Marywood Heights
Inspection history, citations, penalties and survey trends for this long-term care facility in Scranton, Pennsylvania.
- Location
- 2500 Adams Avenue, Scranton, Pennsylvania 18509
- CMS Provider Number
- 395625
- Inspections on file
- 27
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Marywood Heights during CMS and state inspections, most recent first.
A facility failed to provide adequate supervision and safety measures for two residents, resulting in multiple falls and a serious burn. One resident, with hemiplegia and cognitive impairment, suffered a burn from hot soup due to lack of supervision during meals. Another resident, identified as a high fall risk, experienced repeated falls due to insufficient safety interventions and supervision. Interviews with the NHA and DON confirmed the facility's failure to implement necessary individualized measures.
A facility failed to ensure that an attending physician acted on a pharmacist's recommendations regarding a resident's drug regimen. The resident, diagnosed with multiple mental health disorders, was prescribed three anxiety medications. The pharmacist recommended a Gradual Dose Reduction (GDR) for Ativan and an evaluation of the medications to avoid duplication. However, there was no documentation of the physician's response to these recommendations, confirmed by the DON.
The facility failed to maintain accurate clinical records for three residents, including missing documentation of emergency room evaluations, tuberculosis screenings, and psychology appointments. This lack of documentation was confirmed by the facility's staff.
A facility failed to accurately document a resident's fall history in the MDS assessment. The resident, admitted with conditions including hemiplegia and anxiety, was at high risk for falls and had fallen prior to admission. However, the MDS assessment incorrectly indicated no falls in the month before admission.
A resident was admitted with several psychiatric disorders, and a diagnosis of bipolar disorder was added to their medical records without documented clinical findings to support it. Despite a physician's note suggesting bipolar depression and a change in medication, the comprehensive care plan was not updated to reflect a confirmed diagnosis. A later psychiatry consult diagnosed the resident with generalized anxiety disorder, and the DON confirmed the lack of documentation for bipolar disorder, indicating a deficiency in maintaining accurate medical records.
The facility failed to follow physician orders for two residents, resulting in deficiencies. One resident did not receive the prescribed bowel protocol despite not having a bowel movement for six days, with no evidence of medication administration or physician notification. Another resident was observed not wearing prescribed DARCO shoes, confirmed by staff and the resident, indicating non-compliance with the physician's order.
A facility failed to prevent urinary tract infections in a resident with an indwelling catheter. The resident's catheter was not changed as ordered, and there was no verification of irrigation specifics, leading to potential inaccuracies in urinary output documentation. Additionally, unsanitary storage of catheter supplies was observed, and duplicate orders resulted in improper documentation of catheter changes. The DON confirmed the facility's failure to provide appropriate care.
A resident with major depressive disorder exhibited consistent behavioral symptoms, but the facility failed to provide necessary psychiatric follow-ups. A scheduled appointment was canceled due to transportation issues and was not rescheduled, with no evidence of timely follow-up services. The NHA could not provide evidence of the resident receiving recommended psychological services.
A resident was administered Keflex for a possible UTI without clinical justification. Despite no signs or symptoms of a UTI and lack of diagnostic confirmation, the antibiotic was given from June 26 to July 5. The Infection Preventionist confirmed the administration was unjustified.
A facility failed to ensure a resident was free from unnecessary psychoactive drugs by not documenting a prescriber clinical rationale for Xanax use. A pharmacist's request for a gradual dose reduction was not addressed due to a miscommunication, and no evidence of a dose reduction attempt was found. This deficiency was confirmed by the NHA and DON.
Expired medications were found in a medication cart, with two multidose insulin vials labeled with an expiration date that had passed. An LPN confirmed the expired medications during an inspection, and the DON acknowledged that these should have been removed and discarded.
A facility failed to offer routine annual dental services to a Medicaid resident. The resident's care plan noted a decline of dental visits, but there was no documentation proving the resident was offered and declined services in the past year. The DON confirmed the oversight.
A facility failed to maintain infection control practices on a resident care unit. A resident with a urinary tract infection and an indwelling catheter had orders for daily irrigation. However, an undated syringe and an unlabeled bottle of sterile water were found in the resident's bathroom. Staff confirmed the items should have been labeled and dated, indicating a lapse in infection control.
Inadequate Supervision Leads to Falls and Burn Injuries
Penalty
Summary
The facility failed to provide necessary supervision and implement effective individualized safety measures for two residents, leading to multiple falls and a serious burn. Resident 27, who was admitted with hemiplegia and hemiparesis, was severely cognitively impaired and required supervision during meals. Despite having a physician order for a Kennedy cup and other assistive devices, the resident accidentally spilled hot soup on himself, resulting in a burn. The incident occurred when staff placed the soup within reach and turned away to get an ice cube, failing to supervise the resident adequately. Resident 13, admitted with a history of hemiplegia, bipolar disorder, and anxiety, was identified as a high fall risk. Despite receiving transfer paperwork from a prior facility outlining necessary safety interventions, the facility did not timely implement these measures. The resident experienced multiple falls, some resulting in injuries, due to inadequate supervision and failure to maintain functioning alarms. The facility's inaction in addressing the resident's high fall risk and implementing sufficient safety measures led to repeated falls. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed the facility's inability to demonstrate the implementation of necessary individualized fall prevention measures and sufficient staff supervision. The lack of adequate supervision and failure to adhere to safety protocols for both residents resulted in preventable injuries, highlighting deficiencies in the facility's care practices.
Failure to Act on Pharmacist's Drug Regimen Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician acted upon the pharmacist's reports of irregularities in the drug regimen of a resident. The resident, who was admitted with diagnoses including major depressive disorder, anxiety disorder, obsessive-compulsive disorder, and dementia, was prescribed Ativan for anxiety. The consultant pharmacist recommended a Gradual Dose Reduction (GDR) of Ativan, as per CMS guidelines, unless clinically contraindicated. The pharmacist noted that if the drug therapy was to continue, the physician must document why the risk of adverse consequences from a GDR would exceed the benefits. However, there was no written documentation of the attending physician's response to this recommendation. Further reviews revealed that the resident was prescribed three medications for anxiety: Remeron, Ativan, and Buspar. The pharmacist recommended evaluating whether any of these medications could be reduced or discontinued to avoid duplication of effect. Despite a second request from the pharmacist, the facility failed to provide documentation of the attending physician's response or acknowledgment of these recommendations. An interview with the Director of Nursing confirmed the lack of documented evidence that the attending physician acted upon the pharmacy recommendations.
Deficiencies in Clinical Record Maintenance
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for three residents, as required by professional standards. Resident 13, who was admitted with conditions including hemiplegia and anxiety, was sent to the emergency room for dizziness and nausea after a fall. Upon return, there was no documented evidence of the emergency room evaluation or the treatment for a possible urinary tract infection, despite verbal instructions from the hospital to administer medication. Resident 37, diagnosed with Alzheimer's disease and hypertension, lacked documentation of tuberculosis screening in their clinical record, which is required by facility policy. Although the Infection Preventionist confirmed that screenings were conducted, they were not included in the resident's clinical record. This oversight was acknowledged by the Director of Nursing and the Nursing Home Administrator. Resident 60, with diagnoses including polyneuropathies and anxiety, had no documented evidence of attending a scheduled psychology appointment or a subsequent telehealth visit. The resident expressed frustration over the lack of support for the telehealth visit, which required family intervention to provide necessary equipment. The Director of Nursing confirmed the absence of documentation for these appointments and their outcomes.
Inaccurate MDS Assessment of Fall History
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessments accurately reflected the status of a resident. Specifically, the MDS assessment for a resident admitted with diagnoses including hemiplegia, hemiparesis, bipolar disorder, and anxiety did not accurately document the resident's fall history. The resident was identified as being at high risk for falls and had experienced a fall on May 24, 2024, prior to admission. However, the Admission MDS assessment incorrectly indicated that the resident had not fallen in the month prior to admission, as evidenced by the coded answer of 0 in Section J - Health Conditions, question J1700 Fall History on Admission/Entry or Reentry.
Failure to Document Bipolar Disorder Diagnosis
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice by not properly identifying and documenting a resident's diagnosis of bipolar disorder. The resident, who was admitted with major depressive disorder, anxiety disorder, and obsessive-compulsive disorder, had a diagnosis of bipolar disorder added to their medical records on April 4, 2023. However, there was no documented evidence in the clinical record to support this diagnosis with clinical findings from the time of admission through the survey ending on July 25, 2024. A physician's progress note from April 30, 2023, indicated an impression of bipolar depression and a change in medication, but the comprehensive plan of care was not updated to reflect a confirmed diagnosis of bipolar disorder. Additionally, a psychiatry consult in October 2023 diagnosed the resident with generalized anxiety disorder, further complicating the clinical picture. The Director of Nursing confirmed the lack of documented evidence for a bipolar disorder diagnosis, highlighting a deficiency in maintaining accurate medical records according to professional standards.
Failure to Follow Physician Orders for Bowel Protocol and Therapeutic Shoes
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to deficiencies in care. For one resident, the facility did not follow a prescribed bowel protocol despite the resident not having a bowel movement for six consecutive days. The clinical records showed no evidence that the necessary medications were administered, nor was there documentation of physician notification regarding the resident's condition. This oversight was confirmed during an interview with the Director of Nursing, who could not provide evidence that the bowel protocol was followed or that the physician was informed in a timely manner. In another case, the facility did not comply with a physician's order for the application of DARCO shoes for a resident. Observations over several days revealed that the resident was not wearing the prescribed shoes, instead opting for socks and sandals. Interviews with the resident and a licensed practical nurse confirmed the non-compliance with the physician's order. The Nursing Home Administrator and Director of Nursing acknowledged that the staff had not followed the order for the application of the DARCO shoes, as required.
Failure to Prevent Urinary Tract Infections in Resident with Indwelling Catheter
Penalty
Summary
The facility failed to provide necessary care to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident, who was admitted with diagnoses including urinary retention and acute cystitis, had physician orders to change the catheter monthly and as needed for specific issues. However, the Treatment Administration Record for April 2024 did not show evidence of the catheter being changed as ordered. Additionally, orders from a urology appointment in May 2024 included daily irrigation of the catheter to prevent sediment buildup, but there was no evidence that the nursing staff verified the specifics of the irrigation process, such as the solution or amount to be used. This lack of verification potentially led to inaccurate documentation of the resident's urinary output. Further issues were noted in July 2024, when the resident pulled out the catheter, and a new one was inserted, but the change was not documented in the Treatment Administration Record. The catheter was documented as changed on two consecutive days later in July due to duplicate orders. Observations also revealed unsanitary storage of catheter irrigation supplies in the resident's bathroom. The Director of Nursing confirmed the facility's failure to provide appropriate care and services for the resident with recurring urinary tract infections.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to consistently provide necessary behavioral health services to meet the needs of a resident diagnosed with major depressive disorder. The resident, admitted with a history of depression, exhibited consistent behavioral symptoms of yelling out repeatedly, which were not easily redirectable. Despite having a care plan that included psychiatric follow-ups, the resident's scheduled appointment with a psychiatrist was canceled due to the facility's inability to provide transportation. This appointment was not rescheduled by the time of the survey, and there was no documented evidence of timely follow-up psychiatric services being provided. During an interview, the Nursing Home Administrator was unable to provide evidence that the resident received the recommended psychological or psychiatric services.
Unnecessary Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotic drugs. Resident 13, who was admitted with diagnoses including hemiplegia, hemiparesis, bipolar disorder, and anxiety, was sent to the emergency room after a fall. Upon returning to the facility, the resident was prescribed Keflex for a possible urinary tract infection (UTI) without any acute injuries or confirmed diagnosis. The antibiotic therapy was initiated despite the absence of urinalysis results or signs and symptoms of a UTI. The facility continued administering the antibiotic from June 26, 2024, through July 5, 2024, without clinical justification, as confirmed by the Infection Preventionist. The hospital did not perform a culture and sensitivity test, and the urinalysis results did not support the diagnosis of a UTI. The nursing documentation during this period did not indicate any symptoms of a UTI, highlighting the unnecessary administration of the antibiotic.
Failure to Document Clinical Rationale for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychoactive drugs by not having a documented prescriber clinical rationale for the use of a psychotropic medication. Resident 45, who was admitted with a diagnosis of dementia, had a physician order for Xanax to manage anxiety. A pharmacist consult requested a gradual dose reduction (GDR) for the Xanax, but there was no physician response to this request. The consult was mistakenly sent to the wrong physician and had not been reviewed by the correct physician by the time of the survey. The facility could not provide evidence of a GDR attempt or justification for the continued use of the current Xanax dose over the past year. This deficiency was confirmed during an interview with the Nursing Home Administrator and Director of Nursing.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to adhere to medication and pharmaceutical expiration dates, as observed in one of the four medication carts. During an inspection of the second-floor Cart A medication cart, two multidose insulin vials were found to be expired. Specifically, a vial of Lantus 100 units/mL and a vial of Admelog 100 units/mL were labeled with an expiration date of July 17, 2024, yet were still present in the cart on July 25, 2024. This observation was confirmed by a licensed practical nurse at the time of the inspection. An interview with the Director of Nursing further confirmed that these expired medications should have been removed and discarded from the medication cart. The failure to do so was a violation of the facility's obligation to ensure that all drugs and biologicals are stored and managed according to professional standards, as outlined in the relevant Pennsylvania Code sections.
Failure to Offer Routine Dental Services
Penalty
Summary
The facility failed to offer routine annual dental services to a resident whose payor source was Medicaid. The clinical record of the resident, who was admitted to the facility, showed no documented evidence that dental services had been offered in the past year. Although the resident's care plan indicated that they declined dental visits, the facility could not provide documentation proving that the resident was offered and declined dental services during the past year. An interview with the Director of Nursing confirmed that the facility had not offered the resident routine dental services in the past year.
Infection Control Lapse in Resident Care Unit
Penalty
Summary
The facility failed to maintain proper infection control practices on one of its resident care units. A clinical record review revealed that a resident was admitted with several diagnoses, including urinary retention, acute cystitis, and a urinary tract infection, necessitating the use of an indwelling catheter. Orders from a urology appointment required daily irrigation of the Foley catheter to prevent sediment buildup and changes every four weeks. However, during an observation, an undated bulb piston syringe and an unlabeled, opened bottle of sterile water were found in the resident's bathroom, indicating a lapse in infection control practices. Interviews with a licensed practical nurse and the Director of Nursing, in the presence of the Nursing Home Administrator, confirmed the observations. The staff acknowledged that the items should have been labeled and dated to prevent potential infection spread. The facility's failure to maintain resident care equipment properly was confirmed, highlighting a deficiency in infection prevention and control measures.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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