Masonic Village At Sewickley
Inspection history, citations, penalties and survey trends for this long-term care facility in Sewickley, Pennsylvania.
- Location
- 1000 Masonic Drive, Sewickley, Pennsylvania 15143
- CMS Provider Number
- 395638
- Inspections on file
- 24
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Masonic Village At Sewickley during CMS and state inspections, most recent first.
A resident with osteoporosis and cognitive impairment, care-planned for two-person assist with a mechanical lift, was transferred from wheelchair to bed by a single NA using a sit-to-stand lift. Policy and the care plan required two staff for all mechanical lift transfers. The resident had been using the right arm normally earlier in the evening, but after the transfer was found in bed, crying and in pain, with a swollen, hard right arm. An LPN and RN assessed the resident, and imaging later confirmed an acute displaced mid-shaft humerus fracture with soft tissue swelling. Facility investigation, including staff statements, established that no second staff member assisted with the lift, and leadership acknowledged that the NA did not follow the care plan requirement for two-person assistance.
Three residents with indwelling urinary catheters, each with complex medical conditions, were observed with uncovered catheter drainage bags, in violation of facility policy requiring drainage bags to be covered for dignity. Staff, including RNs and an LPN, confirmed the deficiency during interviews, and the DON acknowledged the failure to provide appropriate catheter care.
Surveyors found that medications and biologicals, including insulin pens and tuberculin vials, were not properly labeled, stored, or secured in two medication rooms and on two medication carts. Expired medications and unlabeled opened vials were observed, and an LPN left an insulin pen unattended on a medication cart while administering other medications to a resident with diabetes, hypertension, and COPD. These deficiencies were confirmed by staff interviews.
A resident with hypertension, diabetes, and COPD was found with nasal spray at bedside without a physician's order or interdisciplinary assessment for self-administration, as required by facility policy. An LPN and the DON confirmed that the necessary evaluation and authorization for self-administration had not been completed.
The facility did not provide timely Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) forms to two residents with complex medical conditions, either issuing the notice on the same day services ended or failing to provide it at all, as confirmed by staff and record review.
The facility did not document or communicate essential resident information, such as care plan goals, advanced directives, and contact details, to the receiving health care provider during hospital transfers for two residents with complex medical needs. This failure was confirmed by the DON and was not in accordance with facility policy.
The facility did not obtain physician orders for two residents who went on therapeutic leave and failed to follow the bowel protocol in a timely manner for a resident with Alzheimer's disease and other conditions, resulting in delayed interventions for constipation and lack of required documentation.
Two residents with limited mobility did not receive appropriate services, equipment, or assistance to maintain or improve mobility. One resident experienced skin injury due to an improperly sized hand brace without proper assessment or documentation, while another had a TLSO brace ordered without directions or interventions for monitoring skin integrity. The facility lacked policies and care plan interventions for assistive devices and skin monitoring, as confirmed by staff and the DON.
A resident with a PICC line for IV antibiotics did not have physician orders specifying the substance or amount for required line flushes before and after medication administration. Facility policy required flushing with 10 ml normal saline, but the omission in the orders was confirmed by an LPN, resulting in inadequate care in line with professional standards.
Two residents receiving oxygen therapy did not have their humidification bottles changed weekly as required by facility policy. Observations showed that the bottles were either empty or had not been changed for extended periods, and this was confirmed by nursing staff and the DON.
A resident with severe cognitive impairment, as indicated by a low BIMS score and a diagnosis of dementia, was required to sign a binding arbitration agreement at admission without an option to decline. The agreement was presented as mandatory, and the facility's process did not ensure the resident's capacity to understand or provide a choice to refuse.
The facility did not conduct a required quarterly QAA meeting with all mandated committee members, as the DON was absent for one of the meetings. This was confirmed through policy review, attendance records, and staff interview.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility failed to maintain an effective annual in-service training program for several nurse aides, as their records lacked required trainings in infection control, dementia, communication, and abuse for 2024. Despite policies mandating compliance education, the facility did not ensure completion of these trainings, as confirmed by the NHA.
A facility failed to report an alleged abuse incident involving a resident with renal insufficiency, high blood pressure, and heart failure. The resident reported bruising caused by a nurse aide pressing their leg tightly during care. Despite the resident's account and visible bruising, the facility did not report the incident, as management was unaware of the identified perpetrator. This resulted in a deficiency for not adhering to reporting policies.
A resident reported that a nurse aide pressed their leg tightly during care, resulting in bruising. Despite the resident's medical history and visible bruising, the facility failed to conduct a timely and comprehensive investigation. The alleged perpetrator was interviewed four days after the incident, and the facility did not promptly collect or review investigation forms, violating their abuse prevention policy.
A resident with severe cognitive impairment and a high elopement risk score managed to leave an unsupervised area without staff knowledge. The resident was found at a different location after taking a staff elevator. The incident was confirmed by the DON, who also noted that staff were not reeducated following the event.
A facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy. The resident's care plan lacked necessary interventions, and there was no facility policy for oxygen therapy. Observations showed the resident's oxygen equipment improperly placed, and staff interviews revealed discrepancies in oxygen use documentation. The DON confirmed the absence of a policy, leading to the deficiency.
Failure to Use Two-Person Assist With Mechanical Lift Resulting in Humerus Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from accident hazards and received adequate supervision during a mechanical lift transfer. Facility policy on "Resident Transfers To/From and Within Equipment" required staff to use appropriate safety techniques and to follow the resident’s individualized transfer status as documented in the care plan and nursing assistant documentation. For this resident, the Resident Care Guide directed that transfers be completed using a Sara (sit-to-stand) lift with two-person assist, and the care plan specified use of a Maxi lift with assistance from two staff. The resident’s MDS assessments documented the need for maximal assistance and two-person support for transfers, and the facility’s NHA confirmed that the facility requires two-person assist with all mechanical lifts. The resident had diagnoses including osteoporosis and a displaced fracture of the surgical neck of the right humerus, and later a significant change MDS reflected severely impaired cognition and a change in functional ability requiring a Maxi lift for transfers. On the evening of the incident, the resident was observed at dinner and afterward in her wheelchair using her right arm normally and coloring, with no complaints of pain. Around the time of the event, an LPN was in another resident’s room with a nursing assistant (Employee 3) setting up a shower, and later returned to the office when another nursing assistant (Employee 1) requested that she assess the resident’s arm. When the LPN entered the room, the resident was already in bed, changed into a gown, visibly upset, crying, and in pain, with a hard, swollen right arm that was painful with movement. The resident was unable to explain what had happened but repeatedly referred to "he" and asked the LPN not to leave her. Employee 1 initially told facility administration that a second staff member (Employee 3) had assisted with the stand-up lift transfer, but subsequent investigation and a written statement from Employee 3 confirmed that Employee 3 did not assist with putting the resident to bed. In a written statement, Employee 1 reported transferring the resident into bed with the sit-to-stand lift and then noticing the right arm swelling while the resident was still in a sitting position in bed, at which point the nurse was alerted. An incident report documented that the resident’s right arm appeared swollen, she was crying and expressing pain, and she was unable to explain what may have happened. An x-ray obtained that evening showed an acute mid-shaft fracture of the right humerus with moderate angulation and displacement and mild soft tissue swelling, without dislocation. Subsequent observation showed the resident’s right hand to be non-functional, with curled fingers and wrist and inability to move the right hand, while the left arm and hand remained functional. The DON and NHA confirmed that Employee 1 was the only person who provided evening care and transferred the resident from wheelchair to bed during the shift in question, and agreed that Employee 1 should have followed the care plan and had a second person present for the lift transfer.
Failure to Cover Catheter Drainage Bags as Required by Policy
Penalty
Summary
The facility failed to provide appropriate treatments and services for residents with indwelling urinary catheters, as required by facility policy and state regulations. Specifically, observations revealed that three residents with physician orders for indwelling urinary catheters were found in bed with their catheter drainage bags uncovered, contrary to the facility's Continence Care Program and Indwelling Catheter Management policy, which requires drainage bags to be covered for dignity. These findings were confirmed through staff interviews, including with registered nurses and a licensed practical nurse, who acknowledged that the drainage bags were not covered as required. The residents involved had significant medical histories, including diagnoses such as hypertension, obstructive uropathy, Parkinson's disease, hyperlipidemia, Alzheimer's disease, atrial fibrillation, and heart failure. Despite these conditions and the presence of indwelling urinary catheters per physician orders, the facility did not ensure that the drainage bags were covered during the survey observations. The Director of Nursing confirmed the failure to provide appropriate treatments and services for the use of indwelling urinary catheters for these residents.
Failure to Properly Store, Label, and Secure Medications and Biologicals
Penalty
Summary
The facility failed to properly store and label medications and biologicals in accordance with professional standards and facility policy. During reviews of two out of three medication rooms and two out of three medication carts, surveyors observed expired medications, including a vial of tuberculin and insulin pens, as well as insulin pens that were not labeled with expiration dates as required. Additionally, a tuberculin vial in one medication room was found to be opened without being labeled with the date it was opened. These findings were confirmed by LPNs and the Director of Nursing during interviews. In one instance, a resident with diagnoses of hypertension, diabetes, and COPD was prescribed Basaglar insulin. During a medication pass, an LPN prepared the resident's insulin pen and left it unattended on top of the medication cart while administering oral medications in the resident's room, making the insulin pen accessible to anyone passing by. This was acknowledged by the LPN during an interview. The facility's failure to ensure proper storage, labeling, and security of medications and biologicals was observed and confirmed by staff.
Failure to Evaluate and Authorize Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was properly evaluated and authorized to self-administer medication, as required by facility policy. According to the policy, residents may self-administer medications only after an interdisciplinary team evaluation and approval from their medical provider, followed by a physician's order. During a medication pass observation, a can of nasal spray was found on a resident's over-bed table, and the LPN confirmed there was no physician order for self-administration of this medication. Review of the resident's records showed no current order or interdisciplinary assessment for self-administration. The Director of Nursing confirmed that the necessary evaluation and authorization had not been completed for this resident, who had diagnoses of hypertension, diabetes, and COPD.
Failure to Provide Timely SNF ABN Forms to Residents
Penalty
Summary
The facility failed to provide timely Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) forms to two of three reviewed residents. According to facility policy, residents must be given advance notice when Medicare Part A or Managed Skilled Care benefits will no longer cover their care and services. For one resident, the SNF ABN form was signed on the same day that services were set to end, rather than in advance as required. For another resident, there was no completed SNF ABN form found in the records, and staff confirmed that the notice had not been provided. Both residents had significant medical conditions, including coronary artery disease, high blood pressure, arthritis, heart failure, diabetes, and depression. The deficiency was identified through a review of facility documents, clinical records, and staff interviews, which confirmed that the facility did not adhere to its own policy or regulatory requirements regarding timely notification of non-coverage. This failure was cited under multiple state codes related to admission policy, licensee responsibility, management, and resident rights.
Failure to Communicate Required Resident Information During Hospital Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during hospital transfers for two residents. According to the facility's own policy, information such as the provider's contact details, resident representative or POA contact, advanced directives, special care instructions, care plan goals, and other relevant information must be provided to ensure a safe and effective transition. However, clinical record reviews for two residents who were transferred to the hospital and later returned showed no documented evidence that this required information was communicated to the receiving provider. One resident had diagnoses including lung cancer, stroke, and anemia, while another had a left femur fracture, dysphagia, and muscle weakness. In both cases, the clinical records did not contain documentation of communicated care plan goals, advanced directive information, specific instructions for ongoing care, or resident representative information at the time of transfer. The DON confirmed during interviews that the necessary information was not communicated for these residents, as required by facility policy and regulatory standards.
Failure to Obtain Physician Orders and Timely Follow Bowel Protocol
Penalty
Summary
The facility failed to obtain required physician orders for two residents who went on therapeutic leave and did not follow the established bowel protocol in a timely manner for another resident. Specifically, two residents with diagnoses including vascular dementia, kidney disease, congestive heart failure, Alzheimer's disease, hypothyroidism, and a history of repeated falls were documented in nurse progress notes as being on leave with family, but there were no corresponding physician orders authorizing these therapeutic leaves. The Director of Nursing confirmed that the required orders were not present in the clinical records for these residents. Additionally, a resident with high blood pressure, hyperlipidemia, and Alzheimer's disease experienced significant lapses between documented bowel movements, with intervals ranging from five to seven days. During these periods, there was no evidence in the clinical record of abdominal assessments or timely interventions as outlined in the facility's bowel protocol. The first intervention, administration of bisacodyl, was not provided until after a prolonged lapse, and the Director of Nursing confirmed the protocol was not followed in a timely fashion.
Failure to Provide Appropriate Mobility and Skin Integrity Interventions for Residents with Limited Mobility
Penalty
Summary
The facility failed to ensure that residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility. For one resident with diagnoses including high blood pressure, hyperlipidemia, and Alzheimer's Disease, there was no documented assessment of a right hand brace provided after an orthopedic appointment, nor was the appearance of the hand upon return recorded. The resident subsequently experienced skin irritation and a skin tear below the thumb, with the brace found to be too small and causing damage. The facility did not have a policy for assistive devices or splints, and staff confirmed the lack of documentation and assessment regarding the brace. Another resident with osteomyelitis of the vertebra, depression, and atrial fibrillation had a physician order for a thoraco-lumbar sacral orthosis (TLSO) brace, but the order did not specify directions for use or interventions for monitoring skin integrity under the brace. The resident's care plan also failed to include interventions for monitoring skin integrity. Staff interviews confirmed these omissions, and the Director of Nursing acknowledged the failure to provide appropriate services and documentation for both residents.
Failure to Specify PICC Flush Protocol in IV Medication Orders
Penalty
Summary
The facility failed to provide adequate treatment and care for a resident with a peripherally inserted central catheter (PICC) in accordance with professional standards of practice. Facility policy required that intermittent infusions, such as antibiotics, be flushed with 10 ml normal saline solution (NSS) before and after medication administration. For a resident admitted with osteomyelitis of the thoracic vertebra, depression, and atrial fibrillation, physician orders directed the use of Cefepime HCl Solution intravenously every 12 hours and specified that the right upper arm PICC be flushed prior to and after infusion. However, the orders did not specify the substance or the amount to be used for the flush. This omission was confirmed by an LPN during an interview, indicating that the facility did not ensure the PICC was managed according to professional standards for this resident.
Failure to Provide Timely Respiratory Equipment Changes
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents who required oxygen therapy. According to facility policy, humidification bottles and tubing for oxygen concentrators are to be changed weekly. For one resident with diagnoses including high blood pressure, hyperlipidemia, and Alzheimer's Disease, a physician's order required oxygen via nasal cannula at 2 liters per minute to maintain oxygen saturation above 90%. Observation revealed that the humidification bottle in use was empty and had not been changed for over a week, as indicated by the date on the bottle. A registered nurse confirmed that the bottle was not changed as required. Similarly, another resident with diagnoses of high blood pressure, heart failure, and diabetes had a physician's order for oxygen via nasal cannula at 2 liters per minute. Observation showed that the humidification bottle in use for this resident had not been changed for two weeks, contrary to facility policy. This was also confirmed by a registered nurse. The Director of Nursing acknowledged that the facility did not provide appropriate respiratory care for these two residents.
Failure to Ensure Resident Capacity and Choice in Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident had the capacity to understand the terms of a binding arbitration agreement prior to signing. Review of clinical records showed that the resident had a diagnosis of dementia and a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. Despite this, the resident personally signed the binding arbitration agreement at admission. The agreement was labeled as 'Mandatory Arbitration Agreement' and did not provide an option for the resident or their representative to decline or refuse to sign. Interviews with the Nursing Home Administrator (NHA) confirmed that all new admissions were required to sign the arbitration agreement as part of the admission packet, and the NHA was unable to explain what would happen if a resident chose not to sign. The NHA acknowledged that the process did not allow for resident choice and confirmed the failure to ensure the resident's capacity to understand the agreement. The deficiency was cited under 28 Pa. Code: 201.14(a)(c) and 28 Pa. Code: 201.18(e)(1).
Failure to Hold Required QAA Meeting with All Committee Members
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for one of four quarterly meetings in Quarter One of 2025. Review of the facility's QAPI policy and attendance records revealed that the Director of Nursing (DON) was not present at the QAA meeting for that quarter. This was confirmed during an interview with the DON, who acknowledged the absence and the failure to meet the federal requirement for QAA committee composition and meeting frequency as outlined in facility policy and state code. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Deficiency in Annual In-Service Training Program
Penalty
Summary
The facility failed to implement and maintain an effective annual in-service training program for several nurse aides, as evidenced by a review of personnel records and staff interviews. Specifically, the records for Nurse Aide Employees E3, E4, E5, and E6 did not include required annual in-service trainings for infection control, dementia training, communication, and abuse training for the year 2024. The facility's policy mandates compliance education and training for employees, yet these nurse aides' records were incomplete in these critical areas. Interviews with staff, including a ten-year employee, indicated that while there are numerous online trainings required annually, the facility did not ensure completion of these essential trainings for the mentioned nurse aides. The Nursing Home Administrator confirmed the deficiency, acknowledging the failure to uphold the facility's training requirements as per their policies and procedures, which are designed to maintain high levels of skill and training among staff.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident, identified as Resident R31, who was admitted with diagnoses including renal insufficiency, high blood pressure, and heart failure. The resident's care plan included monitoring for adverse reactions to anticoagulant therapy, which was revised to include monitoring for increased senile purpura. On a specific date, a nurse aide observed large bruises on the resident's legs, and the resident reported that a nurse aide had pressed their leg tightly during care, resulting in the bruising. Despite this allegation, the facility did not include a report of the abuse allegation in their submitted reports for the month. Interviews with the resident and staff confirmed the resident's account of the incident, and the bruising was observed by the survey agency. The RN Supervisor acknowledged the resident's statement and mentioned that the Assistant Director of Nursing was informed, and investigation forms were prepared. However, the Director of Nursing confirmed that the allegation of abuse was not reported to management because it was not known that a specific perpetrator was identified during the initial report. This oversight led to the facility's failure to report the alleged abuse incident as required by their policy and state regulations.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to fully investigate an alleged abuse incident involving a resident, identified as Resident R31, who reported that a nurse aide pressed their leg tightly during care, resulting in bruising. The resident, who has a medical history of renal insufficiency, high blood pressure, and heart failure, was on anticoagulant therapy, which can increase the risk of bruising. Despite the resident's report and visible bruising, the facility did not conduct a timely and comprehensive investigation. The initial report of the incident was made on 7/26/24, but the alleged perpetrator was not interviewed until four days later, on 7/30/24. Interviews with staff revealed a lack of urgency and thoroughness in addressing the allegation. The RN Supervisor indicated that investigation forms were distributed but not promptly collected or reviewed. The Director of Nursing confirmed that the facility did not complete a comprehensive investigation, failing to identify all involved parties and interview potential witnesses in a timely manner. This lack of prompt and thorough investigation is a violation of the facility's policy on abuse prevention and the residents' right to freedom from abuse.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident, resulting in an elopement incident. Resident R17, who was admitted to the facility with diagnoses of dementia, chronic kidney disease, and venous insufficiency, was identified as having severe cognitive impairment with a BIMS score of 1. An Elopement/Exit Seeking Evaluation Form dated December 7, 2023, indicated that the resident was at risk for elopement with a score of 21. Despite this known risk, the resident managed to leave an unsupervised and unauthorized location without staff knowledge. On November 5, 2023, at 6:50 a.m., a nursing assistant on the second floor alerted staff that Resident R17 was found at the Magnolia neighborhood nurses' station after having wandered off and taken the back staff elevator. The resident was reported missing at 6:45 a.m. and was last seen approximately 15 minutes prior, returning from the second floor at 6:55 a.m. An interview with the Director of Nursing on July 31, 2024, confirmed that staff were not reeducated following the incident, indicating a lapse in the facility's response to the elopement event.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident R25, who required oxygen therapy. The clinical record review and observations revealed that the facility did not have a policy for oxygen therapy, and the resident's care plan did not include necessary interventions related to oxygen therapy. Resident R25, diagnosed with Alzheimer's disease, dementia, and chronic obstructive pulmonary disease, was observed with an oxygen concentrator and nasal cannula tubing lying on the floor, which was confirmed by an LPN. The resident stated that she only used oxygen at night, contrary to the physician's order for oxygen administration every shift. Further investigation showed discrepancies in the documentation and administration of oxygen therapy. The Treatment Administration Record indicated compliance with the physician's orders, but interviews with staff revealed that the resident only used oxygen at night. The LPN acknowledged that the physician's order did not reflect the actual use and intended to clarify it. The resident's care plan lacked specific details for oxygen therapy, such as maintenance of equipment and monitoring for potential complications. The Director of Nursing confirmed the absence of a policy for oxygen administration, contributing to the deficiency in providing appropriate respiratory care.
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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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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