ensure the safety and well-being of its residents.
Failure to Conduct Background Checks and Implement Abuse Policy
Penalty
Summary
The facility failed to perform criminal history background checks for two volunteers, identified as Employees E10 and E11, who had been conducting religious activities at the facility for several years. This oversight was confirmed during interviews with the Human Services Director and the Nursing Home Administrator, who acknowledged that the criminal records for these volunteers were neither conducted nor available for review. This failure to adhere to the facility's policy of screening all employees and volunteers for convictions of abuse represents a significant deficiency in ensuring the safety and protection of residents. Additionally, the facility did not implement its established abuse policy to protect residents from abuse. Resident R44, who has a history of bipolar disorder, HIV, and moderate cognitive impairment, was involved in multiple incidents of inappropriate sexual behavior. Despite a psychology note indicating concerns about Resident R44's hypersexual thoughts and behaviors, and a nursing aide's report of witnessing Resident R44 engaging in inappropriate conduct with another resident, the facility's abuse coordinators were unaware of these reports. This lack of awareness and action by the facility's administration highlights a failure to follow through on the policy requiring immediate reporting and investigation of abuse allegations. The facility's policy mandates that all staff, including management and volunteers, receive training on recognizing, reporting, and preventing abuse. However, the interviews with the Nursing Home Administrator and Director of Nursing revealed a disconnect between the policy and its implementation, as they were unaware of the reported incidents involving Resident R44. This deficiency in communication and enforcement of the abuse policy underscores a critical lapse in the facility's responsibility to protect its residents from abuse and neglect.
Failure to Update PASRR with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that revisions were made to the Pre-Admission Screening and Resident Review (PASRR) applications to include updated mental health diagnoses for three residents. Resident R108's PASRR, completed on January 31, 2024, did not reflect the mental health diagnoses of a mental disorder obtained on May 2, 2024, and an anxiety disorder obtained on April 4, 2024. Similarly, Resident R10's PASRR, completed on February 24, 2023, did not include a mood disorder due to a known physiological condition diagnosed on July 24, 2023, despite already listing schizophrenia and altered mental status. Resident R90's PASRR, completed on October 11, 2024, included a diagnosis of bipolar disorder but failed to update the diagnosis of schizophrenia obtained on October 28, 2024. The facility's social worker, Employee E3, confirmed during an interview that the PASRR forms were not updated for residents unless they were a target for level 2. This oversight resulted in the PASRR forms for Residents R108, R10, and R90 not being updated with their additional mental health diagnoses. The failure to update these forms was a violation of the facility's resident care policies and medical records requirements as outlined in 28 PA Code 211.10 (c) and 28 PA Code 211.5(f)(viii).
Failure to Train Volunteers on Abuse and Neglect
Penalty
Summary
The facility failed to provide required training on abuse, neglect, and exploitation to two volunteer staff members, Employee E10 and Employee E11. According to the facility's policy, all employees, including volunteers, must receive training upon orientation and annually. However, a review of personnel records and interviews revealed that the volunteer Pastor, Employee E10, and his wife, Employee E11, who have been conducting religious activities at the facility for several years, did not receive this training. The Human Services Director, Employee E12, stated she was not responsible for volunteer training, and both the Nursing Home Administrator, Employee E1, and the Director of Nursing, Employee E2, confirmed that the required training for these volunteers was neither conducted nor available for review.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The interdisciplinary care planning team at the facility failed to assess a resident, identified as Resident R94, for the ability to self-administer medications, which is a right outlined in the facility's policy. The policy mandates that each resident should be evaluated to determine if they can safely manage their own medications. Despite Resident R94 being cognitively intact, having no swallowing issues, and possessing adequate vision and functional upper extremities, the facility did not conduct the necessary assessment to determine if self-administration was clinically appropriate and safe. Resident R94, a retired pharmacist, expressed a desire to self-administer medications and understood the need for a secure storage solution, such as a locked bedside cabinet. However, the facility did not develop a care plan to accommodate this request. An LPN, identified as Employee E24, confirmed that the resident had been requesting to self-administer medications since admission, yet no assessment or care plan was created to address this request, leading to a deficiency in resident rights and care planning.
Failure to Document and Resolve Grievances Related to Missing Personal Belongings
Penalty
Summary
The facility failed to properly document and resolve grievances related to missing personal belongings for residents. One resident reported missing money, and although the facility investigated, they did not issue a refund due to the absence of documentation on the inventory sheet. Additionally, the facility failed to provide a promised locked drawer for the resident's personal items. Another resident's family reported missing clothing, which was not documented on the inventory sheet, and the facility did not provide a written resolution as requested by the resident. The grievance process was not effectively communicated to residents, and there was a lack of documentation and follow-up on grievances. The facility's process for managing residents' personal belongings was inadequate, as evidenced by the lack of proper labeling and inventory documentation. The Social Worker Director and other staff members confirmed that there was no clear process for tracking clothing when families handled the laundry, leading to unresolved grievances. The facility's failure to educate residents and their families about the inventory process and the lack of a consistent method for documenting and resolving grievances contributed to the deficiency. The report highlights the facility's inability to ensure residents' rights to voice grievances without discrimination or reprisal, as required by regulations.
Failure to Assess and Document Use of Restraints
Penalty
Summary
The facility failed to properly identify and assess the use of physical restraints for two residents, leading to deficiencies in care. Resident R108, who was admitted with difficulty in walking and encephalopathy, was observed in a wheelchair with a locked seatbelt that the resident could not release. This restraint was not ordered by a physician, and the unit manager was unaware of the reason for its use. This indicates a lack of proper assessment and documentation regarding the necessity and appropriateness of the restraint. Similarly, Resident R26, who has diabetes mellitus, morbid obesity, and difficulty walking, was found with their bed placed against the wall, restricting their ability to exit the bed from the left side. The resident confirmed that this was not their preference, and there was no physician assessment or care plan addressing the bed's placement. The unit manager suggested the bed's position might be due to space constraints, but this was not documented or assessed as a restraint. These oversights demonstrate a failure to evaluate and document the use of restraints, compromising resident autonomy and safety.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their specific needs. Resident R30, who had a history of substance-seeking behavior, experienced an overdose requiring Narcan administration. Despite this incident, the care plan was not revised until three days later to address potential substance abuse and related complications. The revised care plan lacked interventions to monitor behavioral changes or signs of drug use after the resident's leave of absence. Resident R36, who was moderately cognitively impaired and incontinent, did not have an individualized care plan for toileting. The resident relied on staff assistance for transfers and toileting hygiene but used an incontinent brief for bowel and bladder episodes. There was no evidence of a prompted toileting program or trial of toileting equipment, such as a bedpan or bedside commode, to address the resident's needs. Resident R94, a cognitively intact individual with no functional limitations, expressed a desire to self-administer medications. Despite being aware of this request, the facility did not develop a care plan to support the resident's self-administration of medications. The resident, a retired pharmacist, understood the need for a secure storage solution for medications but was not provided with a care plan to facilitate this process.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to properly supervise a resident, identified as Resident R57, during medication administration. The facility's policy requires that only licensed or permitted individuals administer medications and that medications should never be left unattended in a resident's room. However, Resident R57, who was admitted with a diagnosis of Traumatic Brain Injury, Hypokalemia, Hypertension, Depression, and Anxiety, was found to be self-administering medications without an order in place. The resident's comprehensive care plan indicated a risk for self-harm and harm to others, yet there was no documented evidence of an order allowing self-administration of medications. During an interview, Resident R57 expressed concerns about not receiving medications on time and admitted to storing medications in a bedside container to self-administer when doses were missed. Observations confirmed the presence of multiple pills in a container at the resident's bedside, which were later identified and counted by staff. The pills included Hydrochlorothiazide, Amlodipine, and Potassium Chloride, with a total of 52 pills found. The facility's failure to ensure proper supervision and adherence to medication administration policies led to this deficiency.
Failure to Provide Postural Support and Nutritional Assessment
Penalty
Summary
The facility failed to provide a resident with the necessary devices to optimize posture during dining and did not collect additional nutritional biochemical data related to the resident's nutritional status. The resident, who was severely cognitively impaired, was observed during a meal service sitting in a wheelchair with her head tilted to the side and chin positioned on her chest. The nursing staff confirmed that the resident had not been evaluated for adapted equipment to ensure upright positioning during meals and safe swallowing until March 26, 2025, when she was finally assessed and supplied with a high back wheelchair for postural alignment. Additionally, the facility did not collect adequate biochemical data to assess the resident's nutritional status. The resident had been prescribed Levothyroxine for hypothyroidism since December 29, 2024, but the only available biochemical data was from August 30, 2024, showing a low thyroid-stimulating hormone level, indicative of probable hyperthyroidism. No further nutritional-related biochemical studies were available for review, as confirmed by a licensed practical nurse.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for Resident R23. The resident was readmitted with diagnoses including sepsis, chronic obstructive pulmonary disease, and hypertension. On March 24, 2025, it was observed that Resident R23 was receiving 2 liters of oxygen, but the oxygen tubing was not dated, and there was no physician order for the oxygen administration. Interviews with facility staff confirmed the absence of a physician order and the lack of a date on the oxygen tubing, indicating a failure to adhere to the facility's policy on oxygen therapy.
Failure to Conduct Pain Assessments for Resident
Penalty
Summary
The facility failed to ensure accurate pain level assessments for Resident R30, who was admitted with diagnoses of low back pain and opioid dependency. The resident had physician orders for pain assessments every shift and was prescribed Oxycodone for pain management. Despite these orders, the Medication Administration Report (MAR) for March 2025 showed no documented pain levels, indicating a lack of compliance with the prescribed pain assessment protocol. Interviews with the resident and staff revealed that the pain assessments were not being completed. The resident reported experiencing severe pain, with a level of 9-10, and expressed dissatisfaction with the effectiveness of the pain medication. Staff members, including a licensed unit manager and a licensed nurse, confirmed the absence of pain assessments, with the nurse attributing it to the resident not communicating her pain levels. The Director of Nursing also acknowledged the failure to complete pain assessments, highlighting a significant lapse in nursing services as per 28 Pa Code 211.12(d)(1).
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for a resident diagnosed with PTSD, as required by professional standards and the facility's own policy. The policy mandates that upon admission, residents should be assessed for trauma and PTSD, with a questionnaire used to identify triggers and gather detailed information about traumatic events. However, the clinical record of a resident with a history of sexual trauma and PTSD showed no evidence of such an assessment, education, or treatment for PTSD. This oversight was confirmed by the Director of Nursing, who acknowledged that the resident's PTSD was not included in their care plan. The resident, who was moderately cognitively impaired, had a history of aggressive behavior and was admitted to a psychiatric hospital due to psychosis triggered by PTSD. Despite this, the facility did not incorporate the PTSD diagnosis into the resident's care plan, nor did they provide the necessary behavioral health care and services to address the resident's mental health needs. This lack of appropriate care planning and intervention for the resident's PTSD represents a failure to adhere to the facility's policy and professional standards of practice.
Failure to Implement Pharmacy Recommendations for Medication Regimen
Penalty
Summary
The facility failed to ensure timely adherence to medication regimen reviews for two residents, resulting in deficiencies. Resident R30, diagnosed with atherosclerotic heart disease and cerebral infarction, was prescribed Atorvastatin Calcium. A pharmaceutical review recommended lipid studies, but there was no documented evidence that these were completed. The Director of Nursing confirmed that the recommendations for lipid labs were not followed on two separate occasions. Resident R61, with a diagnosis of necrotizing fasciitis, amputation, and hypotension, had a physician order for Midodrine to manage low blood pressure during dialysis. A pharmacy review recommended including a blood pressure limit in the order, but this was not incorporated into the physician orders from January to March 2025. The Director of Nursing confirmed that the pharmacy's recommendation was not followed, indicating a lapse in implementing necessary medication regimen adjustments.
Failure to Document Rationale and Duration for PRN Anti-Anxiety Medication
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the administration of as-needed anti-anxiety medication for a resident. Specifically, a physician's order for Lorazepam, intended to be given every twelve hours as needed for agitation, was found to have an indefinite end date. The clinical record for the resident did not contain documentation from the attending prescribing practitioner that provided a rationale for the use of the medication or indicated the duration for the PRN order. This oversight was identified during a review of clinical records and staff interviews, highlighting a deficiency in the facility's medication administration regimen for one of the eight residents reviewed.
Significant Medication Error Due to Incorrect Administration Route
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the prescribed route of medication administration. Resident R116, who was admitted with diagnoses including renal failure and traumatic brain injury, is on a therapeutic diet with a feeding tube. The physician's orders for Resident R116 included medications such as Propranolol, Lansoprazole, and a multivitamin to be administered via peg-tube. However, during a medication pass observation, it was noted that a licensed nurse, Employee E21, crushed the pills and administered them orally to the resident, contrary to the physician's orders. Interviews conducted with Resident R116 and Employee E21 revealed that the resident usually received medications orally, and Employee E21 confirmed that she had always administered the medications in this manner, as instructed during a morning meeting. The Director of Nursing, Employee E2, confirmed that the current orders required the medications to be administered via peg-tube. This discrepancy between the physician's orders and the actual administration method constitutes a significant medication error, as the facility did not adhere to the prescribed route of administration.
Failure to Update Care Plan and Code Status
Penalty
Summary
The facility failed to review and revise the comprehensive person-centered care plan in a timely manner for a resident, leading to a discrepancy between the care plan and physician orders regarding the resident's code status. The resident, who had a complex medical history including Meniere's Disease, cancer, hypertension, and other serious conditions, was admitted with a care plan indicating a full code status. However, physician orders documented the resident's code status as DNR/DNI, which was not reflected in the care plan. The discrepancy arose when the resident's code status was changed to DNR/DNI during a hospitalization due to an intracranial hemorrhage. The facility experienced difficulty contacting the resident's representative, who lived out of the country, to confirm the correct code status upon readmission. Eventually, contact was made, and a temporary verbal agreement was reached to maintain the DNR/DNI status until a signed POLST form could be obtained. However, the care plan was not updated to reflect this change, and the POLST form was not current, leading to the deficiency.
Failure to Address Language Barrier for Resident
Penalty
Summary
The facility failed to assess and address the communication needs of a resident, identified as Resident R10, who was unable to articulate his needs for assistance with activities of daily living due to a language barrier. Observations revealed that Resident R10 required help with bathing, dressing, and grooming, and was speaking his native language, Cambodian, which the nursing staff could not understand. The clinical record indicated a care plan noting the resident's language barrier and communication problem, but it lacked measures to provide an interpreter for assessing cognitive ability and quality of life enrichment. Additionally, there were no documented contacts with family or friends for Resident R10. An interview with the Speech/Language Pathologist confirmed the absence of an assessment and the use of assistive devices, such as a language line or interpreter, to evaluate Resident R10's communication abilities in his preferred language. The interdisciplinary care team also failed to determine if the resident wanted an interpreter to communicate with healthcare staff or the doctor.
Failure to Follow Physician's Orders for Tube Feeding
Penalty
Summary
The facility failed to ensure that the physician's order related to tube feeding was followed for Resident R14. The physician's order, dated June 9, 2024, specified that Resident R14 was to receive Jevity 1.5 via PEG tube, 237 ml bolus, six times a day, totaling 1422 ml per 24 hours, and was also under an NPO order. However, during an observation on June 10, 2024, it was noted that a licensed nurse, Employee E13, administered more than the prescribed amount by giving an extra half container of Jevity to Resident R14, who complained of hunger. Employee E13 admitted to consistently providing this extra feeding without a change in the physician's order. The dietician, Employee E18, was unaware of the additional feeding and confirmed that the resident's caloric intake was calculated based on the existing physician's orders. Employee E18 stated that any weight changes in Resident R14 would have been attributed to the prescribed feeding regimen, not the unauthorized extra feeding. This lack of communication and adherence to the physician's orders led to a deficiency in the care provided to Resident R14.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to ensure proper treatment and assistive devices to maintain vision for a resident, identified as Resident R10. According to the facility's policy on vision services, it is the staff's responsibility to assist residents in obtaining necessary vision care and to notify the vision service provider immediately in cases of emergent problems, such as broken or damaged glasses. Resident R10 was evaluated by an optometrist and prescribed corrective lenses on December 12, 2023. However, during a comprehensive quarterly assessment on April 21, 2024, it was noted that the resident required corrective lenses for adequate vision. On June 12, 2024, observations revealed that Resident R10 was not wearing glasses, and the licensed nurse, Employee E6, confirmed that the glasses had been broken since an argument with another resident on April 24, 2024. The resident was observed holding a pair of broken glasses with a cracked frame and a missing left lens, and was unable to read a printed Vietnamese picture board. A review of the clinical records showed no documentation indicating that the vision service provider was notified about the broken glasses. Employee E6 confirmed that the resident had no corrective lenses available since April 24, 2024.
Failure to Provide Necessary Physical Therapy Services
Penalty
Summary
The facility failed to provide appropriate care for a resident, identified as Resident R14, who exhibited a new onset of decreased functional abilities. During an observation, it was noted that Resident R14 was unable to fully open his right hand, with fingers remaining in a flexed position. The resident reported not having a splint and not receiving physical or occupational therapy services. A review of the resident's clinical record showed that a significant assessment was conducted, and a physical therapy evaluation dated May 3, 2024, indicated a need for skilled physical therapy services due to decreased strength, mobility, and other functional abilities. However, there was no documented evidence that restorative skilled services were provided to Resident R14. Interviews with facility staff revealed that Resident R14 was not picked up for restorative physical therapy because he was considered to be on custodial care, which the facility would not be reimbursed for. The Rehab Director confirmed that the resident could benefit from restorative physical therapy but was not placed on it due to the custodial care status. Additionally, there was no documented evidence that the resident or their next of kin was informed about the lack of necessary services or provided with options to receive them. The resident's payor source was identified as Medicaid, and there was no documentation supporting the custodial care classification.
Failure to Monitor Labs for Resident on Fluid Restrictions
Penalty
Summary
The facility failed to monitor laboratory results for a resident on fluid restrictions, leading to a deficiency in care. The resident, who was admitted from the hospital, had a complex medical history including Guillain-Barre Syndrome, Myoneural Disorder, and other conditions. The resident was placed on a 1200 ml daily fluid restriction due to a history of hyponatremia, potentially linked to hyperproteinemia from IVIG treatment. Despite dietary progress notes recommending lab monitoring on multiple occasions, there was no evidence that lab work had been conducted since the resident's admission. The deficiency was confirmed during an interview with the Director of Nursing. The resident's clinical records did not indicate whether the continuation of fluid restrictions was necessary, and the lack of lab monitoring could have impacted the resident's health management. The failure to perform necessary lab work and reassess the need for fluid restrictions represents a significant oversight in the resident's care plan.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care services for Resident R82, who has a history of paranoid personality disorder, psychophysiological insomnia, and major depressive disorder. The resident had previously been involuntarily admitted to a psychiatric unit for a suicide attempt. Despite repeated requests for non-pharmacological support, specifically a grief support group, the facility did not arrange for these services. Interviews and clinical notes indicate that the resident expressed a strong desire for group therapy to address unresolved grief and loneliness, which were contributing to her depressive symptoms and passive death wishes. Observations and documentation from the facility's nurse practitioner and social worker highlighted the resident's ongoing struggles with depression, self-harm, and aggression towards others. Despite these documented needs and the resident's clear preference for group therapy, the facility did not provide evidence of attempts to arrange such services or explore alternative options. The unit manager acknowledged the resident's preference for a specific facility for outpatient treatment but failed to demonstrate efforts to provide the requested support. This lack of action resulted in the facility not meeting the resident's behavioral health care needs, as required to ensure her highest practicable physical, mental, and psychosocial well-being.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored and labeled according to professional standards in two medication rooms. During an observation of the second-floor medication room, a treatment cart was found inside the room containing an opened tube of Santyl Collagenase without a label indicating the resident's name. A licensed nurse confirmed the presence of the unlabeled tube and acknowledged that it should have been labeled. In the third-floor medication room, an opened 5 ml vial of Tuberculin, Purified Protein Derivative, was found in the medication refrigerator without a date opened affixed to either the vial or its box. The unit manager confirmed the absence of the date opened on the vial and its packaging. These findings indicate a failure to adhere to the facility's policy on medication storage and labeling, as outlined in the facility's policy and state regulations.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for a resident, identified as R36, who was observed refusing to eat due to dental issues. The facility's policy required staff to assist residents in obtaining routine and emergency dental care, but this was not adhered to in the case of R36. Observations revealed that R36 had obvious dental issues, such as cavities or broken teeth, which made it difficult for him to chew harder foods. As a result, softer food alternatives were provided. Despite an evaluation by an outside dental group in March 2024, which recommended extractions and dentures due to periodontal disease, these procedures had not been completed by June 2024. The clinical records for R36 showed a significant weight loss over several months, dropping from 124 pounds to 116 pounds, indicating a 10.8% weight loss. The dietitian's assessment noted that R36 was below his usual and ideal body weight, and a nutritional care plan was implemented to supplement his diet with soft foods and liquid supplements. However, the necessary dental procedures to address his chewing difficulties were not scheduled or documented, as confirmed by the Director of Nursing. This lack of action contributed to the resident's ongoing dental and nutritional issues.
Infection Control Lapses in Tube Feeding and Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during tube feeding and medication administration. During an observation on the second-floor unit, a licensed nurse was seen providing tube feeding to a resident using a bolus method. The nurse wore a glove only on her right hand while using both hands to handle the feeding equipment, including a large syringe and cups. Additionally, the over-bed table where the feeding equipment and cups were placed was dirty and lacked a clean covering. In another instance, a licensed nurse was observed preparing medication for a resident. The nurse placed a bottle of ophthalmic solution into a medication cup containing oral medications, then removed it and administered the oral medications without changing gloves or sanitizing her hands. The nurse proceeded to administer the ophthalmic solution to the resident's eye without changing gloves or sanitizing hands. Furthermore, during medication administration for another resident, the nurse stacked medication cups on top of each other, causing the bottoms of the cups to touch the medications underneath, before administering them to the resident.
Deficiency in Dietary Equipment Maintenance
Penalty
Summary
The facility failed to maintain all mechanical dietary equipment in safe operating condition, as observed in the food and nutrition department. The dish machine was not dispensing any chemical sanitizer during the final rinse cycle due to a malfunctioning mechanical device and tubing, preventing proper cleaning and sanitizing of dishes, bowls, cups, mugs, utensils, pots, and pans. This was confirmed through observations and interviews with dietary staff, who acknowledged the issue with the dish machine's dispensing mechanics. Additionally, the three-compartment sink operation was compromised as dietary staff were unable to test the sanitizer concentration due to a malfunctioning mechanical device connected to the chemical dispenser unit. The sanitizer used was producing a white foam, and the concentration reported by staff was below the manufacturer's recommended levels for effective cleaning and sanitizing. Interviews with the director of dietary services and dietary aides confirmed the malfunctioning equipment, which hindered the proper sanitization process.
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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