Manatawny Center For Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Pottstown, Pennsylvania.
- Location
- 30 Old Schuylkill Road, Pottstown, Pennsylvania 19465
- CMS Provider Number
- 395319
- Inspections on file
- 20
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Manatawny Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
Surveyors found that medication carts on one nursing unit were left unattended with open computer screens displaying residents’ personally identifiable information. On two separate occasions, each involving a different nurse, a cart was observed in the hallway with resident data visible while the assigned nurse was not present in the immediate area. In a subsequent interview, the NHA acknowledged that the facility did not ensure confidentiality of residents’ medical records as required by applicable regulations.
Surveyors found repeated instances of unsecured medications and unlocked medication carts on a nursing unit. On multiple occasions, a medication cart was left unlocked in the hallway with no nurse present, including one instance with crushed medication in a cup and another with an unidentified blister pack left on top of the cart, while the assigned nurse was at the far end of the hallway speaking with staff. Facility policy required carts to be locked when out of the nurse’s sight and prohibited medications from being left on top of the cart, and both the nurse and the DON acknowledged these requirements.
Surveyors found that during a respiratory outbreak on one nursing unit, staff did not follow required transmission-based precautions. Despite signage at the unit entrance instructing staff and visitors to wear masks and posted Contact and Droplet Precaution signs on specific rooms, staff were observed entering multiple rooms, including those on contact and droplet precautions, without masks, gowns, or other PPE while delivering clean laundry. PPE supplies were available outside rooms, and the DON, serving as Infection Prevention Nurse, later confirmed that all staff were expected to wear masks on outbreak units and comply with posted precaution requirements.
Surveyors found that a resident with an indwelling urinary catheter was repeatedly observed in bed with the catheter bag hooked to the side of the bed and visible from the doorway, without a privacy cover in place. A staff member confirmed that no privacy bag cover was used for the catheter bag, and facility leadership later confirmed these findings. This resulted in a failure to maintain the resident’s dignity and privacy related to catheter use.
A resident with Parkinson’s disease, CHF, COPD, GERD, and class II obesity was care planned as being at nutritional risk, with interventions directing staff to monitor and report significant weight loss, including a 3 lb loss in one week. Within a week, the resident lost 7 lbs, but there was no documentation that the physician was notified. The dietician reported that dietary only assesses residents with a ≥5% weight loss or by nursing request, was unaware of the specific 3 lb/week notification requirement, described the intervention as generic rather than resident‑centered, and confirmed the physician was not informed of the weight loss.
A resident with orthostatic hypotension had a physician’s order for midodrine 5 mg PO BID with instructions to hold the dose if systolic blood pressure (SBP) was greater than 130. Review of the MAR and a subsequent medication regimen review showed that staff administered midodrine on multiple occasions when the resident’s SBP was above the ordered hold parameter. The resident reported not being aware that the medication was given outside the prescribed parameters, and the NHA confirmed that staff administered the drug contrary to the physician’s order and facility policy.
The facility did not ensure accurate monitoring and adherence to physician-ordered fluid restrictions for two residents with CHF and CKD. One resident with a 1500 ml/24‑hr restriction consistently received fluids in excess of the order on every day reviewed, based on MARs, task documentation, and meal fluid provision. Another resident with a 2000 ml/24‑hr restriction and a 120 cc daily medication pass order exceeded the total fluid restriction on multiple days and the medication pass volume on most days reviewed. Dietary staff were not involved in ordering or monitoring fluid restrictions, and the culinary department provided fluids per standard guidelines without documenting them in the record. Fluid intake was documented separately by nurses on the MAR and by nurse aides on task forms, which made it difficult to determine the residents’ actual total fluid intake.
The facility failed to implement necessary treatment orders for two residents with pressure ulcers. One resident had a stage 3 ulcer on the left heel, and another had a stage 2 ulcer on the sacrum. In both cases, recommended treatments were not carried out as per the physician's orders, as confirmed by the DON and Nursing Home Administrator.
The facility failed to maintain a safe and homelike environment in the Milestone Unit, with surveyors observing significant wall damage in several rooms. Despite the damage being noted on two separate occasions, staff were unaware of the issues, indicating a lack of communication and timely maintenance.
The facility failed to develop comprehensive care plans for two residents. One resident had urinary retention and a foley catheter inserted, but no care plan was created for these issues. Another resident, treated for CHF, had an increased Lasix dosage and right elbow edema, but these were not reflected in their care plan. These deficiencies were confirmed by the DON.
A resident experienced a 5.89% weight loss over a period, and the dietitian recommended nutritional changes to address this. However, the care plan was not updated to include these changes. The Director of Nursing confirmed the oversight, leading to a deficiency in care plan revision compliance.
The facility was found to have exposed electrical wiring within an electrical junction box that lacked a cover plate, located above the suspended ceiling near the cross corridor double doors to Component 01. This deficiency was confirmed by the Facilities Director.
The facility was found to have improperly used surge suppressors in two areas. In the 1st floor D.O.N. Office, a surge suppressor was daisy-chained to another, and in the basement Medical Records Room, a surge suppressor powered a refrigerator and microwave. These deficiencies were confirmed by the Facilities Director.
The facility did not maintain the fire resistance of exit stairtower enclosures, affecting one smoke compartment. An observation revealed that the basement door to Stairtower 1 failed to positively latch within the door frame, a deficiency confirmed by the Facilities Director.
The facility failed to maintain the positive latching of corridor doors, specifically the double doors to the Kitchen Dry Storage Room, due to a malfunctioning door coordinator. This deficiency was confirmed by the Facilities Director and affects one of the eleven smoke compartments, compromising fire safety standards.
The facility was found to be non-compliant with building construction requirements as it was a two-story, Type III (200), unprotected ordinary structure that is fully sprinklered. This construction type is limited to one story in height for health care settings. The issue was confirmed by the Facilities Director.
The facility did not document monthly visual inspections of exit signage for over a year, as required by NFPA 101 standards. This deficiency was confirmed through a document review and interview with the Facilities Director, revealing non-compliance with safety regulations.
Unattended Medication Carts with Exposed Resident Information
Penalty
Summary
Surveyors identified a failure to maintain the confidentiality of residents’ medical information on Unit A’s medication cart. During an observation on A Wing on March 18, 2026, at 8:33 a.m., a medication cart assigned to licensed nurse Employee E8 was found unattended with the computer screen open, displaying residents’ personally identifiable information, while Employee E8 was not present in the hallway or immediate vicinity. A second observation on A Wing on March 19, 2026, at 8:45 a.m. showed a similar situation, with a medication cart assigned to licensed nurse Employee E9 left unattended and its computer screen open, again displaying residents’ personally identifiable information, and Employee E9 not present nearby. During an interview on March 19, 2026, at approximately 2:10 p.m., the Nursing Home Administrator confirmed that the facility did not ensure the confidentiality of residents’ medical information in accordance with regulatory requirements, specifically 28 Pa Code 211.5(b) related to medical records.
Unsecured Medication Carts and Medications Left Unattended
Penalty
Summary
The deficiency involves the facility’s failure to keep medication carts locked and medications secured in accordance with facility policy and professional standards. The facility’s “Administering Medication” policy, last revised April 2020, requires that medication carts remain closed and locked when out of sight of the medication nurse or aide, and that no medications are kept on top of the cart. On Nursing Unit A, surveyors observed an unlocked medication cart in the hallway outside a resident room with no nursing staff present nearby. During an interview, the assigned licensed nurse (Employee E8) acknowledged that the cart should have been locked. On subsequent observations on Nursing Unit A, surveyors again found unsecured medications and unlocked carts. One observation revealed an unlocked cart outside a resident’s room with crushed medication in a plastic cup left on top of the cart while the assigned nurse (Employee E9) was at the opposite end of the hallway speaking with other staff. Another observation showed an unlocked cart in the hallway between two residents’ rooms with an unidentified blister pack partially covered by papers on top of the cart, while the same nurse (Employee E9) was at the end of the hallway speaking with staff. In interviews, Employee E9 confirmed that the cart should have been locked and medications should not be left unattended on top, and the DON confirmed that staff are required to lock medication carts when unattended and are not permitted to leave medications unsecured on top of the carts.
Failure to Follow Transmission-Based Precautions During Respiratory Outbreak
Penalty
Summary
Surveyors identified a failure to implement transmission-based precautions on one of four nursing units during a confirmed respiratory outbreak. CDC guidance cited in the report recommends Contact Precautions, including use of gloves and gowns, for residents with infections posing increased risk of contact transmission, and Droplet Precautions, including mask use, for residents with infections transmitted by respiratory droplets. The facility’s Infection Prevention and Control Program policy states that important facets of infection prevention include educating staff and ensuring adherence to proper techniques and procedures, and implementing appropriate isolation precautions when necessary. During observation of Unit C, surveyors noted a sign at the unit entrance instructing staff and visitors to wear masks due to a respiratory outbreak, yet staff were seen entering resident rooms without masks while delivering clean laundry. Staff were also observed entering a room with a Contact Precaution sign without any PPE, and moving between rooms without precautions and rooms with droplet precautions in place without donning PPE, despite PPE being available in bins outside every unit where transmission precautions were in place. The DON, who also serves as the Infection Prevention Nurse, confirmed that a respiratory virus outbreak on Unit C had been identified and that all staff were expected to wear masks on outbreak units and follow posted transmission-based precaution signs.
Failure to Maintain Dignity for Resident With Indwelling Urinary Catheter
Penalty
Summary
Surveyors identified a dignity-related deficiency involving the use of an indwelling urinary catheter for Resident 80. On multiple observations conducted on March 17, 2026, at 11:34 a.m., 12:00 p.m., 1:16 p.m., and 2:08 p.m., Resident 80 was observed in bed with the urinary catheter bag hooked to the side of the bed and clearly visible from the doorway, without any privacy bag cover in place. The visibility of the catheter bag from the door indicated that no measures were taken to shield it from view. During an interview at 2:08 p.m. on the same day, Employee 5 confirmed that Resident 80 did not have a privacy cover on the catheter bag. In a subsequent interview on March 19, 2026, at 11:15 a.m., the Nursing Home Administrator confirmed these findings. These observations and interviews demonstrated that the facility failed to ensure privacy and dignity for Resident 80 in relation to the management of the indwelling urinary catheter, in violation of resident rights and nursing services requirements.
Failure to Implement Care Plan for Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, resident-centered care plan intervention to prevent nutritional and hydration alterations for one resident. The resident had multiple medical diagnoses, including Parkinson’s disease, CHF, COPD, GERD, and a BMI of 35.9 (class II obesity), and was identified in a care plan dated March 9, 2026, as being at nutritional risk related to these conditions. The care plan interventions included monitoring, recording, and reporting to the physician signs and symptoms of malnutrition, specifically including significant weight loss of 3 lbs in a week, greater than 5% in one month, greater than 7.5% in three months, and greater than 10% in six months. Review of the resident’s 30‑day weights showed an admission weight of 171.4 lbs on March 5, 2026, 172 lbs on March 9, 2026, and 165 lbs on March 16, 2026, indicating a 7‑lb loss in 7 days. Despite this, there was no documentation in the progress notes that the physician was notified of the weight loss, as required by the care plan intervention. During an interview, the dietician stated that dietary staff only assess residents who trigger for a 5% or greater weight loss or if requested by nursing, and that the 7‑lb loss represented a 4.07% decrease, which did not meet the 5% threshold used by dietary. The dietician confirmed creating the interventions but was not aware of the specific intervention requiring physician notification for a 3‑lb weekly weight loss, acknowledged the intervention was generic and not resident‑centered, and confirmed the physician was not notified of the weight loss.
Medication Administered Outside Ordered Blood Pressure Parameters
Penalty
Summary
The deficiency involves the facility’s failure to administer medication in accordance with a physician’s order and the facility’s own medication administration policy for one resident. The facility policy titled “Administering Medications,” revised April 2020, requires that medications be administered in accordance with prescriber orders, including any required time frame. The resident had a physician’s order dated November 29, 2024, for midodrine 5 mg by mouth twice daily for orthostatic hypotension, with a specific hold parameter to not administer the medication if the systolic blood pressure (SBP) was greater than 130. Review of the January 2026 MAR showed that the resident received midodrine 5 mg on ten occasions when the SBP exceeded the ordered hold parameter. The MAR documented that midodrine was administered despite SBP readings above 130 on multiple dates and times in January, with recorded SBPs of 131, 132, 133, 134, and 138 at the time of administration. A medication regimen review dated February 6, 2026, noted that the resident was given midodrine outside the hold parameters on several dates in January. During an interview, the resident reported not being aware that the medication had been given outside the prescribed hold parameters. In a separate interview, the Nursing Home Administrator confirmed that staff administered midodrine 5 mg outside of the prescribed hold parameters, constituting noncompliance with the physician’s order and the facility’s medication administration policy.
Failure to Monitor and Adhere to Physician-Ordered Fluid Restrictions
Penalty
Summary
The facility failed to properly monitor and adhere to physician-ordered fluid restrictions for two residents with significant cardiac and renal conditions. Facility policy on weight assessment and interventions required the physician and multidisciplinary team to identify medical conditions and medications that may cause fluid and nutrient loss or inadequate availability of food or fluids. One resident with chronic diastolic heart failure had a physician order for a 1500 ml fluid restriction over 24 hours, with 840 ml to be provided with meals and 660 ml by nursing staff. Review of this resident’s Medication Administration Records (MARs) and 30‑day task documentation for February and March 2026, combined with the fluids provided at meals, showed that the resident’s total fluid intake exceeded the 1500 ml restriction on all 30 days reviewed. Another resident with chronic kidney disease stage 3 and chronic diastolic congestive heart failure had a physician order for a 2000 ml fluid restriction over 24 hours, with 1080 ml to be provided with meals and 920 ml by nursing staff, as well as an order for a medication pass of 60 cc twice daily (120 cc total per day). Review of this resident’s February and March 2026 MARs and 30‑day task documentation showed that the combined fluid intake from nursing staff and meals exceeded the 2000 ml restriction on 13 of 30 days, and the ordered 120 cc daily medication pass volume was exceeded on 19 of 30 days. Interviews with the dietician and culinary director revealed that dietary staff were not involved in ordering or monitoring fluid restrictions and that the culinary department followed standard fluid breakdown guidelines but did not document fluids provided with meals in the resident records. An interview with the NHA and DON confirmed that both nurses and nurse aides were documenting fluid intake in different places, making it difficult to determine the exact amount of fluids residents actually received.
Failure to Implement Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to provide necessary treatments for two residents with pressure ulcers, as identified through clinical record reviews and staff interviews. Resident 71 had a stage 3 pressure ulcer on the left heel, and a wound consult recommended cleansing with wound cleanser, applying betadine, and leaving the wound open to air daily and as needed. However, the physician's orders and treatment administration record (TAR) showed that this order was not implemented. The Director of Nursing (DON) confirmed that the treatment order was changed during wound rounds but was not put into place. Similarly, Resident 177 had a stage 2 pressure ulcer on the sacrum, with a wound consult recommending cleaning with wound cleanser, applying house barrier cream, and leaving the wound open to air daily and as needed. Again, the physician's orders and TAR revealed that this order was not implemented. Both the DON and the Nursing Home Administrator confirmed that the order to change the treatment was not implemented. These findings indicate a failure to adhere to professional standards of practice in treating pressure ulcers, as required by regulations.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. 1. Resident R71 and R177's wounds were reassessed, and physicians were notified that new wound orders implemented on wound rounds were not transcribed to the TAR (treatment administration record) and were not implemented. There were no unfavorable outcomes related to the facilities alleged deficient practice. 2. Audit of current residents with pressure ulcers completed to ensure that recommended treatments are in place as recommended by the wound team. 3. DON/Designee will complete training to licensed staff on the components of this regulation, including ensuring treatment orders are transcribed to the TAR in a timely manner. 4. DON/Designee will have complete audits of 5 residents with pressure wounds 2 x a week x 4 weeks, then 1 x a week x 4 weeks, then 2 x a month, then 1 x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings in QAPI. 5. Date of Compliance will be February 28, 2025.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe and homelike environment in the Milestone Unit, as evidenced by multiple observations of physical damage in resident rooms. On January 28, 2025, during an observation of the Milestone Unit, surveyors noted significant damage to the walls in rooms 21, 22, and 23. Room 23 had two holes in the wall by the window, measuring 3.0 x 5.0 inches and 2.0 x 5.0 inches. Room 22 had one hole measuring 5.0 x 7.0 inches, and room 21 had two holes measuring 2.0 x 11 inches and 2.0 x 2.0 inches. These observations were still present during a follow-up observation on January 31, 2025, indicating a lack of timely maintenance and repair. An interview with Employee E3 on January 31, 2025, revealed that the employee was unaware of the holes in the walls of rooms 21, 22, and 23, suggesting a communication breakdown or oversight in reporting and addressing maintenance issues. The findings were discussed with the Nursing Home Administrator on the same day, highlighting the facility's failure to maintain a safe and homelike environment as required by federal and state regulations.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. 1. Facility failed to provide a safe and homelike environment in the Milestones unit in rooms 21, 22, and 23. Holes were repaired in rooms 21, 22, and 23. 2. Audit of all resident rooms in Milestones unit completed to ensure no other areas were observed. 3. Maintenance Director/Designee will complete training of staff on the components of this regulation to include the need to report all changes in environment to maintenance. 4. The Maintenance Director/Designee will complete audits of 5 rooms 2 x a week x 4 weeks, then 1 x a week x 4 weeks, then 2 x a month, then 1 x a month x 2 months to ensure that all rooms have a safe homelike environment. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings in QAPI. 5. Date of compliance will be 2/28/25.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, leading to deficiencies in addressing their medical needs. For Resident 22, the clinical records indicated that the resident was experiencing urinary retention and had a foley catheter inserted as per the CRNP's orders. Despite these medical interventions, the facility did not create a care plan to address the urinary retention or the use of the foley catheter. This oversight was confirmed during an interview with the Nursing Home Administrator and Director of Nursing. Similarly, Resident 108's care plan was found lacking in addressing changes in their medical treatment. The resident, who was being treated for congestive heart failure, had an increase in their Lasix dosage due to persistent edema in the right elbow. However, the facility did not update the care plan to reflect the increase in Lasix or the presence of right elbow edema. This deficiency was confirmed by the Director of Nursing during an interview.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. 1. Facility failed to develop a comprehensive care plan for R22 for urinary retention with placement of a foley catheter and R108 for increase in Lasix and right elbow edema. Care plans were updated for both residents. 2. Audit of current residents completed to ensure that changes were added to care plans. 3. DON/Designee will complete education to licensed staff on the components of this regulation to include the need for comprehensive care plans for changes. 4. DON/Designee will complete audits of 5 residents 2 x a week x 4 weeks, then 1 x a week x 4 weeks, then 2 x a month, then 1 x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/ Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings in QAPI. 5. Date of compliance will be 2/28/2025.
Failure to Revise Care Plan for Nutritional Changes
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as Resident 84, to reflect changes in nutrition despite a significant weight loss. Between December 14, 2024, and January 6, 2025, Resident 84 experienced a 5.89% weight loss. A weight warning note from the dietitian, dated January 6, 2025, identified this weight loss and suggested adding pudding to lunch and dinner, as well as adding dessert for additional calories. However, a review of Resident 84's care plan revealed that it was not updated to include these nutritional changes recommended by the dietitian. An interview with the Director of Nursing on January 31, 2025, confirmed that the care plan had not been revised to incorporate the dietitian's recommendations. This oversight was noted as a deficiency in the facility's compliance with care plan revision requirements.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. 1. Facility failed to revise a care plan to reflect changes in a R84s weight loss. Care plan updated for this resident. 2. Audit of current residents with weight loss completed to ensure that residents have care plans in place and are updated. 3. DON/ Designee will complete training for licensed staff on the components of this regulation to include the need to update care plans. 4. DON/Designee will complete audits of 5 residents with weight loss weekly 2 x a week x 4 weeks, then 1 x a week x 4 weeks, then 2 x a month, then 1 x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings in QAPI. 5. Date of compliance will be 2/28/25.
Exposed Electrical Wiring Found in Facility
Penalty
Summary
The facility failed to comply with the National Fire Protection Association (NFPA) standards for electrical wiring, specifically NFPA 70, the National Electric Code. During an observation, it was found that there was exposed electrical wiring within an electrical junction box that lacked a cover plate. This issue was located above the suspended ceiling near the cross corridor double doors to Component 01. The observation was confirmed through an interview with the Facilities Director, who acknowledged the presence of the exposed wiring.
Plan Of Correction
1. The Maintenance Director installed a cover plate for the electrical junction box to ensure the wiring is properly protected and secure. 2. The Maintenance Director and relevant staff members will receive training on NFPA 70, National Electric Code, with a focus on proper installation and maintenance of electrical wiring and equipment. 3. The Maintenance Director/designee will conduct a thorough inspection of electrical junction boxes and wiring throughout the facility to verify compliance with NFPA 70 standards. Any additional areas of concern will be addressed immediately. Monthly audits of electrical junction boxes and wiring will be conducted by the Maintenance Director/designee to ensure continued compliance with NFPA 70. Findings will be documented and reported for further action, if necessary. 4. Findings will be reviewed at the Quality Assurance Performance Improvement meeting.
Improper Use of Surge Suppressors in Facility
Penalty
Summary
The facility failed to properly monitor the use of surge suppressors, resulting in two deficiencies observed during a survey. The first deficiency was identified in the 1st floor Director of Nursing (D.O.N.) Office, where a surge suppressor was found supplying electrical power to another surge suppressor, a practice known as daisy-chaining. This was confirmed through an interview with the Facilities Director. The second deficiency was observed in the basement Medical Records Room, where a surge suppressor was supplying power to a refrigerator and a microwave, both of which are high-draw devices. This setup was also confirmed by the Facilities Director during the interview.
Plan Of Correction
1. The Maintenance Director has eliminated the daisy-chained surge suppressor powering the D.O.N. office and disconnected the surge suppressor supplying electricity to the refrigerator and microwave in the Medical Records room. 2. The Maintenance Director and relevant staff members will receive comprehensive training on NFPA 101 Standard Electrical Equipment - Power Cords and Extension Cords, with a focus on the appropriate use of power strips in patient care vicinities and non-patient care rooms. 3. The Maintenance Director/designee will conduct routine inspections of patient care vicinities and non-patient care rooms to ensure compliance with electrical equipment standards for power cords, extension cords, and surge suppressors. Monthly audits will be performed to verify ongoing adherence to these standards. 4. Findings will be reviewed at the Quality Assurance Performance Improvement meeting.
Failure to Maintain Fire Resistance of Stairtower Enclosures
Penalty
Summary
The facility failed to maintain the fire resistance of exit stairtower enclosures, specifically affecting one of eleven smoke compartments. During an observation, it was noted that the basement door to Stairtower 1 did not positively latch within the door frame. This deficiency was confirmed through an interview with the Facilities Director, who acknowledged the issue with the stairtower door not latching properly.
Plan Of Correction
1. The Maintenance Director/designee will repair or replace the basement door to Stair Tower 1 to ensure it positively latches within the door frame, maintaining the fire resistance of the exit stair tower enclosure. 2. The Maintenance Director and relevant staff members will receive training on NFPA 101 Standard - Stairways and Smokeproof Enclosures, focusing on the importance of maintaining the fire resistance of exit stair tower enclosures and ensuring proper door functionality. 3. The Maintenance Director/designee will inspect all stair tower doors within the facility to verify they positively latch within the door frame and maintain the required fire resistance. Monthly audits of stair tower doors will be conducted to ensure continued compliance with positive latching requirements. 4. Findings will be reviewed at the Quality Assurance Performance Improvement meeting.
Failure to Maintain Positive Latching of Corridor Doors
Penalty
Summary
The facility failed to maintain the positive latching of corridor doors, specifically affecting the double doors to the Kitchen Dry Storage Room. During an observation on January 15, 2025, at 12:15 PM, it was noted that these doors did not automatically close in the required order, which resulted in their failure to latch within the frame. This issue was attributed to the malfunctioning of the associated door coordinator, which is essential for ensuring the doors close properly and maintain the necessary fire safety standards. An interview with the Facilities Director at the same time confirmed the observation, acknowledging that the doors failed to latch due to the door coordinator's failure. This deficiency impacts one of the eleven smoke compartments within the facility, highlighting a lapse in maintaining the required safety measures for corridor doors, which are crucial for preventing the passage of smoke and ensuring fire safety compliance.
Plan Of Correction
1. The Maintenance Director/designee will repair or replace the door coordinator on the double doors to the Kitchen Dry Storage Room to ensure proper closing and latching within the door frame. 2. The Maintenance Director and relevant staff members will receive training on NFPA 101 Standard - Corridor Doors, focusing on the importance of maintaining positive latching of corridor doors within smoke compartments. 3. The Maintenance Director/designee will inspect all corridor doors in the facility to verify proper latching within door frames. Special attention will be given to doors with coordinating devices. Monthly audits of corridor doors will be conducted to ensure continued compliance with positive latching requirements. Findings will be documented and reported for further action, if necessary. 4. Findings will be reviewed at the Quality Assurance Performance Improvement meeting.
Non-compliance with Building Construction Requirements
Penalty
Summary
The facility was found to be non-compliant with building construction requirements as it was observed to be a two-story, Type III (200), unprotected ordinary structure that is fully sprinklered. According to the NFPA 101 standards, this type of construction is limited to one story in height when used in health care settings. The observation was made during a survey on January 15, 2025, and was confirmed through an interview with the Facilities Director, who acknowledged that the construction type is not allowed for health care facilities.
Failure to Document Monthly Exit Signage Inspections
Penalty
Summary
The facility failed to provide documentation verifying that monthly visual inspections of exit signage had occurred within the previous twelve months. This deficiency was identified during a document review and interview conducted on January 15, 2025. The review revealed that the facility had not documented any visual inspections of exit signs since August 28, 2024. This lack of documentation affects the entire component of the facility's exit signage system. An interview with the Facilities Director on the same day confirmed the absence of documentation for the required monthly visual inspections of exit signage. The failure to maintain records of these inspections indicates non-compliance with the NFPA 101 standards, which require exit and directional signs to be displayed with continuous illumination and to be part of the emergency lighting system. The deficiency impacts the facility's ability to ensure that exit signage is properly maintained and functional.
Plan Of Correction
1. The Maintenance Director will conduct a thorough inspection of all exit signs within the facility to ensure proper functionality and compliance with NFPA 101 Standard - Exit Signage. 2. The Maintenance Director and relevant staff members will be trained on the NFPA 101 Standard - Exit Signage requirements, focusing on the importance of conducting and documenting monthly visual inspections. 3. The Maintenance Director/designee will establish a log or binder specifically for exit signage inspections, where they will document the date and findings of each monthly inspection. The log will be stored in the Life Safety Book located in the NHA's office. The Maintenance Director/designee will perform monthly visual inspections of exit signs and update the log accordingly. The NHA/designee will review the log during monthly audits to verify documentation and compliance with the inspection requirements. 4. Findings will be reviewed at the Quality Assurance Performance Improvement meeting.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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