Kadima Rehabilitation & Nursing At New Castle
Inspection history, citations, penalties and survey trends for this long-term care facility in New Castle, Pennsylvania.
- Location
- 715 Harbor Street, New Castle, Pennsylvania 16101
- CMS Provider Number
- 395524
- Inspections on file
- 24
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Kadima Rehabilitation & Nursing At New Castle during CMS and state inspections, most recent first.
The facility failed to notify the Office of the State LTC Ombudsman when a resident with Type 2 DM with a foot ulcer, HIV, a history of self-harm, and PTSD was transferred to a hospital and later issued an eviction letter. Review of the record showed no documentation that the Ombudsman was informed of the transfer and discharge, and the NHA confirmed that the required notification was not made.
The facility did not consistently monitor or record refrigerator and freezer temperatures as required by policy, with numerous missed entries in both the main kitchen and basement logs. The Dietary Manager confirmed that daily temperature checks were not being completed as expected.
Multiple residents reported excessive delays in call bell response times, often waiting 30 minutes or more for assistance, due to staff being observed on personal cell phones or engaged in personal conversations during shifts. Resident council minutes and direct interviews confirmed that staff cell phone use was a persistent issue, leading to unmet care needs and resident frustration, despite facility policy prohibiting such behavior.
The facility did not post daily menus, failed to notify residents of menu changes or substitutions, and did not provide a nutritionally adequate menu for a resident with a gluten free allergy. Staff confirmed that residents were not informed when their chosen meals were unavailable, and a resident with dietary restrictions had limited food options due to insufficient gluten free items.
The facility did not meet the required minimum NA staffing ratios on the overnight shift for four specific dates. With a census of 58 to 59 residents, the facility required approximately 3.87 to 3.93 NAs but only had 3.00 to 3.63 NAs present. This deficiency was confirmed by the Assistant Director of Nursing.
The facility did not meet the required LPN staffing ratio on an overnight shift, with only 1.32 LPNs available for 58 residents, falling short of the 1.45 LPNs required. This deficiency was confirmed by the Assistant DON.
A resident with multiple health conditions, requiring assistance with bathing, was left unattended in a shower room by a PTA, resulting in a fall and a right shoulder fracture. Despite the care plan indicating the need for assistance, the resident was allowed to bathe unsupervised, leading to the incident. Staff interviews confirmed that leaving residents unattended in the shower is against facility practice.
A resident with complex medical conditions, including schizophrenia and diabetes, required assistance with bathing. The facility failed to implement the care plan, leaving the resident unattended in the shower, resulting in a fall and injury. Staff interviews confirmed the care plan was not followed, highlighting inconsistencies in care delivery.
Failure to Notify State LTC Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to send a copy of a discharge notice to the Office of the State LTC Ombudsman for one resident. The resident was admitted on 6/22/24 with diagnoses including Type 2 diabetes with a foot ulcer, HIV, a history of self-harm, and PTSD. Departmental notes showed that the resident was transferred to the hospital on an unspecified date and was given a letter of eviction on 10/22/25. Review of the clinical record revealed no evidence that the Office of the State LTC Ombudsman was notified of the resident’s transfer and discharge. In an interview on 1/8/25, the Nursing Home Administrator confirmed that the facility did not notify the Office of the State LTC Ombudsman of this resident’s transfer and discharge. This deficiency was cited under 28 Pa. Code 201.14(a) Responsibility of licensee and 28 Pa. Code 201.29(a) Resident rights.
Failure to Monitor and Record Food Storage Temperatures
Penalty
Summary
The facility failed to ensure that food was stored in accordance with food safety standards, as required by its own policy and professional guidelines. Review of the kitchen's refrigeration and freezer temperature logs revealed significant gaps in monitoring, with only 104 out of 216 required temperature recordings documented for the main kitchen's refrigerators and freezers over a specified period, leaving 112 instances unrecorded. Additionally, the basement refrigeration log showed no recorded temperatures for two freezers and one refrigerator over a nearly three-week period. During an interview, the Dietary Manager confirmed that the required daily monitoring of morning and evening temperatures was not being performed as outlined in facility policy.
Failure to Provide Sufficient Nursing Staff and Timely Care Due to Staff Cell Phone Use
Penalty
Summary
The facility failed to provide sufficient nursing staff and services to meet the needs of residents, as evidenced by multiple complaints and observations. Resident council minutes over a three-month period documented repeated concerns about staff being on their personal cell phones during work hours, particularly on day and afternoon shifts. Residents reported excessive call bell wait times, often 30 minutes or longer, with some residents waiting up to 60 minutes for assistance with activities of daily living such as toileting. These delays were attributed to staff being observed using their phones or engaging in personal conversations rather than attending to resident needs. Interviews with alert and oriented residents confirmed that staff cell phone use was a persistent issue, leading to delayed responses to call bells and causing resident frustration. Observations during the survey period corroborated these reports, with staff seen sitting at nurses' stations and in hallways on their personal phones. Facility policy prohibits personal cell phone use during work time, and grievances had previously been filed regarding this issue, with education provided by the DON. Despite these measures, the problem persisted, and administration acknowledged ongoing resident complaints about staff cell phone use.
Failure to Provide Posted Menus, Notify Residents of Substitutions, and Meet Special Dietary Needs
Penalty
Summary
The facility failed to provide daily menus, update menu changes, and notify residents of changes to the menu, as well as failed to provide a nutritionally adequate menu for a resident with a gluten free allergy. Facility policies required that menus be posted in all dining rooms and resident units, that menus be followed, and that substitutions be of equal nutritive value and approved by the dietitian. However, observations and interviews revealed that menus were not posted, and residents were not informed of substitutions or menu changes. Residents reported that alternatives were not always available, and that they were not notified when their chosen food items were unavailable, only learning of substitutions when meals were delivered. One resident with a gluten free allergy was found to have limited food choices due to insufficient gluten free food items available at the facility. The dietary manager confirmed that only gluten free pasta and hamburger buns were purchased, with no bread, cereal, crackers, or other gluten free items available. This resulted in the resident not receiving a nutritionally adequate menu during their stay, as the menu could not be followed in its entirety for this resident. Staff interviews confirmed that the daily menu and alternate menu were not posted for residents and family members to view, and that residents were not notified in a timely manner of food substitutions. The activity assistant collected residents' meal choices each morning but did not inform residents if their choices were unavailable, leading to residents receiving unexpected substitutions at mealtimes. The nursing home administrator acknowledged that menus should be posted and followed, and that residents should be notified of substitutions, confirming the deficiencies identified.
Overnight Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing ratios on the overnight shift for four specific dates. The regulation mandates a minimum of one NA per 15 residents overnight, but the facility did not comply on 10/21/24, 10/25/24, 11/18/24, and 11/19/24. On these dates, the facility had a census of 58 to 59 residents, requiring approximately 3.87 to 3.93 NAs, but only 3.00 to 3.63 NAs were present. This deficiency was confirmed during an interview with the Assistant Director of Nursing, who acknowledged the shortfall in staffing on the specified dates.
Plan Of Correction
1. The facility is unable to correct the nurse aide staffing ratios that were not met during the overnight shifts on 10/21/24, 10/25/24, 11/18/24 and 11/19/24 due to unplanned absences. However, we will educate all nurse aides on the importance of staffing levels and their responsibilities to prevent absences. 2. The facility will work to ensure that nurse aide ratios are met every shift. 3. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing and HR Director/Scheduler on regulation P5520 to ensure nurse aide ratios are met every shift. Daily shift staffing ratios will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible for calling off duty personnel or for calling extra support staff to assist. 4. The Nursing Home Administrator will audit staffing daily for four weeks and then monthly for two months to ensure nurse aide ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations and frequency of audits. 5. The facility will conduct an Employee Retention survey from 12/27/2024 through 1/6/2025 to evaluate staffing concerns and reasons for call-offs. This will be done to prevent further call-off concerns meeting daily staffing ratios. 6. A DON/designee will ensure staffing levels meet direct care requirements and report to DON or Nursing Home Administrator every day with needs or call-offs.
LPN Staffing Deficiency on Overnight Shift
Penalty
Summary
The facility failed to meet the regulatory requirement of having a minimum of one Licensed Practical Nurse (LPN) per 40 residents on the overnight shift. This deficiency was identified during a review of nursing staffing documents and confirmed through staff interviews. Specifically, on the night of October 25, 2024, the facility had a census of 58 residents but only 1.32 LPNs were on duty, whereas 1.45 LPNs were required to meet the minimum staffing ratio. The Assistant Director of Nursing confirmed the shortfall in staffing during an interview conducted on December 2, 2024.
Plan Of Correction
Plan of Correction: 1. The facility cannot correct that LPN staffing ratios that were not met during the overnight shift on one of 21 days (10/25/24). However, we will educate staff on the importance of staffing levels and their responsibilities to prevent absences. 2. The facility will ensure that LPN staffing ratios are met every shift. 3. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5530 and ensuring LPN staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at the daily staffing meeting. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. 4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for two months to ensure LPN staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Employee Retention survey will be taken from 12/27/24 through 01/06/2025 to evaluate staffing concerns and reasons for call-offs. To prevent further call off concerns in order to achieve needed staff ratios daily. 6. ADON and DON will ensure staffing levels meet direct care requirements and report to Director every day with needs or call-offs.
Resident Left Unattended in Shower Room Resulting in Fall and Injury
Penalty
Summary
The facility failed to provide proper assistance during bathing, resulting in a fall and a fracture for a resident. The resident, who had multiple diagnoses including schizophrenia, major depressive disorder, and vascular dementia, required partial/moderate assistance with bathing and transfers according to their care plan. Despite this, the resident was left unattended in the tub room by a Physical Therapist Assistant (PTA), leading to a fall and a comminuted fracture of the right shoulder. The incident occurred when the PTA allowed the resident into the shower room unsupervised, believing the resident demonstrated good safety with setup. However, the resident's care plan indicated a need for assistance during bathing. The resident was later found on the floor by a Nurse Aide, who was unaware that the resident had been left unattended in the tub room. The resident was assisted into a chair using a Hoyer lift after the fall. Interviews with various staff members, including Nurse Aides, Registered Nurses, and the Director of Nursing, confirmed that it was not the facility's practice to leave residents unattended in the shower or tub room. Staff were expected to monitor residents closely for safety during bathing. The investigation revealed that the resident's care plan required assistance, and the failure to provide this led to the resident's fall and subsequent injury.
Failure to Implement ADL Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident, identified as Resident R41, who required assistance with activities of daily living (ADL), specifically bathing and showering. The resident's clinical record indicated a need for partial/moderate assistance with self-care tasks, including showering and tub transfers. Despite this, an incident occurred where the resident was left unattended in the tub/shower area, resulting in a fall and injury. This incident was inconsistent with the care plan, which required the assistance of one staff member during bathing/showering. The resident's medical history included schizophrenia, major depressive disorder, a history of seizures, vascular dementia, transient ischemic attacks, cerebral infarction, altered mental status, gait and mobility abnormalities, and type one diabetes mellitus. The inconsistency in the implementation of the care plan was confirmed during an interview with the Director of Nursing and the Nursing Home Administrator. Staff interviews revealed that the care plan for ADLs should be reviewed before showering residents to ensure proper transfer and assistance levels for resident safety.
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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