Jersey Shore Skilled Nursing And Rehabilitation Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Jersey Shore, Pennsylvania.
- Location
- 1008 Thompson Street, Jersey Shore, Pennsylvania 17740
- CMS Provider Number
- 395359
- Inspections on file
- 27
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Jersey Shore Skilled Nursing And Rehabilitation Ce during CMS and state inspections, most recent first.
Multiple residents did not receive physician-ordered wound care treatments as scheduled, including daily wound cleansing, application of dressings, and negative pressure wound therapy. Documentation was lacking for several treatment dates, and in one case, a delay in supply delivery contributed to missed care. There was no evidence that treatments were completed, refused, or that residents were unavailable.
Two residents did not receive timely or complete pharmaceutical services, including late or undocumented administration of multiple medications for one resident and delayed ordering and administration of IV and oral antibiotics for another. Documentation gaps and missing hospital discharge information contributed to missed and late doses, with required monitoring not consistently performed.
Surveyors found that staff did not consistently use enhanced barrier precautions (gown and glove use) during high-contact care activities for three residents with wounds or indwelling medical devices. Despite facility policy and CMS guidance requiring EBP, staff were observed transferring, changing, and providing care to these residents without donning isolation gowns, and EBP signage was missing or incorrect for affected beds. Staff interviews confirmed a lack of awareness and implementation of EBP requirements.
Two dependent residents did not receive necessary ADL care, including hygiene and toileting, due to staff failing to provide assistance as required by their care plans. Staff interviews and documentation revealed repeated missed care and inaccurate records, with one resident left without morning care for hours and another not receiving scheduled incontinence care or transfers. The DON and administrator were informed of these deficiencies.
On one overnight shift, the facility did not provide the required number of nurse aides per resident, falling short of the mandated minimum staffing ratio. This was confirmed through staffing records and administrator interview.
The facility did not provide the required number of LPNs on both the day and overnight shifts for one day during the review period, resulting in staffing levels below regulatory minimums for the number of residents present. This was confirmed through staffing records and administrator interview.
A resident who was dependent on staff for mobility and care was left unattended in a high bed by a nurse aide, resulting in a fall that caused injuries and required emergency room evaluation. The facility's incident report inaccurately stated that care plan interventions were followed and that enabler bars were present, despite evidence to the contrary. The incident was not reported as a potential neglect case to the appropriate authorities, and key details about the circumstances were omitted from the report.
A resident at Jersey Shore Skilled Nursing and Rehabilitation Center was improperly restrained with a sheet on two occasions without medical necessity or a physician's order. Staff failed to report the incidents, and the facility did not follow its policies on restraint use and abuse prevention. The therapy department had not received updated training following the incidents.
A resident dependent on staff for toileting and hygiene was left in a wet brief for hours, resulting in a persistent diaper rash. The resident was also not provided with dentures for breakfast, affecting her ability to eat. Interviews with nurse aides revealed a lack of incontinence care and provision of necessary aids since the start of their shifts. Facility-acquired skin damage was identified, and the facility's failure to meet care needs was reviewed with the administration.
The facility failed to maintain a clean and orderly environment in two of its three nursing units, affecting multiple residents. Observations revealed significant cleanliness and maintenance issues, such as dust and debris in bathrooms, peeling wallpaper, stained curtains, and non-functional sinks. These findings were reviewed with the DON, indicating a systemic issue with housekeeping and maintenance services.
The facility failed to store food in accordance with professional standards for food service safety and sanitation. Observations revealed multiple areas of concern, including dried food, debris, and spills in various parts of the kitchen, as well as uncertainty about the expiration and storage conditions of bread products. These findings were reviewed with the Nursing Home Administrator and Director of Nursing.
The facility failed to provide adequate housekeeping and maintenance services, resulting in stained and peeling wallpaper, broken closet doors, marred walls, and dirty floors across three nursing units. Common areas were also found to be dirty, with dried food, crumbs, dead bugs, and cobwebs. These issues were reported to the Nursing Home Administrator and DON.
The facility failed to provide timely assessment and implement interventions for four residents' nutritional needs, leading to significant weight loss and inadequate caloric intake. The absence of a qualified dietitian since March 8, 2024, contributed to the oversight, as confirmed by the Nursing Home Administrator.
The facility failed to ensure a resident's medication regime was free from potentially unnecessary medications. A resident's clinical records showed that non-medicinal interventions were not documented prior to the administration of PRN Ativan for most administrations in February, March, and April. This was reviewed with the Nursing Home Administrator and Director of Nursing.
The facility failed to determine a resident's wishes regarding an advance directive before obtaining a physician's order for her code status. The DNR information was obtained from hospital discharge records, but there was no advance directive in the resident's chart, and the source of the physician's DNR information was unclear.
The facility failed to provide the required notification to two residents whose payment coverage changed from Medicare to private pay. There was no documented evidence that the facility provided the CMS-10055 form to the residents or their responsible parties, as confirmed by a staff interview.
The facility failed to develop and implement a comprehensive care plan for a resident who primarily speaks Spanish and has difficulty communicating in English. Despite known communication deficits and interactions with Spanish-speaking staff, no formal care plan was created to address his communication needs, leading to inadequate care.
The facility failed to provide hearing treatment for a resident. An audiologist recommended cerumen removal using Debrox, but there was no evidence that the treatment was ordered or administered. The Nursing Home Administrator confirmed that the recommendations were not reviewed by the physician.
The facility failed to evaluate and manage a pressure ulcer on a resident's left heel, leading to its decline. Inconsistent and incomplete documentation, along with a lack of weekly evaluations, contributed to the worsening of the wound. The Director of Nursing confirmed these findings, and the facility had previous citations for similar issues.
The facility failed to ensure timely addressing and implementation of pharmacy recommendations for two residents. One resident experienced a 10-day delay in receiving a Vitamin D3 order, while another had a significant delay in obtaining a serum Vitamin D level and subsequent supplementation.
The facility failed to employ a qualified registered dietitian in the absence of a full-time certified dietary manager. An interview with the Administrator revealed that the facility has not had a qualified dietitian since March 8, 2024, and does not have a certified dietary manager.
The facility failed to ensure that all nurse aide staff completed a minimum of 12 hours of in-service education training each year. One nurse aide, hired in January 2022, only completed 6.26 hours, and another, hired in February 2016, only completed 3.01 hours of the required training. This included dementia training, abuse prevention training, and areas of weakness or resident special care needs.
A resident with hypercalcemia and hyperparathyroidism missed multiple endocrinology appointments due to the facility's failure to secure reliable transportation. The resident finally attended an appointment nearly eight months after the last visit, highlighting a recurring issue with the use of outside resources.
A resident with hypercalcemia and hyperparathyroidism did not receive the prescribed medication, Sensipar, as instructed by their endocrinologist, leading to elevated ionized calcium levels. The resident missed multiple endocrinology appointments, and the medication was only restarted after an emergency room visit and a subsequent appointment, resulting in improved calcium levels.
A resident experienced significant emotional distress after witnessing the death of her roommate and being left in the room with the deceased body for several hours. The facility failed to provide necessary emotional support or to ask if the resident wanted to leave the room, and there was no documentation of the incident or the subsequent room move in the resident's clinical record.
Failure to Provide Physician-Ordered Wound Care Treatments
Penalty
Summary
The facility failed to provide physician-ordered wound care treatments for four out of five residents reviewed. For one resident, a daily treatment for a Stage 3 right heel wound was not documented as completed on two specific dates. Another resident with orders for wound care to the left lateral foot and multiple venous ulcers did not have documentation of the required treatment on a scheduled date. A third resident with an order for negative pressure wound therapy did not have evidence of the treatment being performed as ordered on a scheduled day. For a fourth resident, daily treatment for a pressure ulcer on the coccyx was not documented on multiple dates, and negative pressure wound therapy for a left hip wound was also not completed as ordered on several occasions. Nursing notes indicated that, in at least one instance, the lack of treatment was related to a delay in supply delivery for a specific negative pressure wound therapy machine, as reported by the DON. There was no documentation to indicate that the treatments were completed, refused by the residents, or that the residents were unavailable for treatment on the missed dates. The findings were confirmed with the DON and Nursing Home Administrator, and no additional information was provided to account for the missed treatments.
Failure to Provide Timely and Complete Pharmaceutical Services
Penalty
Summary
The facility failed to provide timely and appropriate pharmaceutical services to meet the needs of two residents. For one resident, multiple medications, including maintenance inhalers, blood pressure medications, anticoagulants, and pain relievers, were administered outside the facility's policy of a 60-minute window from the scheduled administration time. Documentation showed that morning medications were often given two to three hours late over several consecutive days, and evening doses were sometimes given too early or not documented as administered at all. There was also no evidence that required blood pressure and heart rate checks were performed prior to administering certain cardiac medications, as ordered. Additionally, the same resident's medication administration record lacked documentation for several scheduled doses, with no indication that the resident refused or was unavailable for medication administration. The DON confirmed that the resident was permitted to self-administer medications, but the times recorded reflected when staff provided the medications, not when they were actually taken. For another resident, who was re-admitted from the hospital with a PICC line and orders to continue IV and oral antibiotics, the facility failed to obtain and administer these medications in a timely manner. The IV antibiotic was not ordered or given until three days after admission, and the oral antibiotic was not ordered or administered until six days after admission. The delay was attributed to missing hospital discharge documentation and lack of transcription of the orders, resulting in missed doses as noted by the attending physician. Laboratory results also indicated subtherapeutic levels of the IV antibiotic during this period.
Failure to Implement Enhanced Barrier Precautions for Residents with Wounds and Indwelling Devices
Penalty
Summary
Surveyors identified that the facility failed to implement appropriate enhanced barrier precautions (EBP) for three of four residents reviewed for infection control concerns. According to the CMS memo on EBP, nursing facilities are required to use gowns and gloves during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their multidrug-resistant organism status. The facility's own policy also required EBP for residents with wounds or indwelling devices, including posting EBP signage and donning gowns and gloves for high-contact activities such as dressing, transferring, changing linens, providing hygiene, and device care. For one resident with a urinary catheter and a stage IV pressure ulcer, staff were observed transferring the resident and changing her incontinence brief without donning isolation gowns, despite an EBP sign being posted for her bed. Similarly, another resident with a wound requiring daily treatment did not have EBP signage posted for her bed, and staff only used gloves, not gowns, during high-contact care activities such as transferring, changing briefs, and changing linens. A third resident with nephrostomy tubes and multiple wounds also did not have EBP signage for her bed, and staff were observed assisting with transfers without wearing isolation gowns. In each case, staff interviews confirmed a lack of awareness or implementation of EBP requirements for these residents. The surveyor discussed these findings with facility leadership, including the Nursing Home Administrator and Director of Nursing, confirming that the observed failures to implement EBP were inconsistent with both CMS guidance and the facility's own policies. The deficiencies were documented based on direct observation, clinical record review, and staff interviews, and were not limited to a single staff member or shift, but rather reflected a broader failure to consistently apply EBP for residents at risk.
Plan Of Correction
The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction. 1. Residents #1 and #2 had the Enhanced Barrier Precaution signs corrected at the time of the survey. Residents #1, #2, and #3 had no negative outcome from EBP personal protective equipment not worn during the care that was provided during surveyor observation. 2. An initial audit will be conducted of residents that meet the Enhanced Barrier Precautions by the Director of Nursing/designee to ensure signage and personal protective equipment is in place. An initial audit of residents on EBP will be conducted to ensure staff on each shift are donning the appropriate PPE to complete the care he/she is providing. Corrections will be made as needed. The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction. 1. Residents #1 and #2 had the Enhanced Barrier Precaution signs corrected at the time of the survey. Residents #1, #2, and #3 had no negative outcome from EBP personal protective equipment not worn during the care that was provided during surveyor observation. 2. An initial audit will be conducted of residents that meet the Enhanced Barrier Precautions by the Director of Nursing/designee to ensure signage and personal protective equipment is in place. An initial audit of residents on EBP will be conducted to ensure staff on each shift are donning the appropriate PPE to complete the care he/she is providing. Corrections will be made as needed. 3. Education will be provided to the facility licensed nursing staff regarding facility procedure Enhanced Barrier Precautions. 4. Audits will be conducted weekly x four and monthly x three by the Director of Nursing/designee of residents that meet the Enhanced Barrier Precautions to ensure signage is in place. A random audit of five residents on EBP will be conducted by the Director of Nursing designee weekly x four and monthly x three to ensure staff on each shift are donning the appropriate PPE to complete the care he/she is providing. Corrections will be made as needed. Results of audits will be reported at the Quality Assurance Performance Improvement meetings.
Failure to Provide Required ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary activities of daily living (ADL) care for two dependent residents, resulting in unmet needs for nutrition, grooming, personal, and oral hygiene. For one resident, interviews and clinical record reviews revealed that no staff provided morning care assistance, including bathing, hygiene, or incontinence care, for at least six hours. Documentation showed repeated instances where hygiene and toileting assistance were marked as 'Not Applicable,' indicating care was not provided on multiple dates and shifts. Staff interviews confirmed that assigned nurse aides did not deliver required care, often due to staff being reassigned or leaving the unit for other duties, and no one assumed responsibility for the resident's care during those times. Another resident was observed to have received morning care late in the morning, but was not provided incontinence care or transferred out of her wheelchair for nearly four hours after lunch, contrary to her individualized toileting plan. Documentation indicated that staff initialed completion of toileting tasks even though care was not provided as scheduled. The resident's care plan required assistance with transfers, hygiene, grooming, dressing, oral care, and eating, as well as a specific toileting schedule, but these interventions were not consistently implemented. The deficiencies were confirmed through interviews with staff, review of electronic documentation, and direct observation. The findings were discussed with the Nursing Home Administrator and the Director of Nursing, who were made aware of the lapses in ADL care for both residents. The report documents a pattern of missed care and inaccurate documentation, resulting in the failure to meet the residents' assessed needs for daily living assistance.
Plan Of Correction
The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction. 1. Residents #5 and #7 had no negative outcome from not receiving Activities of Daily Living (ADL) care. Once identified, ADL care was provided to both residents. 2. An initial audit will be conducted by the Director of Nursing/designee of facility residents who require ADL assistance to ensure completion of his/her ADL documentation for the past seven days to determine if there were residents with missed or not completed ADL care. Residents identified with missed or not completed ADL care will be assessed by a Registered Nurse and will ensure care is completed. 3. Education will be provided to facility nursing staff regarding the Nursing Policy Activities of Daily Living (ADLs) and nursing assistant shift responsibilities. 4. Audits will be conducted by the Director of Nursing/designee of ten random facility residents who require ADL assistance to ensure completion of his/her ADL documentation and care will be conducted weekly x four and then monthly x three by the facility Director of Nursing or designee(s). Corrections and/or care will be made as necessary and results of audits will be reported at the Quality Assurance Performance Improvement meetings.
Failure to Meet Minimum Overnight Nurse Aide Staffing Requirements
Penalty
Summary
The facility failed to meet the required minimum staffing levels for nurse aides during the overnight shift on one of the 21 days reviewed. Specifically, on May 25, 2025, with a resident census of 85, the facility provided 5.38 nurse aides when 5.67 were required to comply with the regulation mandating at least one nurse aide per 15 residents overnight. This deficiency was confirmed through a review of nursing care hours and an interview with the Nursing Home Administrator.
Plan Of Correction
The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction. 1. The facility attempts to staff to meet state required hours of staff and ratios per current state regulations. There were no ill effects to any residents. 2. An active recruitment campaign is ongoing including sign on bonuses, shift differentials and employee referral bonuses. The facility utilizes staffing agencies to fill in shifts as needed. 3. The facility nursing home administrator or designee will review with the director of nursing the latest guidelines for staffing ratios. 4. The facility nursing home administrator and director of nursing will meet to review staffing sheets to ensure proper staffing ratios daily x 5, and then weekly x 4 with results to the facility Quality Assessment and Assurance Committee.
Failure to Meet Minimum LPN Staffing Requirements
Penalty
Summary
The facility failed to meet the required minimum staffing levels for licensed practical nurses (LPNs) on both the day and overnight shifts for one of the 21 days reviewed. Specifically, on August 9, 2025, during the day shift with a census of 80 residents, only 3.19 LPNs were provided when 3.20 were required. On the same date during the overnight shift, with a census of 81 residents, only 1.69 LPNs were present when 2.03 were required. These findings were confirmed through a review of nursing care hours and an interview with the Nursing Home Administrator.
Plan Of Correction
The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction. 1. The facility attempts to staff to meet state required hours of staff and ratios per current state regulations. There were no ill effects to any residents. 2. An active recruitment campaign is ongoing including sign on bonuses, shift differentials and employee referral bonuses. The facility utilizes staffing agencies to fill in shifts as needed. 3. The facility nursing home administrator or designee will review with the director of nursing the latest guidelines for staffing ratios. 4. The facility nursing home administrator and director of nursing will meet to review staffing sheets to ensure proper staffing ratios daily x 5, and then weekly x 4 with results to the facility Quality Assessment and Assurance Committee.
Failure to Accurately Report and Classify Resident Fall as Potential Neglect
Penalty
Summary
The facility failed to accurately report and classify an incident involving a resident who sustained a fall from bed as a potential allegation of neglect. The incident occurred when the resident, who was dependent on staff for bathing, hygiene, rolling, and moving from lying to sitting, was left unattended in bed at its highest position while a nurse aide left the room to consult with a nurse about a wound bandage. The resident subsequently rolled out of bed and was found on the floor with injuries including a bruised eye and knee, requiring transfer to the emergency room for evaluation. Documentation and witness statements revealed inconsistencies in the facility's reporting to the State. The initial incident report incorrectly stated that the resident had enabler bars and that care plan interventions were followed. However, clinical records and staff interviews confirmed that no enabler bars were ever ordered or present, and that the resident was left alone in a high bed, contrary to safe care procedures. The nurse aide involved acknowledged leaving the resident unattended and received education on the risks associated with this action. Despite obtaining staff statements and providing education after the event, the facility did not report the incident as a potential neglect case to the appropriate authorities. The omission of critical details—such as the resident being left unattended in a high bed and the lack of enabler bars—resulted in the failure to accurately report the circumstances and potential neglect associated with the resident's fall and subsequent injury.
Improper Use of Restraints on Resident
Penalty
Summary
Jersey Shore Skilled Nursing and Rehabilitation Center was found to be non-compliant with federal and state regulations regarding the use of physical restraints. The facility failed to ensure that a resident was free from abuse when a sheet was used as a restraint on two separate occasions without a medical or emergent need. On January 8, 2025, a licensed practical nurse (LPN) used a sheet to tie a resident to a chair because the resident would not stay seated. This action was not documented as medically necessary, and no physician's order or consent was obtained. Another LPN observed the restraint but did not report it to a supervisor. On January 11, 2025, a similar incident occurred when a nurse aide and an LPN restrained the same resident using a sheet, again without a documented medical reason or physician's order. The resident was observed by other staff and residents to be distressed during the application of the restraint. Statements from staff indicated that this practice had been occurring previously, suggesting a pattern of inappropriate restraint use. The facility's policies on abuse prohibition and restraint use were not followed, as evidenced by the lack of documentation and failure to use the least restrictive alternatives. Additionally, the therapy department had not received updated training on restraint and abuse prevention following the incidents. The facility's administrator acknowledged these findings and confirmed the lack of immediate reporting and training updates.
Plan Of Correction
The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction. 1. Resident #1 was evaluated by the interdisciplinary team for injury and safety needs, as well as the need for any restraint or alternative interventions. Plan of care updated related to needs, with provider and family involvement. 2. All residents have the potential to be affected by this alleged deficient practice. A facility wide abuse audit and restraint audit was completed to ensure no further concerns were found with any other resident or resident representative. 3. All facility staff received abuse and restraint training with emphasis on notifying the provider when a resident has a change in condition that may require a restraint, as well as immediate notification to the abuse coordinator with alleged abuse. Interdisciplinary team will review all alleged abuse/restraint allegations daily to ensure abuse/restraint process is being followed if incidents occur. 4. Administrator/designee will complete an abuse/restraint post test for 10 random employees weekly x 4 weekly, then 5 random employees x 2 months or until substantial compliance is met to ensure training is retained. Administrator/designee will complete abuse/restraint questionnaires with 10 random residents/resident representatives x 4 weeks, then 5 x 2 months or until substantial compliance is met, to ensure all concerns are addressed per process. Administrator and/or designee will bring results of audits to QAPI committee for further recommendations based on tracking and trending presented monthly for the next 3 months or until ongoing compliance is achieved. 5. Date of compliance: 2/25/2025
Failure to Provide Adequate Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate care and assistance to a resident who was dependent on staff for toileting, hygiene, and mobility. The resident, identified as Resident 4, was observed lying in bed waiting for a shower and reported being left in a wet brief since 4:00 AM, resulting in discomfort and a diaper rash that had persisted for two months. The resident's clinical records indicated a dependency on staff for bed mobility and toileting hygiene, with a scheduled toileting plan that was not adhered to. Additionally, the resident was not provided with dentures for breakfast, which were stored out of reach, affecting her ability to eat properly. Interviews with two nurse aides revealed that neither had provided the necessary incontinence care, bedpan, or dentures to the resident since the start of their shifts. A wound evaluation assessment identified facility-acquired moisture-associated skin damage on the resident, with a new order for topical ointment treatment. The facility's failure to meet the resident's care needs was reviewed with the Nursing Home Administrator and Director of Nursing, highlighting deficiencies in promoting continence, toileting hygiene, and providing necessary eating aids.
Facility Fails to Maintain Clean and Orderly Environment
Penalty
Summary
The facility failed to maintain a clean and orderly environment in two of its three nursing units, affecting multiple residents. Observations revealed significant cleanliness and maintenance issues in the rooms and bathrooms of several residents. For instance, Resident 3's bathroom had a thick coating of dust on the light fixture, rusty washers on the floor, and a pile of black and brown debris around the toilet base. Resident 6's bathroom had peeling wallpaper, while Resident 5's room had dried food and debris around the bed frame, discolored bathroom tiles, and a non-functional sink with debris buildup. Additionally, Resident 4's room had a torn and stained curtain, and peeling wallpaper. Further observations in the facility showed that Resident 7's room lacked a closet door, had stained ceiling tiles, and dirt buildup along the flooring edges. Resident 8's room had orange stains on the window shade and stained ceiling tiles in the bathroom. These findings were reviewed with the Director of Nursing, indicating a systemic issue with housekeeping and maintenance services in the facility, as previously cited in April 2024.
Failure to Maintain Food Storage and Preparation Standards
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety and sanitation in the main kitchen. Observations revealed multiple areas of concern, including a coffee station with sliding doors filled with dried food, debris, and ground coffee. A household refrigerator in the preparation area had a dried white substance on the lower interior shelf and dried liquid spills on the interior door. The wall and sliding window behind a preparation table were covered with dried food splatter, and an industrial mixer covered in a garbage bag was also observed with dried food splatter. The cart holding the mixer and the area around a large round garbage can were covered in dust, debris, and dried food. Lower shelves of preparation tables near the food serving line and a preparation table holding a food processor were also observed with a buildup of dust, debris, and dried food splatter. Additionally, a cardboard box of sheet pan liners was soiled with grease spots and dried food, and the lower shelves of a preparation table with a sink were soiled with dried spills and debris. Several packages of bread products in the dry storage area were observed without any visible indication of when they were placed there or when they needed to be used by. Employee 5, a cook, indicated uncertainty about the expiration of the bread products and whether they were delivered fresh or frozen. Shelving units throughout the dry storage area were observed with dust, debris, and dried spills. These findings were reviewed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to maintain food storage and preparation areas in accordance with professional standards for food service safety and sanitation.
Failure to Maintain Clean and Orderly Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services to maintain a clean and orderly environment across three nursing units. Observations revealed multiple environmental concerns, including stained and peeling wallpaper, broken closet doors, marred walls, and dirty floors. Specific rooms had additional issues such as broken heating and air conditioning units, missing closet doors, and broken plastic protective covers. Residents reported that these issues had been ongoing and not addressed by the facility staff. Further observations highlighted significant cleanliness issues, including dirt buildup, used tissues, and brown substances on bathroom floors and toilets. Common areas such as lounges and foyers were found to be dirty, with dried food, crumbs, dead bugs, and cobwebs. These findings were reviewed with the Nursing Home Administrator and Director of Nursing, who were made aware of the deficiencies in maintaining a safe, clean, and comfortable environment for the residents.
Failure to Address Nutritional Needs
Penalty
Summary
The facility failed to provide timely assessment and implement interventions to promote acceptable parameters of nutritional status for four residents. Resident 46 was admitted with a diagnosis of malnutrition and required a feeding tube for nutrition. Despite being assessed as at nutritional risk, there was no documented evidence of a comprehensive dietary assessment or a care plan to address potential weight loss. The resident experienced significant weight loss, and it was only after the surveyor's intervention that a dietary assessment was completed, revealing inadequate caloric intake through the feeding tube. The facility had been without a qualified dietitian since March 8, 2024, which contributed to the oversight. Resident 59, admitted with a history of significant weight loss and dementia, continued to lose weight after an initial nutrition note by the registered dietitian. Despite the resident's severe weight loss, there was no further assessment or intervention by the dietitian or physician. The facility's lack of a registered dietitian since March 8, 2024, further exacerbated the issue, as confirmed by the Nursing Home Administrator. Resident 86, with a poor prognosis due to stage four lung cancer, experienced weight loss and swallowing difficulties. Despite physician orders for nutritional support and medications, there was no documentation of the facility implementing these orders. The resident's weight loss and intake concerns were not adequately monitored or addressed by the dietitians. Similarly, Resident 91 experienced significant weight loss without any new interventions being initiated. The facility failed to identify, monitor, and implement dietary interventions for the resident's weight loss, as confirmed during interviews with the Nursing Home Administrator and Director of Nursing.
Failure to Document Non-Medicinal Interventions Before Administering PRN Ativan
Penalty
Summary
The facility failed to ensure a resident's medication regime was free from potentially unnecessary medications. Clinical record review for Resident 13 revealed a physician's order for Ativan 1 mg PO BID PRN for anxiety, initially dated November 1, 2023, and discontinued on March 6, 2024, but reordered on March 16, 2024, for another 60 days. Review of Resident 13's February, March, and April 2024 MARs showed that non-medicinal interventions were not documented prior to the administration of PRN Ativan for 24 of 25 administrations in February, 29 of 36 administrations in March, and 9 of 10 administrations in April. This information was reviewed with the Nursing Home Administrator and Director of Nursing on April 8, 2024.
Failure to Determine Resident's Wishes Regarding Advance Directive
Penalty
Summary
The facility failed to determine a resident's wishes regarding an advance directive before obtaining a physician's order for her code status. Clinical record review for Resident 27, who was admitted with a left femoral fracture and end-stage renal disease, revealed an advance directive indicating DNR (Do Not Resuscitate). A medical note indicated that Resident 27 was severely lethargic but alert and oriented to person only, and desired to be a DNR. Interviews with the Nursing Home Administrator and Director of Nursing revealed that the DNR information was obtained from hospital discharge records, but there was no advance directive located in Resident 27's chart, and the source of the physician's DNR information was unclear.
Failure to Provide Required Notification of Payment Coverage Change
Penalty
Summary
The facility failed to provide the required notification to two residents whose payment coverage changed from Medicare to private pay. For Resident 34, the facility provided services primarily paid for by Medicare starting September 7, 2023, and the Medicare payment ended on October 3, 2023. Resident 34 began to privately pay for his care on October 4, 2023, and still resides in the facility. There was no documented evidence that the facility provided a CMS-10055 form to Resident 34 or his responsible party. Similarly, for Resident 89, the facility provided services primarily paid for by Medicare starting January 4, 2024, and the Medicare payment ended on February 14, 2024. Resident 89 began to privately pay for his care on February 14, 2024, and still resides in the facility. There was no documented evidence that the facility provided a CMS-10055 form to Resident 89 or his responsible party. The surveyor confirmed these findings during an interview with Employee 1, who indicated that she was not aware that the CMS-10055 form was to be used.
Failure to Develop and Implement Comprehensive Care Plan for Non-English Speaking Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 81, who primarily speaks Spanish and has difficulty communicating in English. Despite being admitted to the facility and having a known communication deficit, there was no care plan addressing his communication needs. Staff interviews revealed that communication with Resident 81 was primarily through one Spanish-speaking LPN and interpreter applications on staff phones. However, there was no consistent presence of Spanish-speaking staff, and no formal interventions were documented in his care plan to address his communication concerns. Clinical records and staff interviews indicated that Resident 81 could communicate through head nods and had previously communicated with a nurse in Spanish regarding his code status. Despite these interactions, the facility did not create a care plan to ensure effective communication with Resident 81. The Director of Nursing confirmed the absence of a care plan addressing his communication needs, leading to a failure in maintaining the highest practicable care for the resident.
Failure to Provide Hearing Treatment
Penalty
Summary
The facility failed to provide treatment to improve hearing for a resident. Clinical record review revealed that an audiologist's progress note indicated the resident's left ear was impacted with cerumen and recommended removal using Debrox as ordered by the facility physician. However, there was no evidence that the Debrox treatment was ordered or administered. An interview with the Nursing Home Administrator confirmed that the audiologist's recommendations were never reviewed by the resident's physician, and the treatment was not completed.
Failure to Evaluate and Manage Pressure Ulcer
Penalty
Summary
The facility failed to evaluate and manage a pressure ulcer on Resident 27's left heel, leading to its decline. Upon admission on March 6, 2024, Resident 27 had a closed wound on her left heel, which was documented as an abrasion with no depth and no drainage. However, subsequent evaluations were inconsistent and lacked detailed documentation. By April 6, 2024, the wound had worsened, showing eschar without a specified percentage, and no dressing or additional care was noted. The care plan initially identified the wound as a deep tissue injury but was later confirmed as an unstageable pressure ulcer with 100% eschar by a wound clinic physician on April 9, 2024. The facility's treatment administration records for March and April 2024 indicated that staff were conducting daily body audits, but there was no documented evidence that the left heel was being assessed during these audits. The facility did not complete weekly evaluations of Resident 27's left heel pressure ulcer, which should have included detailed assessments of the wound's location, size, drainage, pain, tissue type, and wound bed and edges. This lack of consistent and thorough evaluation contributed to the decline of the pressure ulcer. The Director of Nursing confirmed these findings during a meeting on April 10, 2024. The facility had previously been cited for similar deficiencies in May and December 2023, indicating ongoing issues with pressure ulcer management and evaluation.
Delayed Implementation of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the resident's attending physician addressed pharmacy recommendations timely and implemented accepted recommendations for two residents. For Resident 50, a consultant pharmacist recommended the initiation of Vitamin D3 on February 6, 2024. Although the physician accepted and signed the recommendation on February 25, 2024, the resident did not receive a physician's order for the Vitamin D3 until March 6, 2024, resulting in a 10-day delay in implementation. For Resident 80, a consultant pharmacist recommended checking a serum Vitamin D level on October 13, 2023, due to a recent fall. The physician did not review this recommendation until November 27, 2023, over 30 days later. Although the physician accepted the recommendation on November 27, 2023, the serum Vitamin D level was not obtained until February 5, 2024. Subsequently, a recommendation for Vitamin D3 supplementation was made on February 6, 2024, and the order was placed the same day. These delays in addressing and implementing pharmacy recommendations were reviewed with the Nursing Home Administrator and Director of Nursing on April 9, 2024.
Failure to Employ Qualified Dietitian
Penalty
Summary
The facility failed to employ a qualified registered dietitian in the absence of a full-time certified dietary manager. An interview with the Administrator on April 7, 2024, at 2:00 PM revealed that the facility has not had a qualified dietitian either full-time, part-time, or on a consultant basis since March 8, 2024. It was also confirmed that the facility does not have a certified dietary manager.
Failure to Complete Required In-Service Education for Nurse Aides
Penalty
Summary
The facility failed to ensure that all nurse aide staff completed a minimum of 12 hours of in-service education training each year for two of four nurse aides reviewed. During an interview with the Nursing Home Administrator (NHA) and the human resources director, it was confirmed that one nurse aide, hired in January 2022, only completed 6.26 hours, and another nurse aide, hired in February 2016, only completed 3.01 hours of the required annual in-service education. This training included essential topics such as dementia training, abuse prevention training, and areas of weakness or resident special care needs. The deficiency was identified based on a review of facility staff education records and staff interviews.
Failure to Secure Transportation for Resident's Medical Appointments
Penalty
Summary
The facility failed to secure transportation for a resident with hypercalcemia and hyperparathyroidism, resulting in missed endocrinology appointments. The resident had scheduled appointments on March 27, June 27, and August 28, 2023. However, transportation issues led to the cancellation of the August 28 appointment, which was rescheduled for August 30, and subsequently for September 8, 2023. Each of these appointments was missed due to the transport company canceling on the facility, and there was no backup transportation available. The resident finally attended an endocrinology appointment on February 14, 2024, nearly eight months after the last visit in June 2023. In an interview with the Director of Nursing on March 22, 2024, it was confirmed that the resident required transportation via stretcher, and the transport company used for such transfers had canceled on the facility multiple times. The facility pays for the resident's transportation to appointments, but due to the lack of a backup plan, the resident missed critical endocrinology appointments. This deficiency was previously cited on May 11, 2023, indicating a recurring issue with the use of outside resources for transportation needs.
Failure to Continue Prescribed Medication for Resident with Hypercalcemia
Penalty
Summary
The facility failed to provide the highest practicable care for a resident with hypercalcemia and hyperparathyroidism by not continuing the prescribed medication, Sensipar, as instructed by the resident's endocrinologist. The resident's clinical records showed that Sensipar was initially prescribed on March 27, 2023, but was discontinued after 90 days on June 28, 2023, despite instructions to continue the medication. This lapse in medication administration led to elevated ionized calcium levels, as evidenced by lab results on August 21, 2023, and February 12, 2024, which were flagged as high and critically high, respectively. The resident missed multiple endocrinology appointments due to transportation issues, further delaying the necessary follow-up and management of their condition. The resident's ionized calcium level remained elevated until the medication was restarted on February 15, 2024, following an emergency room visit and a subsequent endocrinology appointment. The lab results on February 27, 2024, showed an improvement in the resident's calcium levels after the medication was resumed. Interviews with the Director of Nursing confirmed that the resident did not receive the Sensipar as instructed after the June 27, 2023, endocrinology appointment. The resident experienced a high ionized calcium level on August 21, 2023, missed several endocrinology appointments, and had a critically high calcium level on February 12, 2024, necessitating an emergency room visit. The medication was only restarted after the February 14, 2024, endocrinology appointment, leading to an improvement in the resident's condition.
Failure to Provide Emotional Support After Roommate's Death
Penalty
Summary
The facility failed to provide medically related social services to Resident 2, who experienced significant emotional distress after witnessing the death of her roommate, Resident CR1. Resident 2, who was non-ambulatory due to fractures and injuries from a fall, was left in the room with the deceased body of Resident CR1 from 3:58 AM until 8:20 AM when the funeral home arrived. During this time, no staff approached Resident 2 to offer emotional support or to ask if she wanted to leave the room. Resident 2 expressed that the experience was scary and uncomfortable, and there was no documentation in her clinical record regarding any emotional support provided or her feelings about the incident. Additionally, Resident 2 was moved to another room after the body was removed, but this move was not documented in her clinical record, and the Director of Nursing indicated the move was due to the arrival of a new admission needing a private room. The Director of Nursing confirmed that there was no procedure in place to follow up with roommates of deceased residents to offer emotional support or to ask if they wanted to remain in the room. The facility's failure to provide necessary social services and emotional support to Resident 2 after witnessing her roommate's death and remaining in the room with the deceased body for several hours constitutes a deficiency in care. This lack of support and communication highlights a significant gap in the facility's procedures for handling such sensitive situations.
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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