Kadima Rehabilitation & Nursing At Washington
Inspection history, citations, penalties and survey trends for this long-term care facility in Washington, Pennsylvania.
- Location
- 1198 W. Wylie Avenue, Washington, Pennsylvania 15301
- CMS Provider Number
- 395679
- Inspections on file
- 32
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Kadima Rehabilitation & Nursing At Washington during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow physician orders and care plans for compression therapy and edema management for multiple residents with conditions such as CHF, lymphedema, CAD, atrial fibrillation, Alzheimer’s disease, and diabetes. One resident repeatedly assessed by a wound NP as needing AeroWrap compression had no corresponding physician order and no compression device in use despite visible leg edema. Several other residents had orders and care plan interventions for TED hose or ace wraps to be applied daily, yet TARs showed missing or incorrectly scheduled treatments, and observations on days when staff documented application revealed that residents were not wearing the ordered compression devices. One resident reported staff did not consistently apply or remove ace wraps, and another was observed with swollen legs while not wearing the ordered stockings, despite staff acknowledging the swelling.
The facility failed to provide sufficient nursing staff to meet residents’ daily needs and to respond promptly to call lights, resulting in multiple care concerns. A resident reported that staffing levels were low, sometimes with only four nurse aides for the entire building, and was observed with unmet grooming needs. Another resident stated they had urinated on themselves while waiting for staff to answer a call light, and others reported long waits for assistance, especially at night. A resident dependent on staff for ace wrap application and removal was observed with blood-soiled wraps and reported that staff did not consistently assist with this care or respond to call lights. Resident Council minutes documented ongoing concerns about lack of ice water, slow call light response, difficulty identifying assigned aides, and negative interactions with nursing staff. The administrator acknowledged that nursing staffing was insufficient to meet residents’ needs.
A resident with CHF, history of DVT, and chronic lymphedema was care planned for monitoring of SOB, chest pain, edema, and elevated B/P, and multiple NP and physician notes documented that the resident, on diuretics, needed outpatient follow-up with a lymphedema clinic. Review of the clinical record showed no order or attempt to schedule this follow-up appointment. In interviews, an RN and the Nursing Home Administrator confirmed that the resident did not receive the needed lymphedema clinic appointment, resulting in a deficiency under 28 Pa. Code 211.16(a) for failure to provide necessary medically-related social services.
The facility did not provide the required number of nurse aide (NA) hours on several day shifts, with actual staffing falling short of the mandated minimum based on the resident census. This was confirmed by the Nursing Home Administrator, who acknowledged the shortfall in NA coverage during the reviewed period.
The facility did not provide the required minimum of 3.2 hours of direct nursing care per resident per day over an eight-day period, as confirmed by staffing records and the Nursing Home Administrator.
The facility did not include all required elements in its grievance policy and failed to document, resolve, or provide responses to residents or their responsible parties for multiple grievances. Issues included missing personal items, concerns about cleanliness, staff conduct, and missed care, with incomplete or missing documentation and lack of communication regarding grievance outcomes.
The facility did not follow required procedures to report multiple residents' allegations of abuse and neglect, including verbal abuse by a physician, missed showers, lack of staff assistance, and rough handling by a nurse aide. Although these concerns were documented and known to facility leadership, they were not reported to the appropriate authorities as mandated by policy and state law.
Multiple residents did not receive timely assistance with ADLs, including missed showers, delayed call light responses, and lack of basic care such as fresh water and snacks. Facility records and resident council minutes confirmed ongoing issues with staff not providing scheduled care or completing rounds, and the DON acknowledged these failures.
The facility did not provide required transfer notices to the Office of the State Long-Term Care Ombudsman for the entire year of 2024. This was confirmed by the Nursing Home Administrator and identified through a review of the facility's policy and federal regulations, which require such notifications before transferring or discharging residents.
The facility failed to meet professional standards by not having a Registered Dietitian (RD) physically present to fulfill in-person duties such as participating in interdisciplinary meetings and monitoring Food Service operations. The RD worked remotely, relying on email communication with the Dietary Manager and nursing staff, which did not align with the job description requirements. The Nursing Home Administrator confirmed the deficiency, as the facility had been unable to fill the on-site RD position.
The facility failed to maintain a comprehensive water management program for Legionella, lacking essential documentation and control measures. The absence of logs for chlorine concentration and water temperature testing, along with the recent termination of the Maintenance Director, contributed to this deficiency. The Nursing Home Administrator confirmed the facility's non-compliance with infection control guidelines.
Kadima Rehabilitation and Nursing at Washington failed to provide residents and visitors with the means to file grievances anonymously. The only grievance box was located in front of the NHA's office, compromising anonymity, and no grievance forms or boxes were available on the nursing units. Interviews confirmed the lack of anonymous grievance options, violating the facility's grievance policy.
The facility failed to assess, document, and notify physicians of abnormal blood glucose levels for five residents with diabetes. Despite high or low CBG readings, necessary follow-up actions, including rechecking levels and notifying physicians, were not documented. Interviews with staff revealed inconsistencies in handling abnormal glucose levels, and the Director of Nursing confirmed these deficiencies.
The facility failed to assess three residents for safe smoking practices as required by their policy. Despite having medical conditions that necessitate regular reviews, these residents were not reassessed for smoking safety. The DON confirmed that no further assessments were completed, violating the facility's policy and regulatory requirements.
The facility did not conduct required criminal background checks before hiring a Dietary Aide and an RN, as mandated by their policy. A Human Resources employee mistakenly believed there was a 30-day grace period post-hire for these checks, leading to potential exposure of residents to unvetted staff.
A resident with diabetes received an incorrect dose of Lantus insulin because an LPN failed to prime the insulin pen before administration, as required by the manufacturer's guidelines. The facility's Director of Nursing confirmed the error, which deviated from the facility's medication administration policy.
The facility failed to meet the required nurse aide staffing levels, with shortages during the day, evening, and night shifts over a 21-day period. The Director of Nursing confirmed the facility's inability to provide the mandated nurse aide coverage, with no additional staff available to compensate for these deficiencies.
The facility failed to meet the required LPN staffing levels across various shifts over a 21-day period. During the day shift, the facility was short of the required LPNs on 13 days, with the census necessitating between 2.48 to 2.60 LPNs, but only 2.00 to 2.13 LPNs were provided. The evening shift was understaffed on 7 days, requiring 2.07 to 2.17 LPNs, but only 1.56 to 2.00 LPNs were available. The night shift also experienced shortages on 13 days, with the census requiring 1.55 to 1.60 LPNs, but only 0.25 to 1.25 LPNs were available.
The facility failed to provide the required number of LPNs per residents during various shifts and did not meet the mandated 3.2 hours of direct resident care per resident in a 24-hour period on multiple occasions. The DON confirmed these deficiencies, with PPD hours falling below the required threshold on several dates.
A resident with severe cognitive impairment and a history of exit-seeking behavior eloped from the facility unsupervised. The resident was found outside by staff retrieving personal food deliveries. Despite the door requiring a password, the resident claimed to have pressed buttons to exit. The facility failed to implement effective monitoring as per their policies, leading to this deficiency.
A resident with severe cognitive impairment and a history of exit-seeking behaviors managed to leave the facility, highlighting a deficiency in the facility's training program. The training did not adequately address the specific methods of elopement, despite the resident being care planned as an elopement risk.
The facility failed to maintain the confidentiality of residents' medical information by storing approximately 75 boxes of loose paper with resident information in an unsecured storage shed. This was against the facility's policy requiring secure, fire-protected, and waterproof storage for medical records. The Maintenance Director confirmed the storage was due to space issues, and the Nursing Home Administrator acknowledged the breach of confidentiality.
The facility failed to maintain a safe, clean, and homelike environment in the North Wing Nursing Unit and the main dining room. Observations revealed issues such as a hole in the floor, chipped paint, a cracked ceiling, a broken wall plug plate, unfinished drywall, and a soiled dining room floor. These deficiencies were confirmed by the Nursing Home Administrator and the Maintenance Director.
A resident with a history of diabetes and other medical conditions fell from bed due to neglect when a nurse aide failed to follow physician's orders requiring two staff for bed mobility. The resident expressed discomfort with the procedure, but the aide proceeded, resulting in the fall.
A resident with multiple health issues required two staff for bed mobility, but a nurse aide attempted care alone, leading to the resident's fall. Staff inconsistencies in accessing care information contributed to the incident, highlighting a failure in supervision and adherence to physician orders.
Failure to Follow Physician Orders for Compression Therapy and Edema Management
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders and residents’ care plans, specifically related to compression therapy for edema and lymphedema management. One resident with heart failure, history of DVT, and lymphedema had repeated wound NP notes over several weeks stating the need for AeroWrap inelastic compression for all-day wear at 30–50 mmHg for lymphedema management, and the care plan was updated to reflect lymphedema. However, there was no corresponding physician order for AeroWraps or any compression device in the clinical record, and the resident confirmed she did not have compression stockings; observation showed edematous lower legs with sock indentations. Another resident with high blood pressure, heart failure, and diabetes had a care plan intervention for bilateral knee-high TED hose and a physician order to apply ace wraps to both lower extremities. The March treatment administration record (TAR) showed that an LPN documented application of ace wraps on a specific date, but observation that same day revealed the resident did not have the ace wraps on. A third resident with heart failure, atrial fibrillation, and lymphedema had a care plan and physician order for ace wraps to both lower extremities every morning from the base of the toes to one inch below the knee. The March TAR lacked documentation of ace wrap application on multiple dates, and the order was incorrectly scheduled for nighttime instead of morning. During observation, this resident had ace wraps in place with a large amount of blood on the wraps and reported that staff did not always apply them and did not assist with removal despite call light use. A fourth resident with coronary artery disease, atrial fibrillation, and a need for assistance with personal care had a care plan and physician order for bilateral below-the-knee TED hose to be applied in the morning and removed at night. The March TAR indicated an LPN had applied the wraps on a specific date, but observation that afternoon showed the resident was not wearing compression stockings. A fifth resident with Alzheimer’s disease, diabetes, and a need for assistance with personal care had a care plan and physician order for bilateral lower extremity TED hose to be applied every morning and removed at bedtime for edema. The March TAR lacked documentation of application on multiple consecutive days, and although the TAR showed application on a later date, observation that afternoon showed the resident was not wearing compression stockings; when the resident asked an RN how her legs looked, the RN responded that they were swollen as usual. The Nursing Home Administrator confirmed that the facility failed to follow physician orders for five of seven residents reviewed.
Insufficient Nursing Staff and Delayed Call Light Response Affect Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs and to respond to call lights in a timely manner, as required by facility policy. The Nursing Department Staff policy stated that sufficient personnel would be provided on a 24-hour basis to deliver nursing care in accordance with resident care plans, and the Call Light Response policy required staff to respond to call lights and resident requests in a timely manner. Multiple residents reported inadequate staffing and delayed care. One resident stated there was not sufficient staff and that sometimes only four nurse aides were available for the entire building; this resident was observed with facial hair on her chin, suggesting grooming needs were not being addressed. Another resident reported that staffing adequacy depended on which aides were on shift, and confirmed having urinated on themselves while waiting for staff to respond to the call light. Additional residents described prolonged call light response times, particularly at night, and one resident stated that staffing “could be more.” One resident who required ace wraps reported that staff did not always apply them and did not assist with removing them; during observation, this resident was noted to have ace wraps in place with a large amount of blood present on the wraps, and confirmed being unable to manage them independently and that call lights sometimes went unanswered. Resident Council minutes from two consecutive months documented concerns about ice water not being provided, call light response times, difficulty knowing which aide was assigned, and perceptions that nursing staff were not very nice. In an interview, the Nursing Home Administrator confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services necessary to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the affected residents.
Failure to Arrange Ordered Lymphedema Clinic Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to provide medically-related social services by not arranging a needed follow-up appointment with a lymphedema clinic for one resident. The resident was admitted with diagnoses including heart failure, a history of DVT, and lymphedema. An MDS dated 2/26/26 documented these conditions, and the care plan for high blood pressure and CHF directed staff to observe for signs and symptoms such as SOB, chest pain, edema, and elevated blood pressure. The care plan for actual/potential risk for skin integrity impairment was updated on 3/6/26 to include lymphedema. Multiple provider notes documented the need for a lymphedema clinic follow-up. A nurse practitioner’s note dated 2/24/26 listed lymphedema and specified that the resident, who was on diuretics, needed follow-up with a lymphedema clinic. A physician’s note dated 2/25/26 and another nurse practitioner’s note dated 3/3/26 both reiterated that the resident had chronic lymphedema, was on diuretics, and needed outpatient follow-up with a lymphedema clinic. Review of the clinical record showed no order for this appointment and no attempt to schedule it. In interviews, an RN confirmed the resident was not provided a follow-up appointment, and the Nursing Home Administrator confirmed the facility failed to schedule the follow-up, constituting noncompliance with 28 Pa. Code 211.16(a) regarding social services.
Failure to Meet Minimum Nurse Aide Staffing Requirements on Day Shift
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing levels on the daylight shift for six out of eight days during the period reviewed. Specifically, staffing documents showed that on multiple days, the actual NA hours provided were significantly below the hours required based on the resident census. For example, on days when the census ranged from 66 to 69 residents, the facility provided between 22.5 and 45 NA hours, while the required hours ranged from 49.5 to 51.75. This deficiency was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the facility did not provide the mandated number of NAs on the specified shifts.
Plan Of Correction
1. The facility cannot correct the ratio of 1 NA to 10 residents on the daylight shift on six of eight days (6/23/25 through 6/25/25 and 6/28/25 through 6/30/25) as required. 2. The facility will ensure that nurse aide 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 P5520 and the correct ratios. 4. In order to help to retain/attain sufficient staff for the facility, NHA will continue to focus on hiring qualified candidates as well as utilizing retention strategies. Facility will continue to utilize Indeed postings are being utilized and facility department heads are assisting with recruiting as needed per department. 5. The Nursing Home Administrator/designee will audit staffing daily for four weeks to ensure nurse aide staffing ratios are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
Failure to Meet Minimum Direct Nursing Care Hours
Penalty
Summary
The facility failed to meet the state-mandated minimum requirement of 3.2 hours of direct nursing care per resident per day over an eight-day period. Review of staffing documents and nursing schedules revealed that, from 6/23/25 through 6/30/25, the provided per patient daily (PPD) hours of direct care consistently fell below the required threshold, with daily PPDs ranging from 2.61 to 3.18. This deficiency was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the facility did not provide the minimum required direct care hours on the specified dates. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency were provided in the report.
Plan Of Correction
The facility cannot correct that the minimum number of general nursing hours to each resident in a 24-hour period were not met on eight of eight days (6/23/25 through 6/30/25). 2. The facility will ensure that general nursing hours 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 P5640 and ensuring general nursing hours to each resident are met each shift. 4. In order to ensure staffing is met, the facility will focus on recruitment and retention and continue to utilize Indeed. 5. The Nursing Home Administrator/designee will audit staffing daily for four weeks. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
Failure to Document, Resolve, and Respond to Resident Grievances
Penalty
Summary
The facility failed to ensure that its grievance policy included all required elements and did not properly document, resolve, or provide responses to residents or their responsible parties for grievances. The policy lacked provisions for anonymous grievance filing, identification of a grievance official, the right to a written decision, immediate action to prevent further violations during investigations, mandatory reporting of certain violations, detailed written grievance decisions, appropriate corrective actions, and maintenance of grievance records for at least three years. These omissions were confirmed through review of the facility's grievance policy and interviews with facility leadership. Multiple concern forms reviewed for thirteen residents revealed that for eleven residents, key sections such as immediate actions, summary of findings, and corrective actions were left blank or incomplete. Questions regarding whether the concern was confirmed, if a written decision was requested, and whether the resident or responsible party was notified of the resolution were frequently unanswered. Signature lines for department heads and the NHA were often unsigned, indicating a lack of accountability and follow-through in the grievance process. Specific grievances included missing personal items such as clothing and money, concerns about room cleanliness, staff behavior, missed showers, and rough handling by staff. In several cases, documentation failed to show that the concerns were investigated or resolved, and there was no evidence that residents or their representatives were informed of outcomes. Interviews with facility leadership confirmed these deficiencies in both policy and practice.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to implement its policies and procedures for reporting allegations of abuse and neglect for five of twelve residents. According to the facility's own policy and state law, all suspected abuse or neglect must be reported to the appropriate authorities, including the Department of Health and the Area Agency on Aging. However, review of clinical records, concern forms, and interviews revealed that multiple allegations made by residents were not reported as required. One resident, with a history of diabetes, coronary artery disease, and fibromyalgia, reported verbal abuse by the Medical Director and stated she had informed multiple staff members. Despite this, there was no grievance entered on her behalf, and the allegation was not reported to the state agency. Other residents, all with BIMS scores indicating they were cognitively intact, reported issues such as missed showers, lack of assistance from staff, and rough handling by a nurse aide. These concerns were documented in facility records but were not reported to the appropriate authorities as allegations of neglect or abuse. Interviews with facility leadership, including the Nursing Home Administrator and Director of Nursing, confirmed that the facility was aware of these allegations but failed to follow through with mandated reporting procedures. The review of submitted reports to the state agency showed that none of these incidents were included, indicating a systemic failure to comply with both facility policy and state regulations regarding the timely reporting of suspected abuse and neglect.
Failure to Provide Timely ADL Assistance and Basic Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for eight out of sixteen residents, as evidenced by multiple resident interviews, review of facility documents, and grievances. Residents reported long call light response times, lack of assistance with personal care needs such as showers, and insufficient provision of basic necessities like fresh water and snacks. Several residents specifically mentioned that staff were often short-staffed and unable to meet their needs in a timely manner. Facility records showed missed or undocumented showers on scheduled dates for multiple residents, and grievances confirmed that some residents were not assisted as required, including one resident not receiving help from the overnight nurse aide until early morning hours. Resident Council minutes from three consecutive months further documented ongoing concerns, including lack of snacks, failure to empty catheter bags, and staff not completing rounds or providing care as expected. The Director of Nursing confirmed the failure to provide necessary ADL assistance for the affected residents. The facility's own policy required care to be provided as needed 24 hours a day to help residents attain and maintain the highest level of functioning, but this standard was not met for the residents identified in the report.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to comply with federal regulations regarding the notification of the Office of the State Long-Term Care Ombudsman before transferring or discharging residents. Specifically, the facility did not provide transfer notices to the Ombudsman for the entire year of 2024, as confirmed by the Nursing Home Administrator during an interview. This deficiency was identified through a review of the facility's policy on 'Transfer and Discharge' and the relevant federal regulations, which mandate that a copy of the transfer or discharge notice must be sent to a representative of the Ombudsman. The facility's policy indicated that no resident would be discharged without timely notification to the resident, responsible party, or authorized representative. However, the facility did not adhere to the requirement of notifying the Ombudsman, which is a critical step in the transfer or discharge process. This oversight was consistent across all months from January to December 2024, indicating a systemic issue in the facility's compliance with the notification requirements outlined in §483.15(c)(3).
Plan Of Correction
1. The facility will provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division. The facility cannot retroactively address the concern identified during the annual survey. 2. The facility will send the discharge/transfer list to the state Ombudsman monthly. 3. The Nursing Home Administrator or Designee will re-educate the Director of Social Services on federal tag 0623. 4. The Nursing Home Administrator or Designee will complete an audit monthly for three months to validate the transfer/discharge list is completed and sent to the state Ombudsman monthly. 5. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
Deficiency in Registered Dietitian's On-Site Participation
Penalty
Summary
The facility failed to meet professional standards of quality as required by §483.21(b)(3) Comprehensive Care Plans. The deficiency was identified through a review of facility policies, job descriptions, clinical records, and staff interviews. It was determined that the facility did not adhere to acceptable standards of practice concerning the participation of the Registered Dietitian (RD) in interdisciplinary meetings, monitoring of Food Service operations, conducting resident interviews, and participating in the Quality Assurance and Performance Improvement (QAPI) program. The RD, Employee E6, worked remotely for eight hours per week and had not been physically present in the facility for over a year. This arrangement did not allow the RD to fulfill the in-person duties outlined in the job description, such as encouraging resident and family participation in care plans, maintaining liaison with families and residents, and attending departmental meetings. Interviews with the RD and other staff members confirmed the lack of in-person involvement by the RD. The RD, located out of state, relied on email communication with the Dietary Manager (DM) and nursing staff to address dietary issues. The DM confirmed that she handled in-person communication with residents, while the RD managed remote assessments and documentation. The Nursing Home Administrator acknowledged the facility's failure to have an RD on-site to participate in interdisciplinary meetings, monitor Food Service operations, or perform any in-person duties as required by the job description. This situation arose because the facility had been unable to fill the position for an on-site RD, and the current RD had accepted the role temporarily to assist the facility until a permanent solution could be found.
Plan Of Correction
1. The facility failed to have a Registered Dietitian on premises that participated in interdisciplinary meetings, monitor Food Service operations, or completed any in-person actions of the Registered Dietitian Job Description. 2. The Dietary Manager/Administrator/Designee will be educated by the NHA/Designee. 3. Registered Dietician will be hired for on the premises and will participate in interdisciplinary meetings, monitor Food Service operations, and complete any in-person actions of the Registered Dietitian Job Description.
Failure in Legionella Water Management Program
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program specifically related to water management for Legionella. The deficiency was identified through a review of the facility's Legionella policy, documentation, and staff interviews. The facility's policy, dated January 9, 2025, outlined specific actions for the prevention and investigation of Legionella cases. However, the facility did not adhere to these guidelines, as evidenced by the lack of a comprehensive water management program to monitor and control the potential development and spread of Legionella for the entire year from December 2023 to December 2024. The facility's water management plan lacked essential elements such as a log for Point of Use Disinfectant to measure and record chlorine concentration levels in the water. Additionally, there were no logs for the flushing of hot water and storage tanks or for minimum water temperature testing in all tanks. These omissions were confirmed during an interview with the Maintenance Director, who acknowledged the absence of documentation for water or temperature testing as per the Legionella policy. Further interviews revealed that the facility had recently terminated the Maintenance Director, which contributed to the failure in maintaining a comprehensive water management program. The Nursing Home Administrator confirmed the facility's inability to implement control measures for Legionella, which is a requirement under the Department of Health and Human Services and CMS guidelines. This deficiency highlights the facility's non-compliance with federal, state, and local requirements for infection control and prevention.
Plan Of Correction
-The facility will implement an effective Water Management Program and Infection Control Program that, at a minimum, will have a system of preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. -A Water Management Program will be developed based on the framework outlined in ASHRAE standards. -The Maintenance Director/Designee will be educated on the development of the Water Management Program and its implementation by the Administrator/Designee. -Water samples will be taken in-house and sent to a certified lab for testing. -Audits will be completed by the Administrator/Designee on compliance with the Water Management system. These audits will be completed weekly for 8 weeks. -The Infection Control Program will be revised so that documentation is present for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. -The Infection Preventionist will be educated on the revised process by the Director of Nursing/Designee. -These audits will be forwarded to the monthly Quality Assurance Performance Improvement Committee for review and frequency of audits.
Failure to Provide Anonymous Grievance Options
Penalty
Summary
Kadima Rehabilitation and Nursing at Washington was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically regarding the handling of grievances. The facility failed to provide residents and visitors with the necessary means to file grievances anonymously. During the survey, it was observed that the only grievance box available was located in the front lobby, directly in front of the Nursing Home Administrator's office and within sight of the receptionist, which compromised the anonymity of the grievance process. Additionally, there were no grievance forms or boxes available on the nursing units, further limiting the residents' ability to voice concerns without fear of reprisal. Interviews with the Resident Group and the Nursing Home Administrator confirmed these findings. The Resident Group expressed that they could not file anonymous grievances due to the location of the grievance box. The Nursing Home Administrator acknowledged the lack of grievance boxes and forms on the nursing units and the absence of an opportunity for residents and visitors to file grievances anonymously. This deficiency indicates a failure to adhere to the facility's grievance policy, which is intended to support each resident's right to voice grievances without discrimination or fear.
Plan Of Correction
1. The facility will provide the opportunity for residents and visitors to file an anonymous grievance. 2. The Regional Clinical Consultant or Designee will re-educate the Nursing Home Administrator and the Social Services Director on federal regulation 0585, detailing placing grievance boxes in an area where residents and visitors can file a grievance anonymously. 3. New grievances boxes were placed in designated areas of the facility that will give residents an area to file a grievance anonymously. 4. Social Services Director or designee will educate Residents on the whereabouts of the placement of the new grievance boxes. 5. The New Grievance procedure will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review. 6. SS Director/designee will audit/monitor (using audit grid) grievance box daily for 4 weeks and manager on duty will monitor/audit daily (using audit grid) on weekends for 4 weeks. 7. Discussion/questions/concerns will be discussed at resident council. 8. The results of the audits will be forwarded to the monthly quality assurance and performance improvement committee for review and frequency of audits.
Failure to Monitor and Report Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to properly assess, document, and notify physicians of abnormal capillary blood glucose (CBG) levels for five residents. These residents, who had diagnoses including diabetes, were not monitored according to the facility's policies and physician orders. The facility's policy required documentation of CBG levels, interventions to stabilize blood glucose, and timely communication with physicians when there was a change in a resident's condition. However, the facility did not adhere to these protocols. For Resident R13, multiple instances of hyperglycemia were recorded, with CBG levels significantly above normal. Despite these readings, there was no evidence that the resident was assessed for hyperglycemia, nor was there documentation of any interventions or physician notifications. Similar failures were noted for Residents R26, R28, R29, and R46, where high or low CBG levels were recorded, but the necessary follow-up actions, including rechecking blood sugar levels and notifying physicians, were not documented. Interviews with nursing staff revealed inconsistencies in the actions taken when abnormal CBG levels were detected. Staff members described different procedures for addressing high and low blood glucose levels, indicating a lack of standardized practice. The Director of Nursing confirmed the facility's failure to notify physicians of changes in condition, document assessments or interventions, and follow physician orders for the affected residents.
Plan Of Correction
The facility will assess, document and notify the physician of increased and decreased Capillary Blood Glucose (CBG) levels for all residents. The facility cannot retroactively correct the concerns identified for residents R13, R26, R28, R29 and R46. The previous residents R13, R26, R28, R29 and R46 physicians were notified/will be notified of abnormal CBG results for any new orders. All diabetic residents' orders will be reviewed to ensure accuracy/need for physician notification. The facility will complete a two-week look back of diabetic residents to validate the physician was notified of increased or decreased CBG, and the resident was assessed for hypoglycemia and documented. The Director of Nursing or designee will re-educate licensed nurses on the facility policy and procedures for notifying the physician with resident change in condition, detailing notification of increased or decreased CBG. The Director of Nursing or designee will complete an audit three times a week for four weeks, then monthly for three months to validate physicians are notified of any increased or decreased blood sugars and residents are assessed for hypoglycemia. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
Failure to Conduct Smoking Safety Assessments
Penalty
Summary
The facility failed to assess three residents for safe smoking practices, as required by their own policy. The policy mandates that smokers be reviewed on admission, at least quarterly, and as necessary depending on individual circumstances and changes in the resident's condition. However, the facility did not adhere to this policy for Residents R4, R10, and R54. Resident R4, who has a history of atrial fibrillation, seizures, and cognitive communication deficit, was last assessed for smoking safety on 12/22/23, despite the care plan indicating a need for regular reviews. Resident R10, with diagnoses of diabetes, asthma, and heart failure, was last assessed on 7/2/24, and Resident R54, with diabetes and high blood pressure, was last assessed on 8/20/24. The Director of Nursing confirmed during an interview that no further assessments were completed for these residents as required. The failure to conduct these assessments is a violation of the facility's smoking policy and the regulatory requirement to ensure the resident environment remains as free of accident hazards as possible. This oversight could potentially expose residents to risks associated with smoking, given their medical conditions and the lack of updated safety assessments.
Plan Of Correction
The facility will ensure residents are assessed for safe smoking. A smoking assessment will be completed for residents R4, R10, and R54 to ensure it is current and the resident is safe to smoke. A house audit will be completed to validate residents who smoke have a current smoking assessment completed. The Director of Nursing or Designee will re-educate licensed nurses, including new hires and agency, on the facility policy and procedures for Smoking, detailing completing safe smoking assessments for residents who wish to smoke. The Director of Nursing or Designee will complete an audit weekly for four weeks, then monthly for three months, to validate residents who smoke have a current and accurate smoking assessment. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
Failure to Conduct Pre-Employment Background Checks
Penalty
Summary
The facility failed to ensure the protection of residents from potential abuse by not performing criminal history background checks prior to hiring two employees. The facility's policy mandates that a criminal background check must be submitted to the Pennsylvania State Police before the start of active employment, and applicants cannot be hired or attend orientation until the background clearance is completed. However, the personnel files for a Dietary Aide and a Registered Nurse revealed no evidence of completed background checks before their respective hire dates. During an interview, a Human Resources employee confirmed the oversight, mistakenly believing that the facility had 30 days post-hire to conduct these checks. The employee also mentioned that the facility hesitated to conduct background checks immediately due to concerns about new hires not reporting to work, which would result in wasted resources. This failure to adhere to the established policy potentially exposed residents to individuals who had not been properly vetted for past abuse, neglect, or mistreatment.
Plan Of Correction
1. The facility will ensure that residents are protected from potential abuse by performing criminal history background checks prior to hire for all personnel. The facility cannot retroactively correct the concerns identified with Employees E7 and E12. 2. The Nursing Home Administrator or Designee will re-educate the Human Resources Director on federal regulation 0606, detailing completing criminal background checks prior to hire on all personnel. 3. Criminal history background check audits will be completed weekly for 4 weeks, then monthly for three months to validate criminal background checks are completed prior to hire for all new employees. 4. Criminal background checks were completed for E7 and E12. An audit will be completed on all current staff to ensure criminal background checks were completed. 5. These audits will be forwarded to the monthly Quality Assurance Performance Improvement Committee for review and frequency of audits.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure that residents are free of significant medication errors, as evidenced by an incident involving a resident with diabetes and high blood pressure. The resident was admitted to the facility with a physician's order to receive 12 units of Lantus insulin via a Solostar prefilled pen each morning. During a medication administration observation, an LPN set the insulin pen to the correct dose but neglected to perform the required priming procedure before administering the insulin. This priming step, as outlined in the manufacturer's guidelines, involves selecting a dose of two units, tapping the reservoir to remove air bubbles, and ensuring insulin comes out of the needle tip before administering the full dose. The LPN confirmed during an interview that she failed to prime the insulin pen prior to administering the medication to the resident. The Director of Nursing also confirmed that the facility did not administer the correct dose of insulin due to this oversight. This incident highlights a deviation from the facility's medication administration policy, which mandates that medications be administered safely, accurately, and in a timely manner, in accordance with good nursing principles and practices.
Plan Of Correction
The facility will ensure residents are free of significant medication errors. The facility cannot retroactively correct the concern identified for resident R3. The Director of Nursing or designee will re-educate licensed nurses on the facility policy and procedures for medication administration, detailing priming the insulin pen prior to administering medications. The Director of Nursing or designee will complete 5 nurse medication administration competencies weekly for four weeks, then monthly for three months to ensure insulin pens are primed prior to medication administration and residents are free from significant medication errors. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide staffing levels as per the regulation effective July 1, 2024. Specifically, the facility did not provide the minimum number of nurse aides per residents during various shifts over a 21-day period. During the day shift, the facility was short of the required nurse aides on 12 out of 21 days. The evening shift experienced shortages on 14 out of 21 days, and the night shift was understaffed on 19 out of 21 days. The census data and nursing time schedules revealed that the facility consistently failed to meet the required nurse aide-to-resident ratios, with no additional higher-level staff available to compensate for these deficiencies. The Director of Nursing confirmed these staffing shortages during an interview, acknowledging the facility's failure to provide the mandated nurse aide coverage. The report details specific dates and census numbers, highlighting the discrepancies between the required and actual number of nurse aides present during each shift. This consistent understaffing indicates a systemic issue in maintaining adequate staffing levels to meet regulatory requirements.
Plan Of Correction
1. The facility cannot correct that a minimum of one nurse aide (NA) per 10 residents during the day shift for 12 of 21 days (12/29 and 12/31/2024, 1/3, 1/4/25, 1/5, 1/6, 1/7, 1/10, 1/11, 1/12, 1/14, and 1/16/25), one NA per 11 residents during the evening shift for 14 of 21 days (12/31/2024, 1/3, 1/4/25, 1/5, 1/6, 1/7, 1/8, 1/9, 1/10, 1/11, 1/12, 1/13, 1/16, and 1/18 25) and one NA per 15 residents during the night shift for 19 of 21 days (12/29 and 12/30, 12/31/24, 1/1, 1/2/25, 1/3, 1/4/25, 1/5, 1/6, 1/7, 1/8, 1/9, 1/10, 1/11, 1/12, 1/13, 1/14, 1/17, and 1/18/25). 2. The facility will ensure that nurse aide 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 P5520 and ensuring nurse aide staffing ratios are met each 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 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 three months to ensure nurse aide staffing ratios are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
LPN Staffing Deficiencies
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) across various shifts over a 21-day period. Specifically, the facility did not provide the minimum number of LPNs per resident during the day, evening, and night shifts on multiple occasions. For the day shift, the facility was short of the required LPNs on 13 out of 21 days, with the census ranging from 62 to 65 residents, necessitating between 2.48 to 2.60 LPNs. However, the facility only provided between 2.00 to 2.13 LPNs, with no additional higher-level staff available to compensate for the deficiency. Similarly, during the evening shift, the facility was understaffed on 7 out of 21 days, with the census requiring between 2.07 to 2.17 LPNs, but only 1.56 to 2.00 LPNs were provided. The night shift also experienced staffing shortages on 13 out of 21 days, with the census requiring between 1.55 to 1.60 LPNs, but only 0.25 to 1.25 LPNs were available. These staffing deficiencies were identified through a review of the facility's census data, nursing time schedules, and deployment sheets, indicating a consistent failure to meet the regulatory requirements for LPN staffing levels during the specified period.
Plan Of Correction
1. The facility cannot correct that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift for 13 of 21 days (12/29/24, 1/3, 1/4/25, 1/5, 1/7, 1/8, 1/9, 1/12, 1/13, 1/14, 1/15, 1/16, and 1/18/25), one LPN per 30 residents on the evening shift for 7 of 21 days (12/30/24, 1/5, 1/6, 1/12, 1/14, 1/16, and 1/18/25) and one LPN per 40 residents on the night shift for 13 of 21 days (12/29, 12/30, and 12/31/24, 1/1, 1/2/25, 1/5, 1/6, 1/9, 1/10, 1/11, 1/14, 1/16, and 1/18/25). 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 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 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 three 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.
Staffing and Care Hours Deficiency
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) during various shifts, as confirmed by the Director of Nursing (DON) during an interview. Specifically, the facility did not provide the minimum number of LPNs per residents during the day, evening, and night shifts. Additionally, the facility did not meet the mandated 3.2 hours of direct resident care per resident in a 24-hour period on 17 out of 21 days, as evidenced by a review of nursing schedules and census information. The Patient Per Day (PPD) hours fell below the required threshold on multiple dates, with the lowest being 2.21 hours on one occasion. These deficiencies were acknowledged by the DON, indicating a consistent shortfall in providing adequate nursing care over the specified period.
Plan Of Correction
1. The facility cannot correct that the minimum number of general nursing hours to each resident in a 24-hour period were not met on 17 of 21 days (12/29, 12/30, and 12/31/24, 1/1, 1/3, 1/4/25, 1/5, 1/6, 1/7, 1/8, 1/9, 1/10, 1/11, 1/12, 1/14, 1/16, and 1/18/25). 2. The facility will ensure that general nursing hours 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 P5640 and ensuring general nursing hours to each resident are met each shift. Daily shift staffing hours will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing on the weekends. If the facility projects to not meet general nursing hours to each resident 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 three months to ensure general nursing hours for each resident are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident identified as being at risk. The resident, who was cognitively impaired with a BIMS score of 7, indicating severe impairment, had a history of exit-seeking behavior and was documented to have attempted to leave the facility on previous occasions. Despite these known risks, the resident was able to leave the facility unsupervised and was found sitting in the grass outside the building by staff members who were retrieving personal food deliveries. The incident occurred when two nurse aides noticed the resident outside after exiting the building for personal reasons. The resident claimed to have pressed buttons to open the door, although the door was reported to be functioning correctly and required a password to open. Staff interviews confirmed that the resident frequently exhibited exit-seeking behavior, and the Nursing Home Administrator acknowledged the failure to provide adequate supervision. The facility's policies and procedures for monitoring residents at risk for elopement were not effectively implemented, leading to this deficiency.
Deficiency in Staff Training on Elopement Risks
Penalty
Summary
The facility failed to provide documentation of an effective training program tailored to the needs of its resident population, specifically for one resident identified as Resident R1. The facility's policy on staff development mandates that employees must be competent in skills necessary to care for residents' needs, with an ongoing education program addressing residents' problems, needs, and rights. However, the facility did not demonstrate that such a program was effectively implemented, as evidenced by the incident involving Resident R1, who was at risk for elopement due to cognitive impairment and exit-seeking behaviors. Resident R1, who had a BIMS score indicating severe cognitive impairment, was found outside the facility after reportedly pressing buttons to open a door or being let out by another person. Despite being care planned as an elopement risk, the facility's training did not address the specific method used by the resident to exit the building. Interviews with staff and the Nursing Home Administrator confirmed that while education was provided on identifying and care planning for residents at risk of wandering and elopement, it did not cover the actual circumstances of Resident R1's elopement.
Failure to Secure Residents' Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information by improperly storing approximately 75 boxes of loose paper containing resident information in an unsecured storage shed behind the facility. This action was in direct violation of the facility's policy on confidentiality, which mandates that residents have the right to personal privacy and confidentiality of their personal and clinical records. Additionally, the facility's policy on medical records storage requires that all medical records be stored in a secure, fire-protected, and waterproof area. During an observation, it was noted that the storage shed was left unsecured at all times, compromising the confidentiality of the residents' information. The Maintenance Director confirmed that the paperwork was stored in the shed due to a lack of space. The Nursing Home Administrator acknowledged the failure to maintain the confidentiality and security of the residents' medical information in the storage shed.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in the North Wing Nursing Unit and the main dining room. Observations revealed several deficiencies: two residents had a hole in the floor near the bathroom baseboard, two residents had chipped paint under the window surrounding the heater, and two residents had a cracked ceiling above a bed, with one resident expressing concern about potential leaks. An empty resident room had a broken wall plug plate in the bathroom, and another resident's room had unfinished drywall with spackling behind the beds. Additionally, the main dining room floor was observed to have multiple spots of a brown substance and appeared soiled with food debris. These findings were confirmed by the Nursing Home Administrator and the Maintenance Director during an interview.
Neglect Due to Non-Compliance with Transfer Guidelines
Penalty
Summary
The facility failed to protect a resident from neglect by not following physician's orders during incontinence pad and linen changes. Specifically, a nurse aide (NA) rolled a resident onto her right side, where there was no enabler bar, causing the resident to fall onto the floor. The resident, who required assistance from two staff members for bed mobility, had expressed discomfort with being rolled without a second person present. Despite this, the NA proceeded, resulting in the resident's fall. The resident involved had a medical history that included diabetes, a history of pulmonary blood clots, bacteremia, and a wound on her right leg. The incident occurred during a routine care procedure, highlighting a lapse in adherence to the prescribed care plan, which required two staff members for safe bed mobility. The failure to follow these guidelines directly led to the resident's fall and constituted neglect as defined by the facility's policies and federal regulations.
Inadequate Supervision and Bed Mobility Intervention
Penalty
Summary
The facility failed to provide adequate supervision and implement effective bed mobility interventions for a resident, identified as Resident R8, as per physician orders. Resident R8, who had a history of diabetes, pulmonary blood clots, bacteremia, and a wound on her right leg, required assistance from two staff members for bed mobility. However, during an incident, a nurse aide, identified as Employee E2, attempted to provide incontinence care and linen change alone, rolling Resident R8 onto her right side where there was no enabler bar, resulting in the resident falling onto the floor. This incident occurred despite Resident R8 expressing discomfort with being rolled without a second person present. Interviews with staff revealed inconsistencies in how they accessed and understood the required level of assistance for residents. While some staff referred to a kiosk for information, others relied on clinical records. The Nursing Home Administrator confirmed the facility's failure to provide adequate supervision for Resident R8, which was a violation of the facility's policy on accidents and incidents. The deficiency was identified as past non-compliance, indicating that the facility had not adhered to the required standards of care and supervision at the time of the incident.
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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