Maple Winds Healthcare And Rehabilitation, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Portage, Pennsylvania.
- Location
- 4112 Spring Hill Road, Portage, Pennsylvania 15946
- CMS Provider Number
- 396088
- Inspections on file
- 26
- Latest survey
- July 7, 2025
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Maple Winds Healthcare And Rehabilitation, Llc during CMS and state inspections, most recent first.
Surveyors found that the facility did not complete the required Annual Fuel Quality Test for the emergency generator, as documentation showed the test was failed due to fuel contamination and the issue was not corrected at the time of inspection. This deficiency was confirmed by both the Facility Administrator and Maintenance Director.
A missing ceiling tile was observed in the Physical Therapist's office within the Patient Therapy room, creating an opening that could impact the function of the automatic sprinkler system. This deficiency was confirmed by the Facility Administrator and Maintenance Director and affected one of five smoke compartments.
Surveyors found that corridor doors to two resident rooms did not close and latch properly, as confirmed by the facility's Administrator and Maintenance Director. This deficiency affected one of five smoke compartments and did not meet regulatory requirements for smoke resistance and positive latching.
Surveyors found that the facility did not have a written Emergency Preparedness Plan that included an annually updated facility-based and community-based risk assessment using an all-hazards approach. This deficiency was confirmed through document review and interviews with facility leadership.
Surveyors found that the facility's Emergency Preparedness Plan did not include required procedures outlining the facility's role under a waiver declared by the Secretary of the Department of Health, specifically regarding care provision at an alternate care site as identified by emergency management officials. This omission was confirmed by facility leadership during interviews.
Surveyors found that the facility failed to maintain documentation of initial and annual emergency preparedness training for all new and existing staff. Interviews with the Administrator and Maintenance Director confirmed that required training records were not kept, resulting in a deficiency related to emergency preparedness training documentation.
Maple Winds Healthcare and Rehabilitation LLC did not maintain documentation for the two annual exercises required to test its Emergency Preparedness Plan, as confirmed by interviews and documentation review during a survey.
Surveyors observed that several opened food items, including pasta, cheese, flour, and rice, were not labeled with open dates in the kitchen and dry storage areas. Facility staff confirmed that all opened food items should be dated according to policy, but this was not followed.
The facility did not complete comprehensive admission MDS assessments within the required 14-day timeframe for several residents, with delays ranging from one to eight days. This deficiency was confirmed through clinical record review and staff interviews, as mandated assessment deadlines were not met.
A resident with a history of obstructive uropathy had their indwelling urinary catheter discontinued and subsequently experienced frequent bladder incontinence. The care plan was not updated to reflect this significant change in condition, as confirmed by the DON and review of clinical records.
Surveyors found that the facility did not consistently document urine output for a resident with an indwelling catheter, as required by policy, and failed to ensure proper incontinent care and documentation, including the application of barrier cream, for another resident needing assistance with toileting. These deficiencies were confirmed through record review and staff interviews.
The facility did not ensure that two residents with IV access had their catheters flushed with Normal Saline before and after medication administration, as required by policy and physician orders. Additionally, staff failed to obtain physician orders for the care and maintenance of a midline catheter for one resident. The DON confirmed the lack of documentation for both the required flushes and the necessary physician orders.
A resident with a history of acute respiratory failure and multiple chronic illnesses experienced a significant change in condition, including difficulty to arouse, abnormal vital signs, and a distended bladder. Nursing staff intervened but did not notify the physician or the resident's responsible party as required by facility policy. In a similar later event, proper notifications were made, highlighting the earlier failure.
A facility failed to document and log grievances reported by a resident's family regarding the resident being found soiled and the presence of pills in the resident's room. Although grievance forms were completed and staff were notified, the incidents were not entered into the official grievance log as required by facility policy and federal regulations.
The facility did not provide written transfer notifications, bed-hold notices, or ombudsman notifications for three residents transferred to the hospital, and failed to complete a discharge summary for another resident discharged to a personal care home. These residents had significant medical conditions at the time of transfer, and the required documentation and notifications were not completed as confirmed by the DON.
Two residents received medications, including a diuretic and an anticonvulsant, as documented in physician orders and the MAR, but their MDS assessments were inaccurately coded to indicate these medications were not administered during the required look-back period. This was confirmed by record review and staff interviews, including with the DON.
A resident who was cognitively intact and required extensive assistance with daily care tasks was prescribed an anticoagulant, antiplatelet, and diuretic, but the facility did not develop a care plan to address the specific needs related to these medications. The DON confirmed that such a care plan was not created, despite facility policy requiring individualized, person-centered care planning.
A resident did not receive all ordered doses of IV Meropenem for a UTI, with only 19 out of 21 doses administered as documented in the MAR. The DON confirmed the missed doses, indicating a failure to follow physician orders for antibiotic therapy.
A resident who was at risk for falls and required extensive assistance was found on the floor after fall prevention interventions, including bilateral fall mats, were not in place as specified in the care plan. Observation later confirmed that the required fall mats were still not present, and the DON acknowledged this omission.
A resident who was cognitively impaired and received routine opioid pain management did not have proper documentation for the destruction of Fentanyl patches, as required by facility policy. On multiple occasions, two staff signatures were missing from the controlled drug record after patch removal, and this was confirmed by the DON.
A resident with cancer and cognitive impairment did not have updated hospice nurse aide or RN charting in their clinical record, as required. The last documented charting was nearly a month old, and the DON confirmed the documentation was missing and should have been present.
The QAPI committee failed to effectively address recurring deficiencies, resulting in repeated citations for issues such as care plan revisions, quality of care, accident hazards, intravenous catheter maintenance, and controlled medication accountability. Despite implementing audits and reviews, the committee was ineffective in ensuring sustained compliance with regulations.
The facility did not ensure that the Medical Director attended any of the required quarterly QAA Committee meetings, as confirmed by attendance records and the DON, resulting in noncompliance with regulations for committee composition and participation.
An LPN failed to follow hand hygiene protocols during medication administration for three residents, neglecting to sanitize hands before preparing or handling medications and after removing gloves, as required by facility policy. This was confirmed through direct observation and staff interviews, indicating noncompliance with infection prevention procedures.
A resident's PICC line dressing was not changed weekly as ordered, with the last change documented on December 13, 2024. The resident, who was cognitively impaired, used a sock cuff to secure the dressing, which was not adhering properly. Staff interviews revealed the dressing was on back order, and there was confusion about sourcing alternatives.
Two residents in an LTC facility were found without adequate window coverings, compromising their privacy. Both residents, who are cognitively impaired and require assistance, had beds near windows facing the parking lot without blinds or curtains. Despite requests and orders for blinds, they had not been installed, failing to uphold the residents' rights to dignity and privacy.
A resident's privacy was compromised due to the absence of window coverings in their room, which faced the facility's main parking lot. The resident, who was cognitively impaired and required assistance for daily care, expressed feeling exposed while using the urinal and dressing. The facility had ordered blinds, but they had not yet arrived, and the Director of Housekeeping was unsure of how long the room had been without them.
A resident with severe cognitive impairment and a history of Alzheimer's and Parkinson's diseases was readmitted to the facility with bruising on her hands and arms. The facility failed to conduct a thorough investigation into the cause of her injury, as required by their policy, by not interviewing all staff who had potential contact with her. The Director of Nursing confirmed the lack of documentation for a comprehensive investigation.
A resident with a history of stroke and Parkinson's disease fell while self-propelling in a high-back reclining wheelchair due to improperly installed anti-tippers. The facility failed to follow the manufacturer's safety instructions, resulting in the wheelchair tipping backward.
The facility did not follow its planned menu, failing to provide bread and margarine to residents during a lunch meal. The Dietary Manager was unaware of the change made by a new cook, which violated the facility's policy and resident rights.
The facility failed to follow physician's orders for three residents and did not complete neurological checks after unwitnessed falls for two residents. A resident with diabetes received insulin against orders, another did not receive treatment for a skin tear, and a third did not have bowel protocol administered. These issues were confirmed by the DON.
The facility failed to document the administration of controlled medications for four residents, despite doses being signed out. This discrepancy was confirmed by the DON, highlighting a lack of accountability for controlled substances as per state regulations and facility policy.
The facility failed to address pharmacy recommendations timely for four residents and did not obtain completed recommendations for physician review for two residents. The policy requires monthly drug regimen reviews by a pharmacist, with recommendations reported to the physician. However, recommendations for insulin dose corrections, blood work, and medication adjustments were not addressed or obtained for review, as confirmed by the DON.
A resident with cognitive impairment and decreased mobility was found with an inaccessible call bell and a non-functional bed alarm. The care plan required the call bell to be within reach and alarms to be operational. An LPN and the DON confirmed these requirements were not met.
The facility did not maintain advance directives for a resident with cognitive impairment and diagnoses of cerebral infarction and depression. The facility's policy requires that advance directives be reviewed and documented, but there was no evidence of this for the resident. This was confirmed by the DON.
The facility failed to verify the nursing license of an LPN with the State Board of Nursing until months after employment and did not complete a Nurse Aide Registry verification for a nurse aide before her start date. These lapses were confirmed by the HR Director, despite the facility's policy requiring such verifications.
The facility failed to update care plans for three residents, leading to discrepancies between current medical orders and documented care plans. A resident's diet order was not updated, another's Foley catheter size was incorrect, and a third resident's care plan did not reflect the removal of a PICC line and cessation of antibiotics. These issues were confirmed through observations and staff interviews.
A facility failed to document a registered nurse's assessment after a resident's fall, as required by professional standards. The resident, who was moderately cognitively impaired, was found on the floor, but the clinical record lacked evidence of an RN assessment. The Director of Nursing confirmed this documentation failure.
A facility failed to follow a wound consultant's recommendation to increase the frequency of dressing changes for a resident at risk for pressure ulcers. Despite a recommendation to change the dressing twice daily, the treatment was not updated or documented as completed. The DON confirmed the oversight by the RN Supervisor.
A resident with hemiplegia did not receive prescribed passive ROM exercises twice daily as per the care plan. Documentation showed exercises were performed only once daily on several occasions. Interviews confirmed the facility's failure to adhere to the care plan, resulting in a deficiency in nursing services.
A medication security lapse occurred when a pill was found on the floor of a resident's room. The resident, who was cognitively intact and had gout, was prescribed Allopurinol. An LPN confirmed the pill was Allopurinol, and the DON acknowledged it should have been secured.
A resident, who was moderately cognitively impaired and required assistance for personal care, experienced a fall in her room. Although a registered nurse assessed the resident post-fall, the assessment was not documented in the clinical record, violating the facility's policy and regulatory requirements.
The facility's QAPI committee failed to address recurring deficiencies effectively, as identified in a recent survey. These deficiencies included failure to develop resident care plans, provide quality care, maintain accurate medical records, and ensure proper accounting of controlled medications. Despite previous plans of correction, the committee was ineffective in maintaining compliance with regulations.
The facility failed to ensure that a nurse aide completed the required 12 hours of in-service education annually. Despite the facility's policy mandating this requirement, records showed that a nurse aide hired in 2018 did not complete any annual education between 2022 and 2024. This was confirmed by the HR Director.
The facility failed to provide a written notice of the bed-hold policy to residents and/or their representatives at the time of transfer to a hospital. This deficiency was identified for three residents who were transferred to the hospital on multiple occasions, and the Nursing Home Administrator confirmed the oversight.
The facility failed to permit the readmission of a hospitalized resident without providing evidence that they could not meet the resident's needs. The resident, who had multiple diagnoses and exhibited noncompliant and aggressive behavior, was not readmitted after hospitalization. The decision was made without the required documentation to support the inability to meet the resident's needs.
The facility failed to maintain accurate clinical records for a resident with osteomyelitis and an acquired absence of the right great toe. The Treatment Administration Record lacked documentation for betadine dressings on two specific dates, despite a nurse's claim that the treatments were completed.
Failure to Complete Annual Emergency Generator Fuel Quality Test
Penalty
Summary
The facility failed to perform required emergency generator maintenance testing, specifically the Annual Fuel Quality Test for the emergency generator. Documentation reviewed during the survey revealed that the facility did not pass the Annual Fuel Quality Test due to contaminants found in the fuel. At the time of inspection, the fuel had not been repaired or replaced, and this failure was confirmed in interviews with both the Facility Administrator and the Maintenance Director. This deficiency affected the entire facility, as the emergency generator is a critical component for maintaining essential electrical systems. The lack of compliance with the required maintenance and testing protocols, as outlined by NFPA 101 and related standards, was directly observed and documented by surveyors during the recertification survey.
Plan Of Correction
Emergency generator maintenance testing is now current for the facility. The Maintenance Director/designee has replaced the emergency generator fuel and completed the Annual Fuel Quality Test for the emergency generator maintenance testing and documented passing results. The Facility Administrator will ensure compliance by confirming results of Emergency Generator Fuel Quality test annually. Findings will be reviewed at monthly Quality Assurance Meetings.
Failure to Maintain Sprinkler System Due to Missing Ceiling Tile
Penalty
Summary
The facility failed to maintain the automatic sprinkler system as required, as evidenced by an observation of a missing ceiling tile in the Physical Therapist's office, located in the Patient Therapy room. This opening in the ceiling could allow the passage of heat and smoke, which may affect the operation of the automatic sprinkler system. The deficiency was confirmed during an interview with the Facility Administrator and the Maintenance Director. The issue was identified in one of five smoke compartments within the facility. No information regarding specific patients, their medical history, or their condition at the time of the deficiency is provided in the report.
Plan Of Correction
The automatic sprinkler system is now maintained in the facility in all five smoke compartments. The Maintenance Director replaced the missing ceiling tiles in the Physical Therapist's office and in the Patient Therapy room, ensuring there are no current openings in the ceiling, preventing the passage of heat and smoke, and ensuring correct operation of the automatic sprinkler system. The Maintenance Director/designee will complete a check for missing ceiling tiles monthly for three months, ensuring compliance and no automatic sprinkler system deficiency. Findings will be reviewed at monthly Quality Assurance Meetings.
Failure to Maintain Corridor Doors for Smoke Resistance and Latching
Penalty
Summary
Surveyors observed that the facility failed to maintain corridor doors in accordance with NFPA 101 requirements in two separate instances. During inspections, it was found that the door to resident room 140 and the door to resident room 109 would not close and latch properly in their frames when tested. These deficiencies were identified during routine observations on July 7, 2025, at different times in the morning. Interviews conducted with the Facility Administrator and the Maintenance Director confirmed the issues with the corridor doors. The deficiencies affected one of five smoke compartments in the facility, as the doors did not meet the required standards for resisting the passage of smoke and ensuring positive latching, as specified by regulatory guidelines.
Plan Of Correction
Resident room 140 door now closes and latches in its frame when tested, maintaining corridor doors and all five smoke compartments within the facility. The Maintenance Director/designee will ensure corridor doors close and latch into their frames monthly times three months. Findings will be reviewed at monthly Quality Assurance Meetings. Resident room 109 door now closes and latches in its frame when tested, maintaining corridor doors and all five smoke compartments within the facility. The Maintenance Director/designee will ensure corridor doors close and latch into their frames monthly times three months. Findings will be reviewed at monthly Quality Assurance Meetings.
Failure to Maintain Emergency Preparedness Plan with Required Risk Assessment
Penalty
Summary
The facility failed to provide a written Emergency Preparedness (EP) Plan that included a facility-based and community-based risk assessment, as required by regulations. During a document review and interview conducted on July 7, 2025, it was found that the EP plan did not contain an annually updated risk assessment utilizing an all-hazards approach. This assessment is necessary to identify and address potential emergency events, including missing residents, as part of the facility's preparedness planning. Interviews with the Facility Administrator and Maintenance Director confirmed the absence of the required documentation in the EP plan. The deficiency was identified through both the review of the facility's emergency preparedness documentation and direct confirmation from facility leadership.
Plan Of Correction
A written Emergency Preparedness Plan that includes a facility-based and community-based risk assessment is now present in the facility. The Maintenance Director/designee will complete a check of the written Emergency Preparedness Plan to ensure it includes an annually updated facility-based and community-based risk assessment, utilizing an all-hazards approach. To ensure compliance, this check will be performed monthly for three months. Findings will be reviewed at monthly Quality Assurance Meetings.
Missing Emergency Preparedness Procedures for 1135 Waiver
Penalty
Summary
The facility failed to include procedures in its Emergency Preparedness (EP) Plan that address the role of the facility under a waiver declared by the Secretary of the Department of Health, as required by Section 1135 of the Act. During a review of the EP Plan and interviews conducted, it was found that the plan did not contain written procedures for the provision of care at an alternative care site identified by emergency management officials during such a waiver. This deficiency was confirmed through both documentation review and interviews with the Facility Administrator and Maintenance Director, who acknowledged that the EP plan lacked the necessary written plan outlining the facility's responsibilities and actions during a waiver situation. No information about specific residents or their medical conditions was included in the findings.
Plan Of Correction
A plan for the role of the facility under a waiver declared by the Secretary of the Department is now present in the facility. The Maintenance Director/designee will ensure procedures to address the role of the facility under a waiver declared by the Secretary, in accordance with Section 1135 of the Act, in the provision of care at an alternative care site identified by emergency management officials is included in the Emergency Preparedness Plan. The Facility Administrator will ensure compliance by confirming the Emergency Preparedness Plan contains a written plan of the facility's role during a waiver declared by the Secretary of the Department of Health monthly times three months. Findings will be reviewed at monthly Quality Assurance Meetings.
Failure to Maintain Documentation of Emergency Preparedness Training
Penalty
Summary
Surveyors identified a deficiency related to the facility's Emergency Preparedness (EP) training program. During a review of the facility's EP Plan and associated documentation, it was found that the facility did not maintain records of initial and annual emergency preparedness training for all new and existing staff. This lack of documentation was discovered during an interview and documentation review conducted on July 7, 2025, at 9:00 a.m. Further interviews with the Facility Administrator and the Maintenance Director confirmed that the required training documentation was not maintained. The absence of these records means there was no evidence to demonstrate that staff, individuals providing services under arrangement, and volunteers received the necessary initial and annual EP training as required by federal regulations. No specific residents or patient cases were mentioned in the report, and there were no details provided regarding the medical history or condition of any individuals at the time of the deficiency. The deficiency centers solely on the facility's failure to document and maintain records of emergency preparedness training for its personnel.
Plan Of Correction
Documentation of staff Emergency Preparedness Training and Testing is now present in the facility. The Maintenance Director/designee has completed and will continue to complete initial and annual Emergency Preparedness Training and Testing for all new and existing staff. The Facility Administrator will ensure compliance by confirming the Emergency Preparedness Training and Testing documentation of initial and annual training for all new and existing staff is maintained by checking monthly times three months. Findings will be reviewed at monthly Quality Assurance Meetings.
Failure to Document Required Emergency Preparedness Exercises
Penalty
Summary
Maple Winds Healthcare and Rehabilitation LLC failed to maintain documentation for the two required annual exercises to test its Emergency Preparedness (EP) Plan. During a Medicare/Medicaid Recertification Survey, surveyors reviewed the facility's EP Plan and found that documentation for these exercises was not available for review. An interview and documentation review conducted on July 7, 2025, at 9:05 a.m. confirmed the absence of records for the two annual exercises. The surveyors specifically noted that the facility could not provide evidence that the required emergency plan testing had been conducted as mandated by federal regulations. Further confirmation was obtained during an interview with the Facility Administrator and Maintenance Director later that day. Both individuals acknowledged that the documentation for the two required exercises was not available at the time of the survey. No information regarding specific residents or their medical conditions was included in the findings.
Plan Of Correction
Documentation for the two required annual exercises to test the Emergency Preparedness Plan is now present in the facility. The Maintenance Director/designee will ensure the facility maintains documentation for the two exercises required annually to test the Emergency Preparedness Plan. The Facility Administrator will ensure compliance by confirming documentation for the two exercises are present and available every six months times two. Findings will be reviewed at monthly Quality Assurance Meetings. E 0039
Failure to Date Opened Food Items in Kitchen and Storage
Penalty
Summary
The facility failed to ensure that food items stored in the kitchen and dry storage room were properly dated once opened, as required by facility policy. During observations, surveyors found an opened 10-pound bag of pasta in the dry storage room that was not labeled with an open date. In the kitchen refrigerator, two opened 5-pound bags of cheese, one containing parmesan and the other a mixture of cheddar and mozzarella, were also found without open dates. Additionally, approximately ten pounds of flour and twenty-five pounds of rice in the kitchen were observed to be opened and not labeled with an open date. Interviews with the Dietary Manager and the DON confirmed that all open food items in the kitchen should be labeled with a date once they are opened, in accordance with the facility's policy. The lack of proper labeling and dating of opened food items was directly observed by surveyors and acknowledged by facility staff.
Plan Of Correction
Opened, unlabeled food items in the dry storage room, the kitchen refrigerator, and the kitchen were immediately discarded. Any resident admitted to the facility who receives a meal has the ability to be affected by this alleged deficient practice. A baseline audit of food stored in the dry storage room and in the kitchen has been completed to ensure any opened food item has been labeled with an open date. The Dietary Manager re-educated dietary staff that food items stored in the dry storage area, in the kitchen, and in the kitchen refrigerator are to be labeled with an open date upon opening of the food item. The Dietary Manager/designee will audit the dry storage area, the kitchen, and the kitchen refrigerator to ensure open food items are labeled with an open date weekly times six weeks and then monthly times four months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement, and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times six months or until substantial compliance is noted.
Failure to Complete Admission MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to complete comprehensive admission Minimum Data Set (MDS) assessments within the required timeframe for 10 out of 35 residents reviewed. According to federal regulations and the Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 13 calendar days after a resident's admission. The review of clinical records revealed that for multiple residents, the MDS assessments were completed between one and eight days past the required deadline. Specific examples include residents whose admission dates and corresponding MDS completion dates showed delays ranging from one to eight days. For instance, one resident admitted on May 5 had their MDS completed on May 19, which was one day late, while another admitted on May 12 had their MDS completed on June 12, which was eight days late. These findings were corroborated by documentation in section Z0500B of the MDS and confirmed during an interview with the LPN Assessment Coordinator, who acknowledged that the assessments were not completed within the mandated timeframes. The deficiency was identified through a combination of clinical record review, reference to the RAI User's Manual, and staff interviews. The report does not provide additional details about the residents' medical histories or conditions at the time of the deficiency, focusing solely on the failure to meet the required assessment completion deadlines as specified by federal and state regulations.
Plan Of Correction
Resident 14 no longer resides in the facility. Resident 26 no longer resides in the facility. Resident 34 was assessed with no noted concerns related to her May 26th Admission Minimum Data Set Assessment being completed on June 2, 2025, which was one day late. Resident 43 was assessed with no noted concerns related to her May 7th Admission Minimum Data Set Assessment being completed on May 19, 2025, which was six days late. Resident 44 no longer resides in the facility. Resident 139 no longer resides in the facility. Resident 140 no longer resides in the facility. Resident 141 no longer resides in the facility. Resident 142 no longer resides in the facility. Resident 143 no longer resides in the facility. Any resident admitted to the facility has the ability to be affected by this alleged deficient practice. A whole house audit of recent resident admissions was completed to ensure the Admission Minimum Data Set Assessments were completed on time. Nursing Home Administrator completed re-education with the Registered Nurse Assessment Coordinator and Licensed Practical Nurse Assessment Coordinator of the need to have Admission Minimum Data Set Assessments completed timely, no later than the resident's admission date plus thirteen calendar days as per the Long-Term Care Facility Resident Assessment Instrument User's Manual. Resident 142 no longer resides in the facility. Resident 143 no longer resides in the facility. Any resident admitted to the facility has the ability to be affected by this alleged deficient practice. A whole house audit of recent resident admissions was completed to ensure the Admission Minimum Data Set Assessments were completed on time. Nursing Home Administrator/designee will audit Admission Minimum Data Set Assessments weekly times four weeks, monthly times three months. Results of these audits will be reviewed in Quality Assurance and Performance Improvement for results, areas of improvement and/or continuation of audits times four months or until substantial compliance is noted.
Failure to Update Care Plan After Change in Continence Status
Penalty
Summary
A deficiency was identified when the facility failed to update a resident's care plan to reflect a significant change in their care needs. The resident, who had a history of obstructive uropathy and previously required an indwelling urinary catheter, had the catheter discontinued per physician's orders. Following the removal of the catheter, documentation showed that the resident was frequently incontinent of bladder. Despite this change, there was no evidence in the clinical record that the resident's care plan was revised to address the new incontinence status. The facility's policy required care plans to be reviewed and revised with significant changes in condition, but as of the date of review, the care plan had not been updated to reflect the resident's bladder incontinence. This was confirmed by the Director of Nursing during an interview.
Plan Of Correction
Resident 13's care plan was revised/updated to reflect her bladder incontinence since removal of her indwelling urinary catheter on April 15, 2025. Any resident who has their indwelling urinary catheter removed has the ability to be affected by this alleged deficient practice. A whole house audit of residents recently having their indwelling urinary catheter removed was completed to ensure his/her care plan has been revised to reflect their current bladder continence/incontinence status. Licensed nursing staff, including agency licensed nursing staff, re-educated on the importance of updating/revising resident care plans to reflect resident-specific care needs, including residents who have their indwelling urinary catheter removed to include his/her bladder continence/incontinence status in the care plan. Licensed Practical Nurse Assessment Coordinator will routinely review order summary reports to ensure resident care plans are updated/revised with changes, new orders, and/or discontinued orders that reflect a change to the resident's current plan of care. Interdisciplinary Care Plan Team will continue to review care plans upon resident admissions, at regularly scheduled care plan conferences, and as needed to ensure individualized, person-centered care needs are included and up to date in resident care plans. The Director of Nursing/designee will audit care plans for residents who have had their indwelling urinary catheter removed weekly times twelve weeks and then monthly times four months, and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement, and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times seven months or until substantial compliance is noted. Licensed Practical Nurse Assessment Coordinator/designee will conduct random audits of resident care plans to ensure that all person-centered care needs are included/updated to reflect the resident's current care needs weekly times fifteen weeks, then monthly times four months, and then reviewed by the Quality Assurance and Performance Improvement Committee for results, areas of improvement, and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times eight months or until substantial compliance is noted.
Failure to Document Urinary Output and Incontinent Care
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of urinary output for a resident with an indwelling urinary catheter. According to the facility's policy, urine output was to be documented in the resident's chart or electronic medical record. However, review of the clinical records for a resident with neurogenic bladder and a physician's order for a Foley catheter revealed multiple instances across several dates and shifts where urine output was not recorded as required. This lack of documentation was confirmed by the Director of Nursing. Additionally, the facility did not ensure that proper incontinent care was completed for another resident who required assistance with toileting due to limited mobility. The care plan specified that staff should document the resident's bladder continence or incontinence every two hours, but there were numerous occasions where this documentation was missing. Furthermore, staff were required to document the application of barrier cream to the resident's buttocks, but there was no evidence that this was done on several shifts across multiple days. These deficiencies were identified through review of facility policies, clinical records, and staff interviews. The Director of Nursing confirmed the absence of required documentation for both urinary output and incontinent care, including the application of barrier cream, on the specified dates and times.
Plan Of Correction
Resident 1 was assessed with no ill effects and/or noted concerns related to her not having her urine output documented on the first shift (0600 to 1430) on May 13, 2025; June 11, 2025; June 14, 2025; June 16, 2025; and June 20, 2025. The documentation was also missing on the second shift (1400 to 2230) on May 21, 2025; June 9, 2025; and June 20, 2025, and on the third shift (2200 to 0630) on June 6, 2025, and June 30, 2025. Resident 1's physician was notified of the resident not having her urine output documented on the first shift (0600 to 1430) on May 13, 2025; June 11, 2025; June 14, 2025; June 16, 2025; and June 20, 2025. The physician was also notified of missing documentation on the second shift (1400 to 2230) on May 21, 2025; June 9, 2025; and June 20, 2025, and on the third shift (2200 to 0630) on June 6, 2025, and June 30, 2025. Resident 13 was assessed with no ill effects and/or noted concerns related to her not having her bladder continence/incontinence documented on May 14, 2025, at 0800, 1000, and 1200; May 15, 2025, at 0800, 1000, and 1200; May 17, 2025, at 0800, 1000, and 1200; May 24, 2025, at 0800, 1000, and 1200; May 25, 2025, at 0000, 0200, and 0400; June 4, 2025, at 0000, 0200, and 0400; June 5, 2025, at 0000, 0200, and 0400; June 6, 2025, at 0800, 1000, and 1200; June 10, 2025, at 0800, 1000, and 1200; June 11, 2025, at 0800, 1000, and 1200; June 13, 2025, at 0000, 0200, and 0400; June 15, 2025, at 0800, 1000, 1200, 1400, 1600, 1800, and 2000; and June 25, 2025, at 0800, 1000, and 1200. The physician was notified of the missing documentation of bladder continence/incontinence for Resident 13 on the same dates and times as above. Resident 13 was also assessed with no ill effects and/or noted concerns related to her not having any documented evidence of her barrier cream being applied to her buttocks during the day shift on May 1, 2025; May 15, 2025; May 17, 2025; May 24, 2025; and May 26, 2025. The documentation was missing during the evening shift on May 1, 2025; May 2, 2025; June 3, 2025; and June 15, 2025, and during the night shift on May 24, 2025; May 31, 2025; June 2, 2025; June 3, 2025; June 4, 2025; and June 12, 2025. The physician was notified of the missing documentation of barrier cream application to Resident 13’s buttocks during these shifts and dates. Any resident who has an indwelling urinary catheter has the potential to be affected by this alleged deficient practice. A whole house audit of residents with indwelling urinary catheters was completed to ensure their urinary output has been monitored and documented in the resident's medical record/electronic medical record every shift. Similarly, any resident who has a nurse aide task to document bladder continence/incontinence every two hours has the potential to be affected. A whole house audit of residents with this scheduled task was completed to ensure documentation of bladder continence/incontinence has been monitored and recorded in the medical record/electronic medical record every two hours. Any resident with a nurse aide task to document application of barrier cream also could be affected. A whole house audit of residents with this task was completed to ensure documentation of barrier cream application was present in the Point Click Care - Point of Care electronic record. Direct care staff, including agency staff, were re-educated on the facility's Urinary Output Policy, emphasizing the importance of monitoring and documenting urinary output every shift for residents with indwelling urinary catheters. Staff were also re-educated on the importance of frequently monitoring residents' bladder continence/incontinence throughout the shift and documenting in Point Click Care as scheduled, including every two hours. Additionally, staff were re-educated on the importance of applying barrier cream to residents and documenting the application in the electronic medical record/Point Click Care as per scheduled tasks. The Director of Nursing/designee will audit the documentation of urinary output for residents with indwelling urinary catheters weekly for fifteen weeks, then monthly for six months, and review the results with the Quality Assurance Performance Improvement Committee for areas of improvement and/or continuation of audits. Results of these audits will be reviewed in the Quality Assurance and Performance Improvement meetings for ten months or until substantial compliance is noted. Similarly, the Director of Nursing/designee will conduct random audits of Point Click Care - Point of Care task documentation for bladder continence/incontinence weekly for fifteen weeks, then monthly for six months, with results reviewed by the committee. The same process applies for audits of resident barrier cream applications, with results reviewed in the same manner.
Failure to Document IV Flushes and Obtain Orders for Catheter Care
Penalty
Summary
The facility failed to ensure that intravenous (IV) catheters were flushed according to facility policy and did not obtain physician's orders for the care and maintenance of IV catheters for two residents. Facility policy required that midline dressings be changed weekly or as needed, and that IV lines be flushed according to physician orders. The policy for peripheral IV access specified a regimen of Normal Saline flush before and after medication administration, and a Heparin flush if ordered. For one resident, clinical records showed that the resident was cognitively intact, had a multi-drug resistant organism, was receiving IV antibiotics, and had IV access. Physician's orders included administration of Meropenem and routine saline flushes every shift. However, review of the Medication Administration Records (MARs) revealed no documented evidence that staff flushed the resident's IV with Normal Saline before and after medication administration, as required by policy and physician orders. The Director of Nursing confirmed the lack of documentation for these flushes. For another resident, a midline was placed and later removed without complications, and the resident received IV antibiotics as ordered. However, there was no documented evidence that the physician was contacted for orders regarding the care and maintenance of the midline during the time it was in place. Additionally, MARs did not show documentation that the midline was flushed with Normal Saline before and after medication administration. The Director of Nursing confirmed both the lack of physician orders for midline care and the absence of documentation for required flushes.
Plan Of Correction
Resident 9 assessed with no noted concerns related to having no documented evidence that her peripheral intravenous catheter was flushed with normal saline solution before and after the administration of her physician-ordered meropenem doses on April 10, 2025 through April 16, 2025. Resident 9's physician was notified regarding the facility having no documented evidence that her peripheral intravenous catheter was flushed with normal saline solution before and after her meropenem doses administered on April 10, 2025 through April 16, 2025. Resident 12 assessed with no noted concerns related to having no physician orders regarding care and maintenance of her midline May 22, 2025 through May 29, 2025, and related to having no documented evidence that her midline was flushed with normal saline solution before and after the administration of her physician-ordered meropenem doses May 22, 2025 through May 29, 2025. Resident 12's physician was notified regarding the facility having no physician orders regarding care and maintenance of her midline May 22, 2025 through May 29, 2025, and related to having no documented evidence that her midline was flushed with normal saline solution before and after the administration of her physician-ordered meropenem doses May 22, 2025 through May 29, 2025. Any resident receiving intravenous medications via a peripheral intravenous catheter has the ability to be affected by this alleged deficient practice. A whole house audit was completed for residents with intravenous catheters to ensure physician orders and documentation are present for flushing the intravenous catheter with saline routinely, including before and after the administration of intravenous medication as per his/her physician order. Any resident having a midline has the ability to be affected by this alleged deficient practice. A whole house audit was completed for residents with midlines to ensure physician orders were obtained for the care and maintenance of the resident's midline. Any resident receiving intravenous medications via a midline has the ability to be affected by this alleged deficient practice. A whole house audit was completed for residents with a midline to ensure physician orders and documentation are present for flushing the midline before and after the administration of intravenous medication as per his/her physician order. Licensed nursing staff, including agency licensed nursing staff, were re-educated on the facility Peripheral medication as per his/her physician order. Any resident having a midline has the ability to be affected by this alleged deficient practice. A whole house audit was completed for residents with midlines to ensure physician orders were obtained for the care and maintenance of the resident's midline. Any resident receiving intravenous medications via a midline has the ability to be affected by this alleged deficient practice. A whole house audit was completed for residents with a midline to ensure physician orders and documentation are present for flushing the midline before and after the administration of intravenous medication as per his/her physician order. Licensed nursing staff, including agency licensed nursing staff, were re-educated on the facility Peripheral Intravenous Access Flushing Policy and the facility Peripheral Intravenous Access Medication Administration Policy, including the importance of obtaining a physician order for routine saline flushing and saline flushing prior to and following the administration of intravenous medications. They were also re-educated on the Peripherally Inserted Central Catheter Line and Midline Maintenance and Care Policy and the Peripherally Inserted Central Catheter Line and Midline Access Medication Administration Policy, including the importance of obtaining a physician order for routine saline flushing and saline flushing prior to and following the administration of intravenous medications. Registered Nurse Charge Nurse/Designee will audit residents receiving intravenous medications via a peripheral intravenous catheter to ensure physician orders are present for routine saline flushes as well as saline flushes before and after intravenous medication administrations three times per week for eight weeks, then monthly until resolved. Findings from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution at its regularly scheduled meetings, focusing on results, areas of improvement, and/or continuation of audits. Registered Nurse Charge Nurse/Designee will also audit residents receiving intravenous medications via a peripheral intravenous catheter to ensure documentation is present on the resident's administration record for routine saline flushes as well as saline flushes before and after intravenous medication administrations three times per week for eight weeks, then monthly until resolved. Findings from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution. Similarly, registered nurses will audit residents receiving intravenous medications via a midline catheter to ensure physician orders are present for routine saline flushes as well as saline flushes before and after intravenous medication administrations three times per week for eight weeks, then monthly until resolved. Findings from these audits will also be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution. Finally, registered nurses will audit residents with a midline to ensure documentation is present on the resident's administration record for routine saline flushes as well as saline flushes before and after intravenous medication administrations three times per week for eight weeks, then monthly until resolved. The results and any recommendations will be discussed and reviewed during the committee meetings to determine further actions or continuation of audits.
Failure to Notify Physician and Responsible Party of Change in Condition
Penalty
Summary
A deficiency was identified when the facility failed to notify a physician and the resident's responsible party regarding a significant change in condition for one resident. The facility's policy required immediate notification of physicians and responsible parties in the event of any change in a resident's condition. However, documentation revealed that this protocol was not followed for a resident with a history of acute respiratory failure and multiple chronic conditions, including diabetes, congestive heart failure, and chronic obstructive pulmonary disease. On one occasion, the resident was found difficult to arouse, with abnormal vital signs including elevated blood pressure, low temperature, and a distended bladder with no urine output. Nursing staff intervened by providing warmth, administering BiPAP, and performing straight catheterization, but there was no documented evidence that the physician or the resident's son was notified of this change in condition. This lack of notification was confirmed through review of the clinical record and staff interviews. A subsequent similar event occurred several days later, during which the resident became pale, unresponsive, and had low oxygen saturation. On this occasion, the physician was notified and the resident was sent to the hospital, and a voicemail was left for the resident's son. The Director of Nursing confirmed that, in contrast to the later event, the required notifications were not made during the initial incident, which was not in accordance with facility policy.
Plan Of Correction
Resident 2's physician was notified of her change in condition on November 13, 2024. Resident 2's responsible party was not notified of the change in condition on November 13, 2024, as per her wishes. Immediate re-education was provided to the Registered Nurse by the Director of Nursing regarding the importance of ensuring a resident's physician and responsible family member or legal representative are notified as soon as possible of any changes in the resident's condition. Any resident who has a change in condition has the ability to be affected by this alleged deficient practice. A whole house audit of residents who recently had a change in condition was completed to ensure his/her physician and his/her responsible family member or legal representative were notified as soon as possible of the change in the resident's condition. Licensed nursing staff, including agency licensed nursing staff, were re-educated on the facility Notification of Changes Policy, including the importance of ensuring a resident's physician, responsible family member, or legal representative are notified as soon as possible of any changes in the resident's condition. The Director of Nursing/designee will randomly audit notifications of physicians and responsible family members/legal representatives of residents with changes in condition weekly times eight weeks and then monthly times four months, and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement, and/or continuation of audits. Results of these audits will be reviewed in the Quality Assurance and Performance Improvement meetings times six months or until substantial compliance is noted.
Failure to Log and Document Resident Grievances
Penalty
Summary
The facility failed to follow its own grievance policy regarding the documentation and logging of grievances for one resident. According to the facility's policy, when a concern or grievance is brought forward by staff, family, responsible party, or resident, a concern form should be completed and submitted to the Social Services Director or Administrator, who is then responsible for logging the concern into a grievance log. The policy also requires that the results of grievances be maintained for a minimum of three years. In the case of one resident, the quarterly Minimum Data Set (MDS) assessment indicated that the resident was able to understand and be understood by others. Two separate grievances were documented: one involving the resident's daughter finding the resident soiled with a bowel movement and without a brief, and another involving the discovery of pills in a medication cup, in the resident's bed, and on the floor. Both incidents were reported to staff and the Director of Nursing, and immediate actions were taken to address the resident's condition and to notify staff. Despite the completion of grievance forms for both incidents, a review of the facility's grievance/complaint logs revealed that neither of these concerns was entered into the official log as required by policy. This was confirmed by the Director of Nursing, who acknowledged that there was no documented evidence of these grievances being logged. The failure to document and log these grievances constitutes noncompliance with both facility policy and federal regulations regarding the handling of resident grievances.
Plan Of Correction
Facility's new Social Services Director immediately completed facility grievance/complaint concern forms for the June 14th and June 15th grievances regarding Resident 13 and placed both concerns onto the June 2025 Grievance/Concern and Complaint Log. Any resident admitted to the facility has the ability to be affected by this alleged deficient practice. A whole house audit was completed to ensure recent grievances/complaints and/or concerns were placed onto the monthly Grievance/Concern and Complaint Log, and a grievance/complaint concern form was completed for the grievance. Nursing Home Administrator educated the new Social Services Director on the facility Concern/Grievance Policy and the facility grievance/complaint concern form. Nursing Home Administrator/designee will randomly audit the monthly Grievance/Concern and Complaint Log weekly times four weeks and then monthly times three months, and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement, and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times four months or until substantial compliance is noted.
Failure to Provide Required Transfer Notifications and Discharge Documentation
Penalty
Summary
The facility failed to provide required written notifications and documentation during resident transfers to the hospital for three residents. Specifically, there was no evidence that written notification of transfer was given to the residents or their representatives, nor was a bed-hold notice provided to the responsible parties. Additionally, the facility did not notify the ombudsman of these hospital transfers as mandated by regulation. These deficiencies were confirmed through review of clinical records and staff interviews. The residents involved had significant medical conditions at the time of transfer. One resident was cognitively intact with chronic obstructive pulmonary disease and was transferred to the hospital for acute respiratory failure. Another resident, who was severely cognitively impaired with Alzheimer's, Parkinson's disease, and a history of respiratory failure, was transferred after being found lethargic and difficult to arouse. The third resident, also cognitively intact but with paraplegia, respiratory failure, and pneumonia, was transferred due to difficulty breathing and was later diagnosed with sepsis in the hospital. In all three cases, the required notifications and documentation were not completed. Additionally, the facility failed to complete a post-discharge summary for another resident who was discharged back to a personal care home. The physician did not provide a discharge summary that included the diagnosis, course of treatment, and pertinent test results as required. The Director of Nursing confirmed these documentation and notification failures during an interview.
Plan Of Correction
Written notification of Resident 2's transfer to the hospital on November 18, 2024, was immediately provided by the new Social Services Director to Resident 2 and the resident's representative. Facility's new Social Service Director immediately provided Bed-hold notice to Resident 2's responsible party for her transfer to the hospital on November 18, 2024. Ombudsman was immediately notified by the facility's new Social Services Director, as required, of Resident 2's transfer to the hospital on November 18, 2024. Written notification of Resident 19's transfer to the hospital on November 5, 2024, was immediately provided by the new Social Services Director to Resident 19's representative. Facility's new Social Service Director immediately provided Bed-hold notice to Resident 19's responsible party for her transfer to the hospital on November 5, 2024. Ombudsman was immediately notified by the facility's new Social Services Director, as required, of Resident 19's transfer to the hospital on November 5, 2024. Resident 38 no longer resides in the facility. Physician Discharge Summary Form completed for Resident 37. Any resident transferred from the facility to the hospital has the ability to be affected by this alleged deficient practice. A whole house audit was completed on recent resident transfers to the hospital to ensure written notification was provided to resident and resident's responsible party regarding the reason for transfer to the hospital. A whole house audit was completed on recent resident transfers to the hospital to ensure a bed-hold notice was provided to resident's responsible party. A whole house audit was completed on recent resident transfers to the hospital to ensure the Ombudsman was notified of the transfer to the hospital. Any resident discharged from the facility has the ability to be affected by this alleged deficient practice. A whole house audit was completed on recent resident discharges to ensure the Physician Discharge Summary Form has been completed. Facility's new Social Services Director and Marketing Liaison/Admissions Director were educated by the Nursing Home Administrator on contacting the resident/resident's representative following a facility-initiated transfer to an acute care facility or hospital, including the need to provide written notification of hospital transfer to resident/resident's representative, the need to provide bed-hold notice to responsible party, and the need to notify the Ombudsman as required. Registered Nurses, including agency Registered Nurses, were re-educated on the facility Physician Discharge Summary Policy. Resident transfers to the hospital will be audited by the Nursing Home Administrator/designee to ensure written notification was provided to resident and resident's responsible party regarding the reason for transfer weekly times three weeks then monthly times three months. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times four months or until substantial compliance is noted. Facility transfers to acute care facilities/hospitals will be audited weekly times three weeks then monthly times three months by the Nursing Home Administrator/designee to ensure resident's electronic medical record contains written documentation that the resident/resident's representative was notified via phone call or in person and received a written copy of facility bed-hold policy. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times four months or until substantial compliance is noted. Nursing Home Administrator/designee will audit resident transfers to the hospital to ensure the Ombudsman was notified of the transfer weekly times three weeks then monthly times three months. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times four months or until substantial compliance is noted. Director of Nursing/designee will audit resident discharges to ensure a Physician Discharge Summary Form is completed weekly times six weeks then monthly times six months. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times eight months or until substantial compliance is noted.
Inaccurate MDS Medication Coding for Two Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents, as required by federal regulations. For one resident, physician's orders indicated the administration of Lisinopril-hydrochlorothiazide, a combination antihypertensive and diuretic medication, every morning during the assessment period. However, the corresponding MDS assessment did not reflect that a diuretic was administered during the seven-day look-back period. For another resident, physician's orders and the Medication Administration Record (MAR) showed that Dilantin, an anticonvulsant, was given every morning and at bedtime throughout the assessment period, but the MDS assessment failed to indicate that an anticonvulsant was received during the same timeframe. These discrepancies were confirmed through a review of clinical records, the RAI User's Manual, and staff interviews, including confirmation by the Director of Nursing. The inaccurate coding in the MDS assessments did not accurately reflect the residents' medication administration as documented in the MAR and physician's orders, resulting in noncompliance with regulatory requirements for assessment accuracy.
Plan Of Correction
A Modification Request to correct the erroneous coding for Section N0415G1 for Resident 1 for the Annual Minimum Data Set Assessment dated May 24, 2025 was completed and submitted on July 15, 2025. A Modification Request to correct the erroneous coding for Section N0415K1 for Resident 25 for the Significant Change Minimum Data Set Assessment dated April 22, 2025 was completed and submitted on July 2, 2025. Residents who receive diuretic medications have the ability to be affected by this alleged deficient practice. A whole house audit of recently completed Minimum Data Set Assessments was completed by the Director of Nursing/designee to ensure residents receiving diuretic medications were coded correctly on completed assessments. Residents who receive anticonvulsant medications have the ability to be affected by this alleged deficient practice. A whole house audit of recently completed Minimum Data Set Assessments was completed by the Director of Nursing/designee to ensure residents receiving anticonvulsant medications were coded correctly on completed assessments. The Director of Nursing reviewed the coding instructions for Section N0415G1 in the Resident Assessment Instrument Manual with the Registered Nurse Assessment Coordinator and the Licensed Practical Nurse Assessment Coordinator. The Director of Nursing reviewed the coding instructions for Section N0415K1 in the Resident Assessment Instrument Manual with the Registered Nurse Assessment Coordinator and the Licensed Practical Nurse Assessment Coordinator. Audits will be performed by the Director of Nursing/designee weekly times four weeks then monthly times two months to ensure any resident receiving diuretic medications is coded correctly. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted. Audits will be performed by the Director of Nursing/designee weekly times four weeks then monthly times two months to ensure any resident receiving anticonvulsant medications is coded correctly. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.
Failure to Develop Individualized Care Plan for High-Risk Medications
Penalty
Summary
The facility failed to develop a comprehensive, individualized care plan for a resident who was cognitively intact and required extensive assistance with daily care tasks. Despite the resident receiving multiple high-risk medications, including an anticoagulant (Apixaban), an antiplatelet (Aspirin), and a diuretic (Lasix), there was no documented evidence that a care plan was created to address the specific care and treatment needs associated with these medications. The facility's policy indicated that residents and their representatives should participate in the development and implementation of person-centered care plans, but this was not followed in this case. A review of the resident's clinical records and physician's orders confirmed the ongoing use of these medications. During an interview, the Director of Nursing acknowledged that a care plan addressing the resident's needs related to anticoagulant, antiplatelet, and diuretic use was not developed and confirmed that it should have been. This omission was identified during a review of 35 residents, with this specific deficiency noted for one resident.
Plan Of Correction
Resident 9's comprehensive care plans were updated to reflect her care needs related to her use of anticoagulant, antiplatelet, and diuretic medications. Any resident who uses anticoagulant medications has the ability to be affected by this alleged deficient practice. A whole house audit on residents who use anticoagulant medications was completed to ensure that an individualized written plan of care was developed and in place for these residents addressing their care needs related to their anticoagulant use. Any resident who uses antiplatelet medications has the ability to be affected by this alleged deficient practice. A whole house audit on residents who use antiplatelet medications was completed to ensure that an individualized written plan of care was developed and in place for these residents addressing their care needs related to their antiplatelet use. Any resident who uses diuretic medications has the ability to be affected by this alleged deficient practice. A whole house audit on residents who use diuretic medications was completed to ensure that an individualized written plan of care was developed and in place for these residents addressing their care needs related to their diuretic use. Licensed Nursing Staff, including Agency Licensed Staff, re-educated on the importance of creating an individualized, person-centered plan of care for residents including care needs for residents who use anticoagulant medications, who use antiplatelet medications, and who use diuretic medications. Interdisciplinary Care Plan Team will continue to review care plans upon resident admissions, at regularly scheduled care plan conferences, and as needed to ensure individualized, person-centered care needs are included and up to date. The Director of Nursing/designee will audit care plans for residents who use anticoagulant medications, who use antiplatelet medications, and who use diuretic medications to be sure these medications are addressed in their care plans weekly times ten weeks and then monthly times four months. These will then be reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement, and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times seven months or until substantial compliance is noted.
Failure to Administer All Prescribed IV Antibiotic Doses
Penalty
Summary
A deficiency was identified when a resident, who was assessed as able to understand and communicate, did not receive all prescribed doses of intravenous Meropenem as ordered by the physician for treatment of a urinary tract infection. The physician's order specified that the resident was to receive one gram of Meropenem intravenously every eight hours for seven days, totaling 21 doses. However, review of the Medication Administration Records (MARs) showed that only 19 doses were administered over the prescribed period. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged that the resident did not receive the full course of antibiotic therapy as ordered. The report notes that any resident with a physician order for intravenous antibiotics could potentially be affected by this practice, indicating a failure to ensure that care and treatment were provided in accordance with professional standards and physician orders.
Plan Of Correction
Resident 12 assessed with no noted concerns related to her receiving only 19 of the 21 doses of meropenem intravenously over seven days as ordered by the physician on May 20, 2025. Resident 12's physician notified of meropenem being administered intravenously for only 19 out of 21 doses from May 22, 2025 through May 28, 2025. Any resident with a physician order for intravenous antibiotics has the ability to be affected by this alleged deficient practice. A whole house audit on residents with physician orders for intravenous antibiotics was completed to ensure the correct number of doses was administered to the resident as per the physician orders. Licensed nursing staff, including agency licensed nursing staff, re-educated to administer intravenous antibiotics to residents as per physician orders for the correct number of specified doses. The Director of Nursing/designee will audit medication administration records of residents who are to receive/receiving/received intravenous antibiotics to ensure the resident is administered/receives the correct number of doses as per the physician orders weekly times eight weeks and then monthly times three months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times five months or until substantial compliance is noted.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency was identified when a resident, who was cognitively intact but required extensive assistance with daily care and had limited lower extremity range of motion, was not provided with required fall prevention interventions. The resident's care plan indicated a risk for falls and specified that fall mats should be placed at the bedside. Despite this, a nursing note documented that the resident was found lying on the floor on the left side of her bed, after which new interventions were ordered, including placing the bed in the lowest position and using bilateral fall mats. Subsequent observation revealed that the resident was in bed without fall mats on either side, contrary to the care plan and the interventions ordered after the fall. An interview with the Director of Nursing confirmed that the resident should have had bilateral fall mats in place while in bed. This failure to implement and maintain fall prevention interventions resulted in the environment not being as free of accident hazards as possible for the resident.
Plan Of Correction
Resident 9's bilateral fall mats were immediately placed on each side of her bed while she was in bed. Resident 9 was assessed with no noted concerns related to her not having her bilateral fall mats on each side of her bed while she was in bed. Any resident with the fall/injury prevention intervention of fall mat/mats has the ability to be affected by this alleged deficient practice. A whole house audit on residents with the fall/injury prevention intervention of fall mat/mats was completed to ensure the fall mat/mats were correctly in place. Direct care staff, including agency direct care staff, were re-educated on the importance of ensuring fall/injury prevention interventions are in place, including fall mat/mats, as care planned. The Director of Nursing/designee will conduct audits of residents care planned to have a fall mat/fall mats for fall/injury prevention weekly times eight weeks and then monthly times four months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times six months or until substantial compliance is noted.
Failure to Document Destruction of Controlled Medications
Penalty
Summary
The facility failed to maintain proper accountability for controlled medications for one resident. According to the facility's policy, the destruction of controlled or narcotic medications, such as Fentanyl patches, must be witnessed and signed by two licensed nurses, with the amount destroyed logged on the Control Drug Record. Review of the clinical records and controlled drug count logs for a cognitively impaired resident who routinely received opioid pain medication revealed that, although Fentanyl patches were administered and logged as given, there was no documented evidence that two staff members signed for the destruction of the old patches after removal on multiple occasions. Further review of the Medication Administration Record and controlled drug count record confirmed that the required dual signatures for the destruction of Fentanyl patches were missing for several dates. An interview with the Director of Nursing corroborated that the two witness signatures were not present for the destruction of the patches as required by policy. This failure to document the destruction of controlled substances in accordance with facility policy and regulatory requirements resulted in a deficiency related to pharmacy services and recordkeeping.
Plan Of Correction
Resident 25 assessed with no noted concerns with his pain and/or his pain medications. Any resident having a physician order to receive a narcotic pain patch has the ability to be affected by this alleged deficient practice. A whole house facility audit was completed to ensure the Controlled Drug Count Records of residents who recently received narcotic pain patches have recorded documentation of two licensed nurse witness signatures for the destruction of the narcotic pain patches when removed from these residents. Licensed nursing staff, including agency licensed nursing staff, were re-educated on the facility Narcotic and Controlled Substance Policy and Procedure regarding maintaining accountability for controlled medications, including the importance of witnessing and recording the destruction of any narcotic by two licensed nurses on the resident's Controlled Drug Record, including the removal of narcotic pain patches. The Director of Nursing/Designee will complete random audits of residents receiving narcotic pain patches, including Fentanyl, to ensure accurate documentation of the witnessing and recording of the witnessed destruction of the narcotic pain patch by two licensed nurses on the resident's Controlled Drug Record when the patch was removed. These audits will be conducted weekly for twelve weeks, then monthly for six months until substantial compliance is noted. The Director of Nursing will conduct a thorough investigation of audit findings of any noted discrepancies and/or missing witness documentation of narcotic/controlled medication destruction to rule out any resident misappropriation and to ensure narcotic/controlled drug medication accountability. Findings from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution at its regularly scheduled meetings, times nine months, for results, areas of improvement, and/or continuation of audits.
Failure to Obtain and Document Required Hospice Charting
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for a resident receiving hospice services. Specifically, for a resident with a diagnosis of cancer and cognitive impairment, there was no documented evidence that updated hospice nurse aide or registered nurse charting was obtained and included in the resident's clinical record or the hospice provider's clinical record. The last available hospice nurse aide charting was dated nearly a month prior, and the last registered nurse charting was also outdated. A significant change Minimum Data Set (MDS) assessment indicated that the resident was cognitively impaired and receiving hospice services for basal cell carcinoma of the left upper limb. The care plan and physician's orders confirmed the resident was to be treated by hospice for end-of-life services. Despite these orders, the required documentation from hospice staff was not present in the records as of the review date. An interview with the Director of Nursing confirmed that the hospice nurse aide and registered nurse charting was missing from both the resident's clinical record and the hospice provider's clinical record, and acknowledged that this documentation should have been present. This lack of documentation demonstrates the facility's failure to meet regulatory requirements for coordination and documentation of hospice care services.
Plan Of Correction
F 0849 Resident 25's updated hospice nurse aide and updated hospice Registered Nurse charting was immediately placed into the hospice provider's clinical record. Any resident receiving hospice services has the ability to be affected by this alleged deficient practice. A baseline audit of residents receiving hospice services has been completed to ensure updated hospice personnel charting is present and available in the hospice provider's clinical record. The Director of Nursing re-educated hospice providers regarding the importance of and the need for updated charting documentation to be timely placed into the resident's hospice provider's clinical chart consistently. The Director of Nursing/designee will audit residents receiving hospice services for the presence of timely documentation of hospice providers' charting in the resident's hospice provider's clinical chart weekly times three weeks and then monthly times two months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.
Repeated QAPI Failures Lead to Ongoing Regulatory Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations by not effectively addressing recurring deficiencies identified in multiple state surveys. Despite developing plans of correction that included quality assurance systems such as audits and QAPI committee reviews, the facility continued to have repeated deficiencies in several key areas. These areas included care plan revisions, provision of quality care, ensuring a safe environment free from accident hazards, maintenance of intravenous catheters, and accountability for controlled medications. Specifically, the facility's plans of correction for deficiencies related to care plan timing and revision, quality of care, accident hazards, intravenous catheter maintenance, and controlled medication accountability all involved conducting audits and reporting results to the QAPI committee. However, subsequent surveys found that these measures were not successfully implemented or sustained, as evidenced by repeated citations under F657, F684, F689, F694, and F755. The QAPI committee was found to be ineffective in ensuring ongoing compliance with regulations in these areas. The report does not provide specific details about individual residents or their medical histories, but it does document that the deficiencies persisted across multiple survey cycles. The QAPI committee's failure to implement and sustain corrective actions resulted in ongoing noncompliance with federal and state regulations, as observed in the repeated survey findings.
Plan Of Correction
New Nursing Home Administrator met with the Interdisciplinary Team Facility Directors to review the current outstanding deficiencies and the facility plan to correct these deficiencies to maintain compliance with nursing home regulations. Current facility residents have the ability to be affected by this alleged deficient practice. Quality Assurance Performance Improvement Committee Meetings will continue to be held monthly to ensure quality care is being delivered to the residents residing at the facility and cited deficiencies including recurring deficiencies are being effectively addressed and corrected. New Nursing Home Administrator re-educated Quality Assurance Performance Improvement Committee members on the importance of facility and interdisciplinary team collaboration to correct cited facility deficiencies and ensure plans of correction improve the delivery of care and services to residents and effectively address recurring deficiencies, including care plan timing and revisions, providing quality care, ensuring resident environments are free from accident hazards, maintaining intravenous catheters and preventing issues with the accountability of controlled medications. The New Nursing Home Administrator will hold a weekly Department Head Meeting with the Interdisciplinary Team Facility Directors to review the progress and compliance of the current plan of correction audit process. Concerns and suggestions will be provided and reviewed as needed upon review of outstanding deficiency audits to ensure that improvements are being made and the facility is moving forward and progressing in its quality care being delivered to the residents residing at the facility. Weekly Department Head Meetings will continue until facility compliance is established. Results from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution at monthly meetings times nine months for results, areas of improvement and/or continuation of audits.
Failure to Ensure Required QAA Committee Attendance
Penalty
Summary
The facility failed to ensure that all required members of the Quality Assessment and Assurance (QAA) Committee attended the quarterly meetings, as mandated by federal regulations. Specifically, review of the QAA Committee attendance records for the first quarter of 2025 revealed that the Medical Director did not attend any of the meetings. This was confirmed through an interview with the Director of Nursing, who acknowledged the Medical Director's absence from all QAA Committee meetings during this period. The facility's policy, dated March 12, 2025, states that the QAA Committee meetings are to be held at least quarterly and must include the Nursing Home Administrator, Director of Nursing, all department heads, a community member, and the Medical Director. Despite this policy, the required participation of the Medical Director was not met, resulting in noncompliance with both federal and state regulations regarding the composition and functioning of the QAA Committee.
Plan Of Correction
Director of Nursing reviewed the Quality Assessment and Assurance Committee Meeting minutes from the first quarter of 2025 with the facility's new Medical Director. Current facility residents have the ability to be affected by this alleged deficient practice. Nursing Home Administrator educated the new facility Medical Director of the requirement to attend the Quality Assessment and Assurance Committee Meetings on at least a quarterly basis and provided the date of the next upcoming scheduled Quality Assurance Committee Meeting. Nursing Home Administrator will audit attendance of members of the Quality Assessment and Assurance Committee Meetings to ensure the Medical Director attends at least on a quarterly basis monthly times six months until resolved. Results from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution at its regularly scheduled meetings times six for results, areas of improvement and/or continuation of audits.
Failure to Follow Hand Hygiene Protocols During Medication Administration
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper hand hygiene protocols during medication administration for three residents. The facility's hand hygiene policy required staff to sanitize their hands before preparing or handling medications and after removing gloves. However, during a medication pass, the LPN prepared and administered medications to one resident, then donned gloves and took another resident's blood pressure without sanitizing her hands. After removing her gloves, she again failed to sanitize her hands before preparing and administering medications to the next resident. This pattern continued as the LPN checked a third resident's blood sugar, removed gloves, and prepared medications without hand sanitizing, only using hand sanitizer at the medication cart after completing the rounds. Interviews with the LPN and the Director of Nursing confirmed that the LPN did not adhere to the required hand hygiene procedures during the medication pass and after glove removal. The observations and staff interviews demonstrated a failure to implement the facility's infection prevention and control policies, specifically regarding hand hygiene during direct resident care activities.
Plan Of Correction
Resident 45 was assessed with no ill effects and/or noted concerns related to License Practical Nurse 1 failing to use proper hand washing techniques during her medication administration. Resident 29 was assessed with no ill effects and/or noted concerns related to License Practical Nurse 1 failing to use proper hand washing techniques during her medication administration. Resident 2 was assessed with no ill effects and/or noted concerns related to License Practical Nurse 1 failing to use proper hand washing techniques during her medication administration. The Director of Nursing immediately spoke to Licensed Practical Nurse 1 regarding proper hand sanitization during medication administration, including after glove removal, with Licensed Practical Nurse 1 verbalizing understanding and willingness to comply. Current facility residents receiving medications have the ability to be affected by this alleged deficient practice. A baseline audit was completed on residents currently receiving medications to ensure licensed nurses completed hand washing/hand hygiene during medication administration, including after glove removal. Hand washing/hand hygiene competencies were completed with current facility licensed staff and current agency licensed staff. Direct care staff, including agency direct care staff, were re-educated on the facility's Hand Hygiene Policy, including the importance of proper hand sanitization during medication administration and after glove removal. Facility direct care staff, including agency direct care staff, received training regarding appropriate practices for wearing gloves, changing gloves, hand washing, and hand hygiene, including when to wear and change gloves, perform hand washing and/or hand hygiene during resident care and treatment. Facility licensed staff, including agency licensed staff, were re-educated on preventing the spread of infection, including hand washing/hand hygiene. The Director of Nursing/designee will audit licensed nurses administering medications to residents weekly times four weeks then monthly times three months to ensure proper hand washing/hand hygiene utilized throughout medication administration. Results from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution at its regularly scheduled meetings times four months for results, areas of improvement, and/or continuation of audits.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to ensure that peripherally-inserted central catheters (PICC lines) site dressings were changed according to physician's orders for one resident. The facility's policy required that PICC line dressings be changed weekly. However, for one resident, the dressing had not been changed since December 13, 2024, despite physician's orders to change it weekly. This was confirmed through clinical record reviews, observations, and interviews with the resident and staff. The resident, who was cognitively impaired and required assistance for daily care needs, expressed concern that the dressing was not sticking and might fall off, potentially leading to the PICC line being pulled out. The resident had improvised by using a sock cuff to hold the dressing in place. Interviews with a registered nurse and the Director of Nursing revealed that the dressing was on back order from the pharmacy, and there was uncertainty about why it was not sourced from elsewhere. The deficiency was noted as a failure to adhere to physician's orders and facility policy.
Plan Of Correction
1. Resident 2's peripherally inserted central catheter line dressing changed on December 26, 2024. Resident 2 noted to not have any complications from the incident. Resident 2 assessed with no noted/additional concerns as well. 2. All residents having peripherally inserted central catheter line dressings have the ability to be affected by this alleged deficient practice. A whole house audit completed for residents with peripherally inserted central catheter line dressings to ensure licensed nurses changed dressing weekly. 3. Licensed nursing staff, including agency licensed nursing staff, were re-educated on the facility Peripherally Inserted Central Catheter Line Maintenance and Care Policy, including the importance of changing the dressings weekly and proper documentation of dressing changes on the medication/treatment administration records. 4. Registered Nurse Charge Nurse/Designee will audit residents with peripherally inserted central catheter line dressings to ensure proper weekly dressing changes are completed by licensed nurses three times per week times four weeks then monthly until resolved. Findings from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution at its regularly scheduled meetings times three for results, areas of improvement and/or continuation of audits.
Failure to Provide Privacy for Residents
Penalty
Summary
The facility failed to maintain resident dignity for two residents by not providing adequate window coverings, which compromised their privacy. Resident 2, who is cognitively impaired and requires assistance for daily care needs, was observed without a curtain or blind covering the window next to his bed, which faced the facility's main parking lot. He expressed discomfort and a sense of exposure when using the urinal, bedside commode, and while dressing, as he could not pull the privacy curtain around his bed due to its location and his physical limitations. Despite his request for a curtain or blind, none had been installed. Similarly, Resident 6, also cognitively impaired and requiring assistance, was observed in a similar situation with her bed near a window without blinds or curtains, facing the parking lot. The Director of Housekeeping confirmed that blinds had been ordered for both residents' windows but had not yet arrived, and she was unsure of how long the rooms had been without these coverings. This lack of window coverings failed to uphold the residents' rights to dignity and privacy as outlined in the facility's policy and federal regulations.
Plan Of Correction
1. A blind covering the window to the outside has been installed in Resident 2's room. Resident 2 interviewed with no further verbalized concerns. Window blind covering has been installed in Resident 6's room. 2. Any resident who resides in the facility has the ability to be affected by this alleged deficient practice. A whole house random audit was completed with interviewable residents to verify maintenance of his/her resident dignity. 3. Facility staff, including agency staff, were re-educated on the facility Resident Rights Policy, including the importance of maintaining resident dignity and protecting/promoting the rights of each resident, particularly those rights that pertain to a dignified existence. 4. Director of Nursing/designee will randomly audit residents to ensure protection/promotion of resident dignity is maintained weekly times four weeks and then monthly times three months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.
Failure to Ensure Resident Privacy Due to Lack of Window Coverings
Penalty
Summary
The facility failed to ensure personal privacy for a resident, identified as Resident 2, as required by federal regulations. The resident's room lacked a curtain or blind covering the window, which faced the facility's main parking lot. This deficiency was observed during a survey on December 26, 2024. The resident, who was cognitively impaired and required assistance for daily care needs, expressed concerns about feeling exposed while using the urinal, bedside commode, and dressing himself. He was unable to pull the privacy curtain around his bed due to its location and his physical limitations, and he preferred not to have the curtain closed at all times as he enjoyed watching TV and looking outside. An interview with the Director of Housekeeping revealed that blinds had been ordered for the windows of Resident 2 and another resident, but they had not yet arrived. The Director was unsure of how long the rooms had been without curtains or blinds. The facility's policy on Resident Rights, dated May 6, 2024, stated that the facility would protect and promote the rights of each resident, including the right to a dignified existence, which was not upheld in this instance.
Plan Of Correction
1. Window blind covering has been installed in Resident 2's room. Resident 2 interviewed and verbalized he no longer feels exposed to the parking lot and had no further concerns. 2. Any resident who resides in the facility has the ability to be affected by this alleged deficient practice. A whole house audit was completed to ensure each resident's room contained window blind coverings to ensure resident personal privacy. 3. Facility staff, including agency staff, were re-educated on the importance of ensuring residents are provided personal privacy. 4. Nursing Home Administrator/designee will randomly audit resident rooms to ensure presence of window blind coverings for personal privacy weekly times three weeks and then monthly times two months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.
Inadequate Investigation of Resident's Injury
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for a resident, identified as Resident 5, to rule out abuse or neglect. The facility's policy requires the Director of Nursing or designee to conduct investigations, review accident/incident reports, obtain written statements from staff, and interview witnesses. However, there was no documented evidence that the investigation was expanded to include interviews with all staff who had potential contact with the resident around the time she complained of pain and swelling in her right wrist. The Director of Nursing confirmed the lack of documentation for a comprehensive investigation. Resident 5, who has severe cognitive impairment due to Alzheimer's and Parkinson's diseases, was readmitted to the facility after a hospital stay. Upon readmission, she had scattered bruising on her hands and arms. A subsequent skin assessment noted multiple small bruises on her hands. A nursing note indicated increased pain and swelling in her right wrist, which was not thoroughly investigated. Witness statements from staff revealed that some aides did not have contact with the resident, but there was no evidence of further interviews with other staff members who might have interacted with her.
Plan Of Correction
1. Physical assessment completed by a Registered Nurse on Resident 5. Incident report and investigation of Resident 5's injury of unknown cause on November 19, 2024 that included wrist swelling and pain to her right hand/wrist with movement was completed to rule out abuse. Immediate re-education provided to Licensed Nursing Staff, including licensed agency staff, on facility policy regarding reporting incidents and accidents and completing incident reports/investigations thoroughly with staff interviews to rule out abuse. 2. All residents with injuries of unknown cause have the ability to be affected by this alleged deficient practice. A whole house audit of current incident and accident reports has been completed to ensure each incident report with an injury of unknown cause has a thorough investigation, including staff interviews, to rule out abuse. 3. Facility Staff, including Agency Staff, were re-educated on facility policies regarding abuse prevention and reporting and abuse, neglect and mistreatment of residents including importance of reporting, investigating and obtaining/providing witness statements. The Charge Nurse will be notified of incidents and/or accidents including injuries of unknown origin, so medical attention may be provided and a physical assessment and thorough investigation, including staff interviews, can be completed to rule out abuse. Incident reports are reviewed daily for completion, including review of staff interview statements. 4. Director of Nursing/designee will audit injuries of unknown origin to ensure that their completed incident reports include a thorough investigation with staff interview statements to rule out abuse weekly times six weeks, monthly times two months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.
Improper Wheelchair Setup Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards by not following the manufacturer's directions for the use of a high-back reclining wheelchair. Specifically, the anti-tippers, which are required for safety on recliner models, were not properly installed on the wheelchair used by a resident with a history of cerebral vascular accident and Parkinson's disease. This oversight led to the resident experiencing a fall while self-propelling in the hallway, as the wheelchair tipped backward. The resident, who had been experiencing back pain and required a high-back reclining wheelchair for better support, was found to have tipped backward in the wheelchair due to the anti-tippers being installed upside down. The occupational therapist, responsible for evaluating the wheelchair upon its arrival, missed the incorrect installation of the anti-tippers, which were only corrected after the incident occurred. This failure to adhere to safety instructions resulted in the resident's fall, highlighting a deficiency in maintaining a safe environment.
Failure to Follow Planned Menu
Penalty
Summary
The facility failed to adhere to their planned menu, which is a requirement to meet the nutritional needs of residents. According to the facility's policy on menu management, menus should be posted on boards in the dining room and hallway, and any temporary changes should be updated daily. On June 3, 2024, the written and posted menu indicated that residents were to receive bread with margarine for lunch. However, observations during the lunch meal revealed that residents did not receive the bread or margarine as planned. An interview with the Dietary Manager confirmed that a new cook had removed the bread from the menu without explanation, and the residents should have been provided with the bread and margarine as per the menu. This deficiency is a violation of 28 Pa. Code 211.6(a) Dietary Services and 28 Pa. Code 201.29(j) Resident Rights, as the facility did not follow the pre-approved menu, thereby failing to meet the dietary needs of the residents.
Failure to Follow Physician's Orders and Complete Neurological Checks
Penalty
Summary
The facility failed to adhere to physician's orders for three residents and did not complete necessary neurological checks following unwitnessed falls for two residents. Resident 11, who has diabetes and requires insulin, received Glargine insulin on multiple occasions despite blood sugar levels being below the threshold specified in the physician's orders. This was confirmed by the Director of Nursing. Resident 27, who is cognitively impaired and requires extensive assistance, did not receive the prescribed treatment for a skin tear on her left forearm, as documented in the Treatment Administration Record. Additionally, Resident 13, who is moderately cognitively impaired, experienced an unwitnessed fall, but there was no documented evidence of neurological checks being completed, which was confirmed by the Director of Nursing. Similarly, Resident 35, who had a fall with injury, did not have documented neurological checks following an unwitnessed fall. Furthermore, Resident 35 did not receive the bowel protocol as ordered, despite not having a bowel movement for several days. These deficiencies were identified through a review of facility policies, clinical records, and staff interviews.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for four residents, as identified through a review of facility policies, clinical records, and staff interviews. The facility's policy on medication administration required that all medications be ordered, acquired, and administered in accordance with Pennsylvania State Regulations and the facility's procedures. However, discrepancies were found in the controlled drug records and the Medication Administration Records (MAR) for several residents, indicating that doses of controlled medications were signed out but not documented as administered. For Resident 2, the controlled drug record showed multiple doses of Oxycodone signed out over several months, but there was no documented evidence in the MAR or nursing notes that these doses were administered. Similarly, Resident 11 had doses of Hydrocodone-acetaminophen signed out without corresponding documentation of administration. Resident 29's records showed doses of Tramadol signed out, but again, there was no evidence of administration in the MAR or nursing notes. Lastly, Resident 34's records indicated doses of Tramadol signed out without documentation of administration. Interviews with the Director of Nursing confirmed the lack of documentation for the administration of these controlled medications. The absence of documented evidence for the administration of these medications constitutes a failure to maintain accountability for controlled substances, as required by state regulations and facility policy.
Failure to Address Pharmacy Recommendations Timely
Penalty
Summary
The facility failed to respond timely to pharmacy recommendations for four residents and did not obtain completed pharmacy recommendations for physician review for two residents. The facility's policy requires a licensed pharmacist to perform a monthly drug regimen review for each resident, with any medication irregularities and recommendations reported to the attending physician. The physician is expected to respond to these recommendations, which are then filed in the resident's chart. For Resident 3, a pharmacy review sheet dated March 5, 2024, recommended a correction to the insulin dose at bedtime, but there was no evidence that this was addressed timely by the physician. Similarly, for Resident 11, a recommendation for blood work related to drug therapy was not addressed timely. Resident 35 had pharmacy recommendations made on three separate occasions, but none were addressed timely by the physician. Resident 36 had a recommendation to discontinue one of the medications for anxiety and insomnia, but this was also not addressed timely. Additionally, for Resident 10, a pharmacy review was conducted, but the recommendations were not obtained for physician review. The same issue occurred for Resident 29, where pharmacy recommendations were made but not obtained for physician review. These deficiencies were confirmed through interviews with the Director of Nursing, who acknowledged that the recommendations should have been addressed and obtained for review.
Failure to Ensure Call Bell Accessibility and Bed Alarm Functionality
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident by not ensuring that the call bell was within reach. Resident 35, who was cognitively impaired and required maximum assistance for transfers and toileting, was observed lying in bed with the call bell placed in a closed nightstand drawer, making it inaccessible. Additionally, the resident's bed alarm was found unplugged and non-functional. The resident's care plan specified that the call bell should be within reach and that bed and chair alarms should be operational while the resident was in bed or a chair. Interviews with an LPN and the Director of Nursing confirmed that the call bell should have been accessible and the bed alarm should have been plugged in and functioning.
Failure to Maintain Advance Directives in Clinical Record
Penalty
Summary
The facility failed to address and maintain advance directives as part of the clinical record for one resident, identified as Resident 29. The facility's policy, dated May 6, 2024, requires that upon admission, residents or their responsible parties are asked if an advance directive or living will exists, and if so, it should be reviewed and placed in the resident's chart. If no directive exists, the resident or their responsible party is asked if they wish to complete one. These directives are to be reviewed as needed by a social worker, with acknowledgment forms filed in the resident's medical record. A quarterly Minimum Data Set (MDS) assessment for Resident 29, dated April 25, 2024, indicated that the resident was cognitively impaired, required assistance with care needs, and had diagnoses including cerebral infarction and depression. However, there was no documented evidence that advance directives were addressed with Resident 29 or maintained in her clinical record. This was confirmed during an interview with the Director of Nursing on June 5, 2024.
Failure to Verify Nursing Licenses and Registry Status
Penalty
Summary
The facility failed to ensure proper verification of nursing licenses and nurse aide registry status, leading to deficiencies in their hiring process. Specifically, the facility did not verify the nursing license of a Licensed Practical Nurse (LPN) with the State Board of Nursing until several months after her employment began. Additionally, the facility did not complete a Nurse Aide Registry verification for a nurse aide before her start date. These oversights were confirmed during an interview with the Human Resources Director, who acknowledged the lapses in verifying the credentials of the staff members in question. The facility's policy requires potential employees to pass a pre-employment screening process, including criminal background checks and verification with licensing boards and registries, which was not adhered to in these cases.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to update and revise care plans to reflect the current care needs of three residents. For Resident 13, the care plan was not updated to reflect a change in diet orders from mechanically soft with nectar thick liquids to a carbohydrate-controlled, mechanically soft textured diet with thin consistency liquids. This discrepancy was confirmed by the Director of Nursing during an interview. Similarly, Resident 29's care plan was not revised to reflect the correct size of the Foley catheter, which was changed from a 16 French, 10 ml balloon to an 18 French, 5-15 ml balloon as per physician's orders. Observations confirmed the presence of the new catheter size, yet the care plan remained outdated. Resident 43's care plan was also not updated to reflect the discontinuation of a PICC line and cessation of antibiotic treatment. The resident confirmed that the PICC line was removed shortly after admission, and this was corroborated by observations and an interview with the Director of Nursing. These failures to update care plans were identified through clinical record reviews and staff interviews, indicating a lapse in ensuring that care plans accurately reflected the residents' current medical orders and conditions.
Failure to Document RN Assessment After Resident Fall
Penalty
Summary
The facility failed to ensure that a registered nurse assessed a resident after a fall, as required by professional standards of quality. According to the Pennsylvania Code, registered nurses are responsible for collecting and analyzing data to determine nursing care needs and carrying out actions to promote well-being. However, in the case of Resident 13, who was moderately cognitively impaired and required assistance for personal care, there was no documented evidence in the clinical record of an assessment by a registered nurse following her fall on February 17, 2024. A licensed practical nurse documented that Resident 13 was found on the floor, but the fall investigation, which was privileged and confidential, only included a comment from a registered nurse agreeing with the assessment done by the nurse on duty. This comment was not part of the medical record. The Director of Nursing confirmed the absence of documentation of a registered nurse's assessment in the clinical record, indicating a failure to meet the required nursing services standards.
Failure to Follow Wound Care Recommendations
Penalty
Summary
The facility failed to follow treatment recommendations for a resident at risk for pressure ulcers. The facility's policy required a wound care nurse consult to include assessment and treatment recommendations. A resident, who was dependent on staff for care and at risk for pressure ulcers, had a physician's order for daily wound care on the right heel. However, a wound consultant later recommended increasing the frequency of the dressing change to twice daily. Despite this recommendation, there was no documented evidence that the treatment was adjusted accordingly. The Director of Nursing confirmed that the Registered Nurse Supervisor did not update the order, resulting in the treatment not being completed as recommended.
Failure to Provide Prescribed Passive ROM Exercises
Penalty
Summary
The facility failed to provide contracture management services as care planned for a resident with hemiplegia, who was dependent on staff for daily care needs. The resident was supposed to receive passive range of motion (ROM) exercises to all joints in her left hand twice a day, as per occupational therapy orders and the care plan. However, documentation revealed that the resident only received these exercises once per day on multiple occasions in May and June 2024. Interviews with the occupational therapist and the Director of Nursing confirmed that the passive ROM program was recommended to be performed twice daily and should have been documented accordingly. The lack of documentation indicated that the facility did not adhere to the care plan, resulting in a deficiency in providing the necessary nursing services as required by the resident's condition.
Medication Security Lapse
Penalty
Summary
The facility failed to ensure that medications were properly secured in the medication cart, as evidenced by an observation on June 3, 2024, where a round white pill was found on the floor of a resident's room. The resident, identified as Resident 244, was cognitively intact and required assistance for personal care needs, with a diagnosis of gout. Physician orders dated May 13, 2024, indicated that the resident was prescribed 100 mg of Allopurinol in the morning for gout. An interview with an LPN confirmed that the pill on the floor was Allopurinol, which was currently prescribed to the resident. The Director of Nursing confirmed that the medication should have been labeled and secured, not left on the floor.
Incomplete Clinical Documentation for Resident Post-Fall
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for a resident. According to the facility's policy on nursing documentation, all care provided must be documented in the electronic record system, Point Click Care (PCC). However, for one resident, there was no documented evidence of a registered nurse's assessment in the clinical record following a fall incident. The resident, who was moderately cognitively impaired and required assistance for personal care needs, was found sitting on the floor in her room with her alarm sounding. Although a fall investigation was conducted, and a registered nurse was present during the fall assessment, the assessment was not documented in the clinical record. The Director of Nursing confirmed that the resident was assessed by a registered nurse, but acknowledged the absence of documentation in the clinical record. This lack of documentation is a violation of the facility's policy and the regulatory requirement under 28 Pa. Code 211.5(f) Clinical Records, which mandates that clinical records be complete and accurately maintained. The failure to document the registered nurse's assessment in the clinical record represents a deficiency in the facility's compliance with accepted professional standards for maintaining medical records.
QAPI Committee Fails to Address Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as identified in the current survey ending June 5, 2024. The deficiencies included failure to develop resident care plans, provide quality care, maintain complete and accurate medical records, and ensure a complete and accurate accounting of controlled medications. These issues were also noted in the previous survey ending June 1, 2023, indicating that the facility's plans of correction were not successfully implemented. The facility had developed plans of correction for the deficiencies cited in the previous survey, which included conducting audits and reporting the results to the QAPI committee. However, the current survey revealed that the QAPI committee was ineffective in maintaining compliance with regulations related to comprehensive care plans (F656), quality of care (F684), accounting of controlled medications (F755), and accuracy of clinical records (F842). This indicates a failure in the facility's quality assurance systems to ensure ongoing compliance with nursing home regulations.
Deficiency in Nurse Aide In-Service Education
Penalty
Summary
The facility failed to ensure that one of the five nurse aides reviewed, specifically Nurse Aide 6, completed the required 12 hours of in-service education annually. According to the facility's policy dated May 6, 2024, Certified Nursing Assistants are required to complete a minimum of 12 hours of education each year. However, records showed that Nurse Aide 6, who was hired on May 18, 2018, did not complete any annual education between May 2022 and May 2024. This deficiency was confirmed during an interview with the Human Resources Director on June 5, 2024, at 10:40 a.m., who acknowledged that Nurse Aide 6 did not meet the required educational hours based on her hire date.
Failure to Provide Written Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide a written notice of the bed-hold policy to residents and/or their representatives at the time of transfer to a hospital. This deficiency was identified for three residents who were transferred to the hospital on multiple occasions. The facility's policy, dated October 6, 2023, requires that the admission director or designee contact the resident or their representative following a transfer and provide a written copy of the bed-hold policy, which should be documented in the resident's electronic medical record. However, there was no documented evidence that this procedure was followed for the three residents reviewed. Nursing notes for Resident 1, Resident 2, and Resident 3 revealed multiple instances of hospital transfers without the required written notice of the bed-hold policy being provided. Interviews with the Nursing Home Administrator confirmed that the facility did not provide the necessary documentation to the residents or their responsible parties at the time of transfer. This failure to comply with the facility's policy and state regulations was noted as a deficiency under 28 Pa. Code 201.14(a) and 28 Pa. Code 201.18(b)(3).
Failure to Document Inability to Meet Resident's Needs
Penalty
Summary
The facility failed to permit the readmission of a hospitalized resident without providing evidence that the facility was not able to meet the resident's needs. The facility's policy indicated that a resident should not be transferred or discharged unless it is necessary for the resident's welfare, the safety of individuals in the facility is endangered, or the health of individuals in the facility would otherwise be endangered. However, there was no documented evidence that the facility could not meet the resident's needs related to behaviors, and no documented evidence that the resident's discharge was based on a valid discharge reason. The resident, who had diagnoses including osteomyelitis, diabetes, COPD, and an acquired absence of the right great toe, was noncompliant with his nonweight bearing status and exhibited agitated and threatening behavior towards staff. Despite these challenges, the facility did not document the reasons why they could not meet his needs before deciding not to readmit him after hospitalization for altered mental status and toe infection. The Director of Nursing confirmed that there was no documented evidence in the clinical record of the reasons why the facility was not able to meet the resident's needs. The resident was described as very noncompliant, wandering into other residents' rooms, and being verbally aggressive towards staff. The decision not to readmit the resident was made after discussions among the team and with the physician, but this decision was not supported by the required documentation. The facility's failure to document the inability to meet the resident's needs and the lack of a valid discharge reason led to the deficiency.
Failure to Accurately Document Clinical Records
Penalty
Summary
The facility failed to maintain accurately documented clinical records for one of the three residents reviewed. Specifically, for Resident 1, the admission Minimum Data Set (MDS) assessment indicated that the resident had osteomyelitis and an acquired absence of the right great toe. A wound healing center note recommended that the dressing on the resident's foot be left for three days and then replaced with betadine dressings daily. However, the Treatment Administration Record (TAR) for January 2024 showed that the betadine dressing was only documented as completed on January 5, 2024, with no evidence of completion on January 6 and 7, 2024, as per the wound healing center's recommendations. The Director of Nursing confirmed the lack of documentation for the betadine dressing on January 6 and 7, 2024. Additionally, a Registered Nurse stated that she had completed the betadine dressing on those dates but did not document it. She mentioned that the resident was noncompliant and often standing on the foot, which caused the dressing to come off, necessitating reapplication. This failure to document the treatment accurately led to the deficiency noted in the report.
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.
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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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