John J Kane Regional Center-sc
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 300 Kane Boulevard, Pittsburgh, Pennsylvania 15243
- CMS Provider Number
- 395617
- Inspections on file
- 25
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at John J Kane Regional Center-sc during CMS and state inspections, most recent first.
A resident with morbid obesity, heart failure, muscle weakness, and a documented need for substantial/maximal assistance and 2-person assist for bed mobility was being provided incontinence care by a single CNA, who partially rolled the resident and then left the bedside to obtain supplies, leaving the resident slightly turned on her side. While the CNA was away, the resident fell from the bed to the floor. The resident was found alert and oriented but later complained of head, neck, shoulder, and back pain, and had bleeding through bandages on a chronic wound. Facility records and the CNA’s statement confirmed that the resident’s care plan and assignment sheet requiring 2-person assist for bed mobility were not followed, and the facility determined this failure constituted neglect that resulted in the resident’s injury.
A resident with morbid obesity, heart failure, muscle weakness, and a documented need for substantial/maximal assistance with rolling had a care plan and assignment sheet specifying two-person assist for transfers and bed mobility. During incontinence care, a CNA partially turned the resident in bed and then left the bedside to obtain supplies, leaving the resident unattended in a slightly turned position. While the CNA was away, the resident fell from the bed to the floor, was found alert and oriented with bleeding from a pre-existing leg wound, and later complained of head pain. Facility investigation concluded that the CNA failed to follow the resident’s plan of care requiring two-person assist for bed mobility, leading to the fall.
A resident with Alzheimer's disease and a seizure disorder, known for wandering behaviors and identified as an elopement risk, was able to leave a secured unit during a planned power outage when maglocks on stairwell doors became disengaged. The resident accessed another floor before being safely returned by staff, with no injury or distress noted.
Two residents suffered injuries due to neglect in an LTC facility. One resident, with limited mobility, fell and fractured a femur when a nurse aide failed to follow the policy of rolling residents towards staff. Another resident, requiring two-person assistance, sustained a head laceration when a single aide attempted to reposition him, causing him to hit his head. Staff interviews confirmed the facility's failure to adhere to care policies, resulting in harm.
The facility failed to prevent falls and injuries for two residents. One resident with hemiplegia slid off the bed and fractured a femur when a nurse aide turned away during care, contrary to policy. Another resident with quadriplegia sustained a head laceration when a nurse aide attempted to adjust a sheet without required assistance. Staff interviews confirmed non-adherence to care policies, leading to these injuries.
A resident with complex medical needs, including quadriplegia and dementia, suffered a head injury when a nursing assistant attempted to reposition them without the required assistance. Despite documented care needs and staff awareness, the facility failed to investigate the incident as potential abuse or neglect, violating care policies.
The facility did not provide required training on abuse, neglect, and exploitation prevention for two staff members, a Unit Clerk and a Nurse Aide. This deficiency was confirmed by the Assistant DON and noted in the facility's training records.
The facility failed to provide mandatory QAPI training for two staff members, NA Employee E1 and NA Employee E2, as required. Employee E1, hired in 2014, and Employee E2, hired in 2002, did not receive the necessary in-service education within the specified time frames. This deficiency was confirmed by the Assistant Director of Nursing.
Failure to Follow Bed Mobility Care Plan Resulting in Resident Fall from Bed
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not following the resident’s care plan for bed mobility and by leaving the resident unattended in an unsafe position. The facility’s abuse/neglect policy defined neglect as the failure to provide goods and services necessary to avoid or that may result in physical harm, pain, mental anguish, or emotional distress. The resident involved had diagnoses including morbid obesity, heart failure, and muscle weakness, and the MDS indicated the resident required substantial/maximal assistance to roll left and right. The resident’s care plan and unit assignment sheet specified that the resident required assistance of two staff for transfers and bed mobility due to decreased mobility and generalized weakness and being at risk for injury related to falls. On the day of the incident, the resident experienced a fall from bed during care. A progress note documented that the ADON was called to the unit regarding a fall from bed and found the resident on the floor lying on her back, alert and oriented and able to answer questions. Another progress note recorded that the resident complained of pain in the head area, 911 was called, and the resident remained on the floor until paramedics arrived. The emergency department physician later documented that the resident presented after a fall out of bed with head injury and was complaining of pain in the head, neck, shoulder, and back, and had bleeding through the bandages on a chronic left wound. Facility documentation and staff statements showed that a nurse aide provided incontinence care alone, despite the care plan and assignment sheet indicating a two-person assist for bed mobility. The aide reported sliding and partially rolling the resident, then leaving the resident slightly turned on her side to go to the bathroom to obtain a washcloth and towel. While the aide was in the bathroom, the resident fell from the bed. The facility’s investigation concluded that the CNA failed to follow the resident’s plan of care requiring two-person assistance for bed mobility and walked away from the resident while she was slightly turned, which resulted in the resident falling out of bed and sustaining injury, including bleeding from a prior wound and complaints of neck pain.
Failure to Follow Two-Assist Bed Mobility Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to implement required fall-prevention interventions and provide adequate supervision during bed mobility for one resident. The resident had diagnoses including morbid obesity, heart failure, and muscle weakness, and the MDS documented a need for substantial/maximal assistance to roll left and right. The resident’s care plan, initiated earlier in the year, identified the resident as at risk for injury related to falls due to decreased mobility and generalized weakness and specified that two-person assistance was required for transfers and bed mobility. On the day of the incident, the resident was being provided incontinence care by a CNA. The CNA reported sliding the resident toward herself and then rolling the resident slightly toward the window, leaving the resident slightly turned onto her right side. At that point, the CNA left the bedside to go to the bathroom to obtain a washcloth, towel, and soap, leaving the resident unattended in a partially turned position. While the CNA was in the bathroom, the resident fell from the bed to the floor. Progress notes documented that the resident was found on the floor lying on her back, alert and oriented, with bleeding noted from a pre-existing left leg wound and later complaining of pain in the head area. The facility’s investigation determined that the CNA failed to follow the resident’s plan of care requiring two-person assistance for bed mobility and walked away from the resident while she was slightly turned, which resulted in the resident falling out of bed. The unit assignment sheet in use that day also indicated that the resident required two-person assistance for bed mobility, and in interview the CNA acknowledged receiving the assignment sheet but not recognizing the two-assist requirement for bed mobility, despite knowing the resident required two-person assistance for transfers.
Failure to Prevent Elopement During Power Outage
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for a resident with Alzheimer's disease and a seizure disorder who had a documented history of wandering behaviors. The resident was identified as being at risk for elopement through an evaluation and was ordered a security bracelet to alert staff when approaching monitored doors. The care plan specifically addressed the risk for elopement due to the resident's diagnosis and history. Progress notes documented repeated incidents of the resident testing door handles, keypads, and attempting to open windows, as well as sprinting toward open doors when noticed. During a scheduled facility power outage, the magnetic locks on the stairwell doors became disengaged, allowing the resident to leave the locked unit and access another floor via the stairwell. Security staff observed the resident on CCTV, and the nursing supervisor was notified and returned the resident to the unit. The resident did not sustain any injury or show signs of emotional distress. Staff interviews confirmed that the facility did not provide adequate supervision to prevent the elopement incident.
Neglect Leads to Injuries in Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from neglect, resulting in actual harm to two residents. Resident R91, who had right-sided hemiplegia and hemiparesis due to a stroke, was dependent on staff for bed mobility. During incontinence care, Nurse Aide Employee E9 turned away from Resident R91, who then slid off the bed and sustained a fractured left distal femur. The facility's policy required residents to be rolled towards staff, but Resident R91 was rolled away, contrary to the policy. Interviews confirmed that the bed was raised, and Resident R91 was unable to stop the slide, leading to the fall. Another incident involved Resident R3, who had anoxic brain injury, quadriplegia, and other conditions, requiring dependent care with two staff members for bed mobility. Despite this, NA Employee E8 attempted to readjust a sheet around Resident R3's waist without additional assistance, resulting in Resident R3 hitting his head on an overbed table and sustaining a laceration. The facility's policy and care sheets indicated the need for two staff members, but this was not followed, leading to the injury. Interviews with staff and the Director of Nursing confirmed the facility's failure to adhere to its policies, resulting in neglect and harm to the residents. The incidents highlighted the lack of compliance with the facility's procedures for resident care, specifically regarding the need for adequate staff assistance during care activities to prevent harm.
Failure to Prevent Falls and Injuries in Residents
Penalty
Summary
The facility failed to provide appropriate assistance to prevent falls and injuries, resulting in actual harm to two residents. Resident R91, who had right-sided hemiplegia and hemiparesis due to a stroke, was dependent on staff for bed mobility. During incontinence care, Nurse Aide Employee E9 turned away from Resident R91, who then slid off the bed and sustained a fractured left distal femur. The facility's policy required residents to be rolled towards staff, but Employee E9 rolled Resident R91 away, contrary to the policy. Resident R3, who had anoxic brain injury, quadriplegia, and other conditions, required dependent care with rolling and assistance from two staff members. However, NA Employee E8 attempted to readjust a sheet around Resident R3's waist without additional assistance, resulting in Resident R3 hitting his head on the overbed table and sustaining a head laceration. The facility's policy and care sheets indicated that Resident R3 required assistance from two staff members due to his condition and behaviors. Interviews with staff and the Director of Nursing confirmed that the facility failed to adhere to its policies for providing care, which led to the injuries of Residents R91 and R3. The staff were aware of the care requirements and the availability of additional assistance, yet the necessary precautions were not taken, resulting in harm to the residents.
Failure to Investigate Potential Abuse and Neglect
Penalty
Summary
The facility failed to identify and investigate potential abuse and neglect for a resident, referred to as Resident R3, who was admitted with multiple diagnoses including anoxic brain injury, quadriplegia, schizoaffective disorder, contractures, anxiety, blindness, and dementia. The Minimum Data Set indicated that Resident R3 required dependent care with rolling, necessitating assistance from two staff members. Despite this, an incident occurred where a nursing assistant, NA Employee E8, attempted to readjust a sheet around Resident R3's waist without additional assistance, resulting in the resident's head hitting an overbed table and causing a laceration. Interviews with staff members, including NA Employee E5, E6, E7, and the Director of Nursing, confirmed that Resident R3 was known to be rigid and combative, requiring two staff members for care. The care needs were documented on care sheets and communicated during shift reports. However, the facility did not properly identify or investigate the incident as potential abuse or neglect, as confirmed by the Director of Nursing. This oversight was a violation of the facility's policy and state regulations regarding resident care and management.
Failure to Provide Abuse Prevention Training
Penalty
Summary
The facility failed to provide mandatory training on abuse, neglect, and exploitation prevention for two staff members, identified as Employee E3 and Employee E4. Employee E3, a Unit Clerk hired on 4/16/07, did not receive the required in-service education on these topics between 4/16/23 and 4/16/24. Similarly, Employee E4, a Nurse Aide hired on 5/19/14, lacked documented training on abuse, neglect, and exploitation prevention between 5/19/23 and 5/19/24. This deficiency was confirmed during an interview with the Assistant Director of Nursing on 9/26/24. The facility's failure to provide this essential training was noted in the review of facility documents and training records, which were supposed to include these topics as per the Facility Assessment reviewed on 7/12/24.
Failure to Provide QAPI Training for Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) Program for two out of ten staff members, specifically Nurse Aide (NA) Employee E1 and NA Employee E2. Employee E1, hired on May 19, 2014, did not receive QAPI Program in-service education between May 19, 2023, and May 19, 2024. Similarly, Employee E2, hired on July 1, 2002, lacked documented QAPI Program training between July 1, 2023, and July 1, 2024. This deficiency was confirmed during an interview with the Assistant Director of Nursing on September 26, 2024, who acknowledged the facility's failure to provide the required training for these staff members.
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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