Kingston Court Skilled Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in York, Pennsylvania.
- Location
- 2400 Kingston Court, York, Pennsylvania 17402
- CMS Provider Number
- 395037
- Inspections on file
- 37
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Kingston Court Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with hypertension, a history of falls, and bladder cancer was admitted with a physician’s order for DNR status, but the interdisciplinary care plan and a social services progress note documented the resident as Full Code with instructions to initiate CPR. The Nursing Home Administrator confirmed that the correct status was DNR, showing that the facility failed to maintain a complete and accurate medical record regarding the resident’s code status in accordance with professional standards.
Some residents were served meals in different types of bowls and cups, with some receiving reusable items and others receiving disposable ones, due to an insufficient supply of serving ware. Staff interviews confirmed the lack of enough bowls and cups, resulting in inconsistent meal presentation.
Surveyors found that the facility did not consistently provide a clean and homelike environment, with multiple residents reporting unclean rooms and bathrooms, and observations revealing dirty floors, debris, and neglected cleaning under furniture and in bathrooms.
The facility did not properly review and update care plans for two residents. One resident's care plan included an intervention for an ostomy that the resident never had, while another resident's care plan listed insulin and anticoagulant therapy that had already been discontinued. These inaccuracies were not corrected in a timely manner, resulting in outdated care plans.
Surveyors found that food items in the kitchen and nourishment pantries were not properly labeled, dated, or securely closed, and several areas and equipment were not cleaned according to professional standards. Staff interviews confirmed that required procedures for labeling, dating, and cleaning were not consistently followed, and there was confusion about cleaning responsibilities. Maintenance issues such as broken equipment and missing tiles were also observed.
A resident with diabetes did not consistently receive prescribed insulin at the scheduled time, as documented by multiple late administrations in the medication record. The DON confirmed that medications should be given within an hour of the scheduled time but could not provide a reason for the delays. This failure to follow physician orders and facility policy resulted in a deficiency.
A resident with multiple fractures and neuropathy did not receive pain medication (Gabapentin) at the scheduled times on two consecutive days, with doses given over two hours late despite the resident requesting assistance. Facility policy lacked clear guidance on medication administration timing, and the DON confirmed no specific timeframe was in place.
The facility did not consistently provide food and drink that were palatable, attractive, or served at safe and appetizing temperatures. Multiple residents reported issues with food quality, flavor, texture, and temperature, and a test tray evaluation confirmed that hot foods were served below the required temperature, with missing items on trays and inconsistent meal preparation.
Two residents experienced significant delays in receiving prescribed pain medications, resulting in uncontrolled pain. One resident with Chronic Pain Syndrome did not receive Methadone and Lyrica until late afternoon, despite morning prescriptions. Another resident with Chronic Pain had to request Tramadol multiple times before receiving it hours later. The DON acknowledged the issue, and the responsible nurse was terminated.
The facility failed to prevent significant medication errors for three residents, resulting in harm to two of them. A resident with moderate cognitive impairment did not receive their prescribed Methadone and Lyrica on time, leading to unmanaged pain. Another resident with epilepsy did not receive Phenobarbital, and a third resident with chronic pain experienced a delay in receiving Tramadol, causing severe pain. The DON acknowledged the need for timely medication administration.
A resident with multiple sclerosis and atrial fibrillation experienced a significant delay in being transferred out of bed, despite requiring extensive assistance. The resident, who is cognitively intact, was not assisted until late afternoon, although she typically gets out of bed by noon. The delay was confirmed by her roommate and a nurse aide, who could not explain the reason for the delay.
The facility failed to provide proper wound care and timely medication administration. A resident's wound care was delayed, and medications for 21 residents were administered hours late. The DON and NHA acknowledged the issues, and the responsible nurse was terminated.
A resident with muscle weakness and ileus missed a scheduled gastroenterology appointment due to the facility's failure to arrange transportation, as required by their policy. The appointment was initially set for mid-November but had to be rescheduled after the oversight was identified.
A resident with cognitive loss and safety awareness issues attended a medical appointment without an escort due to a miscommunication, despite being at risk for elopement and falls. The facility's policy required staff to escort residents if needed, but the assigned Nurse Aide remained at the facility, leaving the resident unattended.
A resident with multiple sclerosis and muscle weakness suffered a skin tear during a transfer using a sit-to-stand lift operated by a single nurse aide, despite the requirement for two-person assistance. The incident occurred due to space constraints in the bathroom, leading to the resident being sent to the hospital for treatment.
The facility failed to provide appropriate restorative care for two residents with limited mobility. One resident, with muscle weakness and dementia, was not assisted out of bed as per the care plan, and there was no documentation of their participation in the restorative program due to a system error. Another resident, with hemiplegia and hemiparesis, did not receive the prescribed range of motion exercises, and the care plan lacked a clear program description, also due to a system error.
A facility failed to provide appropriate dialysis care for a resident, as evidenced by incomplete records and lack of an emergency dialysis kit. The resident, dependent on renal dialysis, had missing documentation for vital signs and AV shunt assessments. Facility staff were unaware of the missing documentation, and the dialysis center often did not complete their section of communication sheets.
The facility failed to ensure nurse aides completed the required 12 hours of annual in-service training, including dementia management and abuse prevention, for several employees. The Nursing Home Administrator confirmed the absence of training documentation, attributing it to missing binders previously maintained by the former DON.
A facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to a resident whose Medicare coverage ended. The resident's skilled services ended, and their payor source changed to Medicaid, but the facility could not produce the SNF ABN. The Nursing Home Administrator confirmed the document was missing from the resident's medical record.
The facility failed to maintain a safe and home-like environment, with issues such as peeling molding, missing vinyl on a dining chair, and nails protruding from a wall in resident rooms. These deficiencies were identified during a survey, and no prior work orders were found for these concerns.
The facility failed to ensure accurate resident assessments, leading to discrepancies in the MDS for two residents. One resident was incorrectly coded as using a limb restraint without a physician's order, while another resident's significant weight loss was not accurately reflected in their MDS. These errors were confirmed by staff and the NHA during interviews.
A facility failed to complete a Discharge MDS for a resident with hypertension and multiple sclerosis who left AMA. The omission was confirmed by staff, including the RN Assessment Coordinator and Acting DON.
The facility failed to adhere to care policies for two residents. A resident with bipolar disorder and peripheral vascular disease did not receive timely dressing changes, and refusals were not documented or communicated to the physician. Another resident with diabetes experienced missed insulin doses and inadequate documentation. These deficiencies highlight issues in care and documentation practices.
A facility failed to provide proper respiratory care for a resident with obstructive sleep apnea (OSA) by not storing the CPAP mask in a sanitary manner and not including CPAP use in the care plan. Observations showed the mask on the floor and bedside table, contrary to the facility's policy on respiratory equipment cleaning and disinfection. The acting DON confirmed the mask should be cleansed and bagged after each use and that the care plan should reflect the resident's CPAP use.
The facility failed to document and act on pharmacy recommendations for two residents. One resident did not receive a timely gradual dose reduction of antipsychotic medication, and antipsychotic monitoring was not implemented as recommended. Another resident's pharmacy recommendations and physician's response were not documented. Staff interviews revealed process issues and misunderstandings regarding care responsibilities.
The facility did not adhere to professional principles for medication storage in the Heritage Medication Storage Room. A single-dose vial of Aranesp was found open without an opened date, contrary to product guidelines that require disposal after a single use. A Registered Nurse Supervisor indicated the facility used the medication until empty, citing cost concerns, while the Nursing Home Administrator expected adherence to manufacturer guidelines.
The facility did not document education on the benefits and risks of the influenza vaccine for two residents who refused it. The Infection Preventionist could not find documentation for one resident, and the staff member documenting the other resident's refusal was unaware of the education requirement. The Acting DON confirmed the need for documented education at the time of refusal.
The facility failed to adhere to professional standards for IV care for three residents. One resident did not have their IV line flushed or central line dressing changed as required, another resident lacked an order for a central line dressing change, and a third resident's scheduled PICC/Midline dressing change was not documented. The Director of Nursing confirmed these lapses in care.
Inaccurate Documentation of Resident Code Status in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record regarding a resident’s code status. Facility policy on Code Status Orders states that code status communicates whether a patient desires CPR in the event of cardiopulmonary arrest. For one resident with diagnoses including hypertension, a history of falls, and malignant neoplasm of the bladder, the admission physician’s order summary documented a Do Not Resuscitate (DNR) status effective as of the admission date. However, the resident’s interdisciplinary plan of care, initiated after admission, documented the resident as "Full Code" with instructions to start CPR in the event of cardiac arrest. Further review of the clinical record showed that a progress note by the Social Services Director documented the resident’s advance directive as "Full Code," which conflicted with the physician’s DNR order. During an interview, the Nursing Home Administrator confirmed that the resident’s correct code status was DNR and that the documentation in the clinical record indicating a full code status was not accurate. This inconsistency demonstrated that the facility did not ensure the resident’s medical record was complete and accurately documented in accordance with professional standards and practices.
Inconsistent Use of Serving Ware During Meal Service
Penalty
Summary
During a lunch meal service, some residents were served peach cobbler in plastic thermal bowls while others received Styrofoam bowls, and some were provided with reusable plastic tumblers while others received disposable plastic cups. This inconsistency in serving ware was observed during tray line service and was confirmed through staff interviews. The Food Service Director stated that there were not enough bowls and cups available to serve all residents uniformly, leading to the use of Styrofoam bowls and disposable cups for some. The Nursing Home Administrator acknowledged that reusable thermal bowls had been ordered but the order process was delayed, and she needed to verify if cups had been ordered. It was also confirmed that the facility should have sufficient bowls and cups for all residents.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in resident rooms on two nursing units, as evidenced by multiple observations, resident complaints, and documentation. Facility policy requires daily cleaning of all resident areas, but observations over several days revealed dirty floors, accumulation of debris such as cereal and medicine cups, and grey fuzzy substances in corners and under furniture in several resident rooms. Residents reported that their rooms were not cleaned to their satisfaction, with specific mention that staff did not move furniture to clean underneath and that bathrooms and floors were only cleaned twice a week. Additional observations included dirty bathroom walls, brown film along baseboards, dust and debris on vents and televisions, and stained privacy curtains. Resident council minutes and the facility grievance log documented ongoing complaints about housekeeping, including unclean rooms and bathrooms. Interviews with residents confirmed that cleaning was not thorough or routine, with some areas like under dressers and tops of furniture being neglected. Physical observations also noted maintenance issues such as ripped wallpaper. These findings collectively demonstrate that the facility did not consistently provide a clean and homelike environment as required by regulation.
Failure to Review and Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to review and revise care plans for two residents as required by policy and regulation. For one resident with diagnoses including congestive heart failure and gastroesophageal reflux disease, the care plan included an intervention to encourage discussion about an ostomy, despite the resident never having had an ostomy or being at risk for one. This intervention was entered erroneously and was not removed or corrected in a timely manner. For another resident with diagnoses of type 2 diabetes mellitus, cerebrovascular accident, and localized edema, the care plan continued to list interventions related to insulin administration and anticoagulant therapy (Plavix), even though both medications had been discontinued. The care plan was not updated to reflect the discontinuation of these medications, resulting in outdated and inaccurate care planning for the resident.
Failure to Store, Label, and Maintain Food and Equipment per Professional Standards
Penalty
Summary
The facility failed to store and serve food and beverages in accordance with professional standards for food safety in the kitchen and two nourishment pantries. Observations revealed multiple food items in the walk-in and reach-in refrigerators that were not labeled or dated, including sliced turkey, grated cheese, tossed salads, pureed foods, diced peaches, and thickened lemon water. Several open packages were not securely closed, and some items were not covered. Bulk items such as brown sugar were not date marked, and there were visible cleanliness issues, including dried food splatters on shelves, dirty pans and lids, a caked blender base, and a charred oven interior. The baker's rack contained uncovered coffee cake, and the steam table and prep areas had visible food debris. In the nourishment pantries, a thawed shake was not date marked, and the microwave contained dried splattered substances. Interviews with staff, including the Food Service Director and Diet Aide, confirmed that items should be labeled, dated, securely closed, and that cleaning schedules were in place but not consistently followed. There was uncertainty among staff regarding responsibility for cleaning certain equipment and areas, such as the ceiling and microwave. Additionally, there were maintenance issues, including broken plate warmer covers, missing baseboard tiles, missing grout, and a ceiling with a dark fuzzy substance. These findings indicate a failure to adhere to facility policies and professional standards for food storage, labeling, and cleanliness.
Failure to Administer Insulin According to Physician Orders and Facility Policy
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards of practice for one resident with diabetes mellitus. According to facility policy, medications are to be administered at the correct time as ordered by an authorized licensed practitioner. Review of the clinical record for a resident with diabetes showed physician orders for Humulin, a long-acting insulin, to be administered once daily at 8:00 AM. However, the Medication Administration Record documented multiple instances where the insulin was administered late, with times ranging from over an hour to more than two hours past the scheduled time on several dates. Interviews with the resident confirmed that insulin administration and blood sugar checks were sometimes performed after meals. The DON stated that medications should be administered within one hour before or after the scheduled time, but was unable to provide a rationale for the late administration of Humulin. The deficiency was cited under state regulations for management and resident care policies.
Failure to Provide Timely Pain Management for Resident with Fractures
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident with multiple fractures, including a displaced fracture of the right fibula and an unspecified fracture of the right tibia. Physician orders specified that Gabapentin 800 mg was to be administered four times daily at set times (8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM) for neuropathy. However, documentation showed that on two consecutive days, the resident's morning and noon doses were administered more than two hours late. The resident reported that despite using the call bell to notify staff of her pain and the delay in medication, her pain medication was not given on time. Review of the facility's medication administration policy revealed no guidance regarding the timeframe for administering medications relative to the ordered times. The DON confirmed that there was no policy specifying medication administration windows, but expressed an expectation that medications should be given within one hour before or after the scheduled time. The lack of a clear policy and the failure to administer pain medication as ordered resulted in the resident experiencing delays in pain relief.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to provide food and drink that were palatable, attractive, and served at safe and appetizing temperatures. Review of food service and resident council meeting minutes revealed ongoing concerns, including missing condiments, incomplete trays, inconsistent meal preparation, hard hamburgers, dry baked ziti, small portion sizes, undercooked vegetables, tough meat, and insufficient soup portions. Multiple residents interviewed reported dissatisfaction with the quality, flavor, texture, and temperature of the food, specifically noting that meals were often cold, lacked flavor, and did not always match tray ticket requests. A test tray evaluation further confirmed these issues, with hot food items such as roast turkey, mashed potatoes, and brussels sprouts served below the required 140°F, and a dessert missing from the tray. The test tray was delivered after a 19-minute delay from preparation to service, and the cold beverage was within acceptable temperature range, but the dessert was served at room temperature. The Food Service Manager acknowledged that hot foods should be above 140°F and that tray tickets should be followed, confirming the deficiencies observed.
Delayed Pain Management for Two Residents
Penalty
Summary
The facility failed to provide timely pain management for two residents, resulting in actual harm due to uncontrolled pain. Resident 9, who has diagnoses of Polyneuropathy and Chronic Pain Syndrome, experienced a significant delay in receiving prescribed pain medications. On December 28, 2024, Resident 9 was supposed to receive Methadone and Lyrica in the morning, but both medications were not administered until late afternoon, causing the resident to endure pain throughout the day. This delay was documented in a grievance filed by the resident, who reported having to request their routine morning pain medications and suffering from pain all day. Similarly, Resident 14, who has a diagnosis of Chronic Pain, also experienced a delay in receiving pain medication. Despite requesting Tramadol for pain relief at noon, the medication was not administered until 4:05 PM, after multiple requests. The resident's written statement indicated severe pain and consideration of hospital admission due to the delay. The Director of Nursing acknowledged the grievances and confirmed that the Nurse Practitioner/Physician was not informed of the late administrations until two days later. The nurse responsible for the delays was terminated on the day of the incident.
Plan Of Correction
Residents 9 and 14 were assessed and no adverse reactions, therefore no further adjustments to treatment was required per CRNP. A comprehensive review of current residents with scheduled pain medication ordered will be reviewed for the previous two weeks to ensure that pain medications were given as ordered and were effective. The Director of Nursing / Designee will educate licensed staff on F tag 0697 pain management, focusing on ensuring pain medications are administered at the prescribed time. Audits of 5 random residents with scheduled pain medication will be completed by unit managers / designee per week for 4 weeks to ensure pain medications are administered at.
Medication Administration Errors Result in Resident Harm
Penalty
Summary
The facility failed to prevent significant medication errors for three residents, resulting in harm to two of them. Resident 9, who has moderate cognitive impairment, did not receive their prescribed Methadone and Lyrica at the scheduled times on December 28, 2024, leading to a day of unmanaged pain. The medication administration audit confirmed that Methadone was administered at 4:50 PM and Lyrica at 4:51 PM, despite being scheduled for the morning. Resident 9 filed a grievance stating they had to request their routine morning pain medications and experienced pain throughout the day. Resident 10, diagnosed with epilepsy and hypertension, did not receive their prescribed Phenobarbital on the same day, although it was signed off as administered on the Medication Administration Record. The controlled drug record count sheet confirmed the medication was not given. Resident 14, with intact cognition and diagnosed with hypertension and chronic pain, requested Tramadol for pain at noon and again two hours later, but only received it at 4:05 PM after a third request. The delay in administering pain medication led Resident 14 to consider going to the hospital due to severe pain. The Director of Nursing acknowledged that pain medication should be administered timely.
Plan Of Correction
Residents 9, 10 and 14 were assessed and no adverse reactions, therefore no further adjustments to treatment was required per CRNP. The nurse involved has since been terminated. No other like residents identified. A comprehensive medication administration review of current residents will be completed to ensure that medications were completed and signed off as ordered. Director of nursing / Designee will educate licensed staff on F tag 0760 residents are free of significant med errors, focusing on ensuring medications are administered as prescribed. Audits of 5 random medication administration will be completed by unit managers /designee per week for 4 weeks to ensure pain medications are administered as prescribed. Results of the audits will be reviewed by the QAPI committee for recommendations.
Failure to Provide Timely Transfer Services
Penalty
Summary
The facility failed to provide necessary transfer services for a resident who required extensive assistance for activities of daily living. The resident, diagnosed with multiple sclerosis and atrial fibrillation, was admitted for long-term care and required a two-person assist for transfers out of bed. Despite being cognitively intact, as indicated by a BIMS score of 15, the resident experienced a significant delay in being transferred out of bed. On the day in question, the resident activated the call bell in the morning but was not assisted out of bed until 4:30 PM, despite her usual routine of being out of bed by lunchtime. The delay was corroborated by the resident's roommate, who also had a BIMS score of 15, confirming her cognitive intactness. The roommate verified that the resident typically gets out of bed by noon. An interview with a nurse aide revealed that the resident was washed and changed in the morning, but the aide could not explain the delay in transferring the resident. The resident mentioned that the lift used for her transfer sometimes did not work, causing further delays. This incident highlights the facility's failure to meet the requirement of providing necessary services for residents unable to carry out activities of daily living.
Plan Of Correction
The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency (s) herein. To remain in compliance with all federal and state regulations, the facility has taken, and will take, the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance. All alleged deficiencies cited have been, or will be corrected by the date or dates indicated. The facility is committed to taking all actions necessary to remain in substantial compliance with state and federal regulations. The plan of correction addresses our intention to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psychosocial well-being. Resident 23 got out of bed and had no ill effect for not getting out of bed at preferred time after miscommunication between resident and nurse aide. Aide thought resident wanted to stay in bed late. No other like residents. A comprehensive review of current residents will be completed to determine preferences on getting out of bed and to ensure they are getting out of bed as preferred. Director of nursing / Designee will educate nurse aides on Ftag 0677 ADL Care Provided for Dependent Residents, focusing on getting out of bed as preferred. Audits of 5 random residents will be completed by unit managers / designee per week for 4 weeks to ensure they are getting out of bed as preferred. Results of the audits will be reviewed by the QAPI committee for recommendations.
Deficiencies in Wound Care and Medication Administration
Penalty
Summary
The facility failed to provide the highest practicable care and adhere to professional standards of practice for wound care and medication administration. Specifically, the facility did not implement wound care treatments as ordered for a resident with a lateral right ankle vascular ulcer. The treatment, which included cleansing and applying specific wound dressings, was signed off as completed on the dayshift but was actually performed on the evening shift, indicating a delay in care. Additionally, the facility did not adhere to scheduled medication administration times for 21 out of 23 residents reviewed. Medications were administered several hours later than scheduled, with delays ranging from 1 1/2 to 9 hours. This widespread issue affected numerous residents, each with varying numbers of medications scheduled for administration at specific times. The Nurse Practitioner was informed of the late medication administrations two days after the incident, and it was noted that no adverse reactions occurred among the residents. During an interview, the Director of Nursing and the Nursing Home Administrator acknowledged that treatments and medications should be administered as ordered and not signed off until completed. The nurse responsible for the residents was terminated following the incident.
Plan Of Correction
Resident 9 wound care provided, and residents 1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22 and 23 were assessed and no adverse reactions, therefore no further adjustments to treatment was required per CRNP. Nurse involved has since been terminated. A comprehensive review of current Residents medication administration and treatment for the previous 1 weeks will be audited to ensure that medications and treatments were completed as ordered. Director of nursing / Designee will educate licensed staff on F tag 0684 quality of care, focusing on medication administration and wound treatments. Audits of 5 random residents will be completed by unit managers / designee per week for 4 weeks to ensure medications are administered timely and wound treatments are completed. Results of the audits will be reviewed by the QAPI committee for recommendations.
Failure to Arrange Transportation for Resident's Medical Appointment
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, the facility did not arrange transportation for Resident 5 to attend a scheduled appointment with Gastroenterology Associates on November 15, 2024. This oversight was identified through a review of the facility's policy on transportation and escort services, which mandates that the center staff provide assistance in scheduling transportation for residents who need it for appointments outside the center. Resident 5, who has diagnoses including muscle weakness and ileus, had a physician's order for a gastroenterology appointment on November 15, 2024. However, the facility failed to set up transportation, resulting in the appointment being rescheduled. A progress note from November 18, 2024, confirmed the missed transportation arrangement, and an interview with the Nursing Home Administrator on December 2, 2024, verified the failure. The appointment was eventually rescheduled for November 22, 2024, after the oversight was discovered.
Plan Of Correction
The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency (s) herein. To remain in compliance with all federal and state regulations, the facility has taken, and will take, the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance. All alleged deficiencies cited have been, or will be corrected by the date or dates indicated. The facility is committed to taking all actions necessary to remain in substantial compliance with state and federal regulations. The plan of correction addresses our intention to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psychosocial well-being. Resident 5 appointment was rescheduled and resident was transported. Residents with scheduled transport in the last week will be audited to ensure they were transported to their appointments. Director of nursing / Designee will educate licensed staff on Ftag 0684 quality of care, focusing on arranging transports to appointments. Audits of 5 random residents with scheduled appointments will be completed by unit managers / designee per week for 4 weeks to ensure transports are arranged. Results of the audits will be reviewed by the QAPI committee for recommendations.
Failure to Escort Resident to Medical Appointment
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, identified as Resident 2, who was at risk for elopement and falls due to cognitive loss and lack of safety awareness. The resident's care plan included the use of a Wander Guard device to prevent elopement and required that the resident not leave the facility without an escort. Despite these precautions, Resident 2 attended an out-of-facility urology appointment without being accompanied by facility staff, due to a miscommunication that resulted in the assigned escort, a Nurse Aide, remaining at the facility. Resident 2's medical history included obstructive uropathy and chronic kidney disease, conditions that necessitated regular medical appointments. The failure to provide an escort for the resident's appointment was a direct violation of the facility's policy on transportation and escort services, which mandates that staff may escort patients if needed. This oversight was confirmed during an interview with the Nursing Home Administrator, who acknowledged that Resident 2 should not have been left unattended at the appointment.
Plan Of Correction
Resident 2 had no ill effect for not having an escort to his appointment. Residents with scheduled transport in the last week will be audited to ensure residents who needed escorts were escorted to their appointments. The Director of Nursing / Designee will educate licensed staff on Ftag 0689 free of accident/Hazard/Supervision/Devices focusing on residents escorts to appointments. Audits of 5 random residents with scheduled appointments will be completed by unit managers / designee per week for 4 weeks to ensure residents who need escorts have arranged escorts. Results of the audits will be reviewed by the QAPI committee for recommendations.
Inadequate Supervision During Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents, resulting in actual harm to a resident. The incident involved a resident with multiple sclerosis, muscle weakness, and unsteadiness on feet, who was being assisted to the toilet using a sit-to-stand (STS) lift by a nurse aide. The nurse aide was operating the lift alone due to limited space in the bathroom, despite the requirement for two-person assistance. During the transfer, the resident's leg was not straight, and when the aide attempted to adjust it, a skin tear occurred on the resident's right lower extremity. The nurse aide noticed a bubble of blood under her hand, which popped, causing the skin tear. A Licensed Practical Nurse (LPN) was present but not assisting due to space constraints. The LPN assessed the wound and called for the Registered Nurse (RN) Supervisor, who decided to send the resident for further treatment. The resident, who was on Eliquis, a blood thinner, was observed with some bleeding and required stitches for the deep cut. The resident reported leg pain and was given medication for pain management. The facility's investigation revealed that the nurse aide was aware of the two-person requirement for operating the STS lift but proceeded alone due to space limitations. The aide had previously managed to use the lift with two people in tight spaces. The incident led to the resident being sent to the hospital for evaluation and treatment of the laceration, and the facility suspended the nurse aide during the investigation.
Failure to Provide Restorative Care for Residents with Limited Mobility
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve mobility for two residents with limited mobility. Resident 8, diagnosed with muscle weakness, lack of coordination, and dementia, expressed a desire for more therapy and was observed not being assisted out of bed as per the care plan. The care plan specified that Resident 8 should be assisted out of bed daily using a hoyer lift, but observations over several days showed this was not done. Additionally, there was a lack of documentation regarding the resident's participation in the restorative program, which was attributed to an error in the nurse aide task entry system. Resident 60, who has hemiplegia and hemiparesis following a stroke, was supposed to be on a Restorative Nursing Program for range of motion exercises. However, the care plan and kardex lacked a clear program description, and there was no documentation of the resident receiving the prescribed restorative care. The Nursing Home Administrator confirmed that an error in the electronic health record system prevented the task from triggering, leading to a lack of documentation and provision of the restorative nursing program.
Deficiency in Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident requiring such services, as evidenced by incomplete and inaccurate records related to dialysis communication. The facility's policy required documentation of vital signs, pre-dialysis assessments, and the condition of the AV access site, but these were not consistently recorded for Resident 93. The resident, who depended on renal dialysis and had conditions such as hypertension and hyperkalemia, did not have an emergency dialysis kit at her bedside, which was confirmed by both the resident and a Licensed Practical Nurse. Additionally, the facility's policy only mentioned having hemostats for residents with external chest port access, which was not initially provided for Resident 93. The review of dialysis communication sheets revealed multiple instances where necessary documentation was missing. These included failures to document pre-dialysis vital signs, AV shunt assessments, and post-dialysis assessments. Furthermore, the dialysis center often did not complete their section of the communication sheets. Interviews with facility staff, including a Physician Assistant and the Acting Director of Nursing, indicated a lack of awareness and follow-up regarding the missing documentation. Despite attempts to contact the dialysis center for missing information, the facility was unable to locate or provide the required documentation.
Deficiency in Nurse Aide Training Compliance
Penalty
Summary
The facility failed to ensure that nurse aides received the required in-service training of no less than 12 hours per year, as evidenced by the review of personnel training records for five nurse aides. Specifically, Employees 6, 7, 8, 9, and 10 did not complete the mandated annual training hours. Additionally, the facility did not provide annual training in dementia management and resident abuse prevention for Employee 7, and failed to provide abuse prevention training for Employee 6. These deficiencies were identified through a review of facility training records, which lacked evidence of the required training completion. During an interview, the Nursing Home Administrator acknowledged the absence of training documentation, attributing it to the former Director of Nursing's practice of maintaining staff education files in a binder that could not be located. The administrator confirmed that the only available records were corporate reports of staff education completion and expressed an expectation that nurse aides should complete their annual required training topics and hours. The facility's failure to maintain proper training records and ensure compliance with training requirements led to these deficiencies.
Failure to Provide SNF ABN for Discontinued Medicare Coverage
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to a resident whose Medicare coverage was discontinued. The resident, identified as Resident 341, was readmitted to the facility after a hospital stay with Medicare A as the payor source. Skilled services for the resident ended on April 14, 2024, and the payor source changed to Medicaid. However, the Notice of Medicare Non-Coverage (NOMNC) was issued on April 16, 2024, and the facility could not provide a copy of the SNF ABN to show it was given to the resident. During an interview, the Nursing Home Administrator confirmed the absence of the SNF ABN in the resident's medical record, acknowledging that it should have been completed and filed.
Environmental Deficiencies in Resident Rooms and Dining Area
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and home-like environment in one of its dining areas and in four resident rooms. Observations revealed that Resident 60's room had plastic molding peeling away from the wall and hanging under the heating/air conditioning unit. Resident 71's room was missing plastic molding from the wall at the head of their bed, and Resident 114's room had gouges in the wall near the head of their bed. Additionally, the Heritage Dining Room contained a stationary dining chair with a missing piece of vinyl from the seating surface. Further observations identified that Resident 94's room had nails sticking out of the wall between the windows, which were remnants from a previous resident. Interviews with the Nursing Home Administrator (NHA) revealed that there were no prior work orders entered for these environmental concerns, and maintenance staff were expected to identify such issues during their rounds. The lack of documentation and proactive maintenance led to these deficiencies being present at the time of the survey.
Inaccurate Resident Assessments in MDS
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, leading to discrepancies in their clinical records. For one resident, the Minimum Data Set (MDS) inaccurately indicated the use of a limb restraint on a daily basis, despite the absence of a physician's order for such a restraint. This error was confirmed during interviews with a staff member and the Nursing Home Administrator (NHA), who acknowledged the incorrect coding of the MDS. Another resident's MDS inaccurately reported no significant weight loss, despite clinical records showing a 9.01% weight loss over one month and an 18.02% weight loss over six months. This discrepancy was also confirmed by the NHA during an interview, acknowledging that the MDS should have reflected the resident's significant weight loss. These inaccuracies in resident assessments were identified during a review of clinical records and staff interviews.
Failure to Complete Discharge MDS for Resident Leaving AMA
Penalty
Summary
The facility failed to coordinate the resident assessment for one of four discharged residents reviewed, specifically Resident 110. Resident 110 had diagnoses including hypertension and multiple sclerosis and was admitted to the facility on an unspecified date. On May 31, 2024, Resident 110 left the facility against medical advice (AMA). However, as of August 26, 2024, the facility had not completed a Discharge Minimum Data Set (MDS) for Resident 110. This was confirmed during staff interviews on August 29, 2024, with Employee 11, a Registered Nurse Assessment Coordinator, and the Acting Director of Nursing, who acknowledged that the Discharge MDS should have been completed following Resident 110's departure AMA.
Deficiencies in Care and Documentation for Two Residents
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for two residents. Resident 6, diagnosed with bipolar disorder and peripheral vascular disease, had a physician's order for daily dressing changes on an open wound. However, the dressing was not changed for eight days, and the resident complained of sharp pain. The treatment was documented as refused for several days, but there was no documentation of notifying the supervisor or the physician about the refusals, as required by the facility's policy. Resident 94, with diagnoses including type 2 diabetes and major depressive disorder, had issues with insulin administration. The resident reported not always receiving insulin as prescribed. The Medication Administration Record (MAR) showed missed doses and lack of documentation for certain dates. There was no nurse's note explaining why insulin was not administered on specific occasions, and the facility staff could not provide a rationale for these discrepancies during interviews. The deficiencies highlight a lack of adherence to care policies and documentation requirements, impacting the residents' treatment and care. The facility's failure to document refusals and notify relevant parties, as well as inconsistencies in medication administration, were identified as significant issues during the survey.
Failure to Provide Proper Respiratory Care for a Resident
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for a resident diagnosed with obstructive sleep apnea (OSA), chronic kidney disease, and muscle weakness. The resident had a physician's order for the use of a CPAP machine at bedtime, with instructions to document if refused. However, observations revealed that the resident's CPAP mask was found on the floor and on the bedside table, not stored in a sanitary manner after use. The Treatment Administration Record indicated that the resident utilized the CPAP machine overnight, but the care plan did not include any notation of the resident's use of the CPAP machine. During interviews, the acting Director of Nursing (DON) acknowledged that the CPAP mask should be cleansed and bagged after each use and that the resident should have a care plan addressing the need for CPAP machine use due to the diagnosis of OSA. The facility's policy on respiratory equipment cleaning and disinfection, which requires cleaning and disinfection by a respiratory therapist, licensed nurse, or equipment technician, was not adhered to, leading to the deficiency.
Failure to Document and Act on Pharmacy Recommendations
Penalty
Summary
The facility failed to maintain proper documentation and timely action regarding pharmacy recommendations for two residents. For Resident 46, the facility did not implement a gradual dose reduction (GDR) of antipsychotic medication as recommended by the pharmacist on February 27, 2024, until July 31, 2024, following an interdisciplinary meeting. Additionally, a recommendation for antipsychotic monitoring was not reviewed by the physician, and no order for such monitoring was found in the resident's Medication Administration Record (MAR) as of August 27, 2024. Interviews with staff revealed that the process for antipsychotic monitoring on the MAR was still being developed, and there was a misunderstanding regarding the involvement of Meditelecare in the resident's care. For Resident 119, the facility failed to provide a record of the pharmacist's recommendations and the physician's response from a medication regimen review completed on February 27, 2024. The acting Director of Nursing was unable to locate these documents during an interview on August 28, 2024. This lack of documentation and follow-up on pharmacy recommendations indicates a failure to adhere to the facility's policy on Medication Regimen Review and Reporting, which requires that recommendations be documented and acted upon within a specified timeframe.
Improper Storage and Use of Aranesp in Medication Room
Penalty
Summary
The facility failed to store medication in accordance with professional principles in the Heritage Medication Storage Room. During an observation, a single-dose vial of Aranesp, a medication used to treat low red blood cell count, was found open with the cap removed and no opened date on the vial. According to the product information, Aranesp should be used only once and discarded after a single use, even if there is medicine left. However, an interview with a Registered Nurse Supervisor revealed that the facility used the medication until the bottle was empty, as long as it was not past the expiration date, due to the high cost of Aranesp. The Nursing Home Administrator expected the medication to be disposed of after a single use, following manufacturer guidelines.
Failure to Document Vaccine Education at Refusal
Penalty
Summary
The facility failed to document education regarding the influenza vaccination at the time of refusal for two residents. Clinical record reviews and staff interviews revealed that Residents 46 and 85 refused the 2023/2024 influenza vaccine. However, the facility was unable to provide documentation that education on the benefits and potential risks of not accepting the vaccine was provided to these residents or their representatives. During an interview, the facility's Infection Preventionist admitted that documentation for Resident 46's education could not be located. Additionally, the staff member who documented Resident 85's refusal was unaware of the requirement to provide education on the risks and benefits of the vaccine or its refusal. The Acting Director of Nursing confirmed that there should have been documented evidence of education provided at the time of the vaccine refusal.
Failure to Adhere to Professional Standards for IV Care
Penalty
Summary
The facility failed to ensure care and services were provided in accordance with professional standards for three residents. Resident 1, who had diagnoses including diabetes mellitus, osteomyelitis, and chronic kidney disease, was admitted with orders for Cefazolin to be administered via IV. However, the facility did not flush Resident 1's IV line from January 30, 2024, through February 7, 2024, and failed to change the central line dressing weekly as required, with no documentation of a dressing change on February 7, 2024. The Director of Nursing confirmed these lapses in care via electronic mail communication on March 5, 2024. Resident 3, diagnosed with sepsis, methicillin-resistant staphylococcus aureus, and diabetes mellitus, did not have an order for a central line dressing change until March 4, 2024, despite facility policy requiring weekly changes. The Director of Nursing confirmed that Resident 3 should have had a central line dressing change order prior to March 4, 2024. Resident 4, diagnosed with osteomyelitis and diabetes mellitus, had an order for a weekly PICC/Midline dressing change starting February 12, 2024, but there was no documentation that this dressing change was completed on the scheduled date. The Director of Nursing confirmed that the dressing change should have occurred on February 12, 2024. The Nursing Home Administrator was made aware of these concerns during an interview on March 5, 2024, but no further information was provided.
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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