Meadow View Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Montrose, Pennsylvania.
- Location
- 225 Park Street, Montrose, Pennsylvania 18801
- CMS Provider Number
- 395092
- Inspections on file
- 23
- Latest survey
- September 4, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Meadow View Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of behavioral issues, including verbal threats and inappropriate sexual behavior toward another resident, did not have an updated, individualized care plan to address ongoing incidents. Despite repeated behavioral events, the care plan lacked specific interventions and risk management strategies, as confirmed by the DON and administrator.
Two residents reported significant delays in call bell responses, sometimes waiting up to 45 minutes to an hour for assistance, particularly with toileting needs. Resident council minutes and grievance records confirmed ongoing concerns about untimely staff responses, with audit data showing prolonged response times across multiple shifts. Facility leadership acknowledged the expectation for timely care but could not account for the delays.
Two residents with incontinence and cognitive impairment did not receive scheduled incontinence care as outlined in their care plans, with documentation missing for required two-hour checks and changes. One resident subsequently developed a UTI and hematuria. The NHA confirmed the facility did not provide or document incontinence care as planned.
A resident with hemiplegia following a cerebral infarction did not receive prescribed diazepam for anxiety on two consecutive nights because the medication was not available and had not been received from the pharmacy in time. Facility records showed no documentation of administration, and the Nursing Home Administrator confirmed that procedures were lacking to ensure timely medication acquisition and administration.
The facility failed to ensure call bell accessibility for three residents, as observed on different occasions. A resident was seated with the call bell draped over the headboard, another had it wrapped around the bed rail, and a third found it hidden under bedding. Staff confirmed these observations, and the Nursing Home Administrator acknowledged the requirement for call bells to be within reach at all times.
A facility failed to accurately document the administration of Oxycodone for a resident. Although nursing staff signed out doses of the medication, the administration was not recorded on the resident's MAR on two occasions. This inconsistency was confirmed by the Nursing Home Administrator, indicating a deficiency in pharmacy services.
A facility failed to ensure timely assistance and dignified care for residents, as evidenced by reports of long wait times for call bell responses and inaccessible call bells. A resident with moderate cognitive impairment was left without assistance for at least 45 minutes, unable to reach her lunch tray or call bell. Other residents reported similar issues, with some waiting up to two hours for help, impacting their quality of life.
The facility failed to implement effective fall prevention measures for a resident with severe cognitive impairment, resulting in nineteen falls over several months. Additionally, the facility did not conduct safety assessments for two residents using motorized wheelchairs, despite one resident exhibiting unsafe behaviors. The lack of effective interventions and safety assessments led to repeated falls and potential safety risks.
The facility failed to implement individualized toileting plans for several residents, leading to deficiencies in incontinence management. One resident, cognitively intact but requiring assistance, was not provided with a scheduled toileting program despite being a candidate. Another resident with severe cognitive impairment did not receive consistent incontinence care as planned. A third resident, moderately impaired, was not given a two-hour check and change program despite frequent incontinence. Lastly, a resident with severe cognitive impairment and a history of falls lacked a bladder diary and assessment, and a physician's order for a bladder tracker was not completed.
A facility failed to create and implement a person-centered care plan for a resident with dementia, who exhibited behaviors such as wandering, delusions, and verbal aggressiveness. The care plan lacked specific interventions tailored to the resident's needs, relying instead on general strategies like medication administration and redirection. Despite documentation of the resident's behaviors, the facility did not provide evidence of effective behavioral management, leading to a deficiency in care.
A resident with a history of inappropriate sexual behaviors was involved in an incident where he inappropriately touched another resident with severe cognitive impairment. The facility failed to follow up on previous incidents, did not revise the resident's care plan, and lacked proper staff supervision, leading to the failure to protect the resident from sexual abuse.
A facility failed to conduct a timely investigation and thorough assessment following an alleged incident of sexual abuse between two residents. Resident 35, with a history of inappropriate sexual behaviors, was observed engaging in inappropriate conduct with Resident 24, who has severe cognitive impairment. The facility did not ensure a thorough assessment of Resident 24 by an RN and failed to submit a complete investigation to the State Survey Agency within the required timeframe.
The facility failed to develop policies and procedures to protect residents from being disenrolled from Medicare Health Plans without their request, consent, knowledge, and/or complete understanding. The Nursing Home Administrator confirmed the absence of documentation and procedures to ensure residents or their representatives were fully informed about the risks and impacts of changing their Medicare health plans.
The facility failed to implement effective fall prevention measures and provide adequate supervision for a resident with a history of falls and unsafe behaviors. Despite being placed at the nurse's station for observation, the resident fell twice, resulting in a hip fracture and a hematoma. The facility's repeated use of ineffective interventions highlights a deficiency in their fall prevention strategies.
A resident experienced an unwitnessed fall and was found with confusion and not at her baseline. The LPN on duty did not perform necessary neurological assessments, and the DON did not come to the facility to conduct a professional nursing assessment. The facility's documentation showed that the LPN was deemed proficient but failed to demonstrate competency in this instance.
The facility failed to demonstrate the clinical necessity for the initiation of an antipsychotic drug for a resident with dementia and a history of falls. Despite displaying unsafe behaviors, there was no documented evidence of a clinical indicator or psychiatric diagnosis justifying the use of Seroquel, which was prescribed and administered for anxiety and agitation. The medication was given without proper documentation of clinical necessity or a supporting diagnosis.
Failure to Update Care Plan for Behavioral Management
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that addressed the individual behavioral management needs of a resident with a history of alcohol abuse, adjustment disorder, depression, anxiety, and a below-the-knee amputation. The resident was moderately cognitively impaired and exhibited ongoing verbal and physical behavioral concerns, including threats toward staff and other residents, as well as inappropriate sexual behavior involving another resident. Despite multiple documented incidents, including verbal threats and inappropriate touching, the care plan was not revised to reflect these ongoing behaviors or to include individualized interventions to mitigate risk and ensure resident safety. Clinical record reviews and staff interviews confirmed that the care plan only addressed verbal aggression and a general desire for sexual expression, without incorporating specific strategies or updates related to the resident's repeated behavioral incidents, particularly those involving another resident. The Nursing Home Administrator and DON acknowledged that the care plan did not adequately reflect person-centered approaches or risk management strategies for the resident's interactions, resulting in a failure to meet regulatory requirements for comprehensive care planning.
Delayed Call Bell Responses Impact Resident Dignity and Care
Penalty
Summary
The facility failed to provide care in a manner that promotes each resident's quality of life by not responding timely to residents' requests for assistance. Resident council meeting minutes documented concerns from residents about delayed call bell response times, particularly regarding assistance with toileting. Facility grievance records for the same period also noted complaints about slow call bell responses, with documented call bell audit results showing response times ranging from 2 to 45 minutes on day and evening shifts, and 2 to 10 minutes on night shift. Interviews with two residents confirmed that call bell response times could extend up to 45 minutes to an hour, with longer delays at night. These residents reported that the delays sometimes resulted in remaining in soiled briefs or experiencing incontinence before staff could provide assistance. During an interview, the NHA and DON acknowledged that all residents should be treated with dignity and respect but could not explain the cause of the untimely staff responses.
Failure to Provide Scheduled Incontinence Care and Documentation
Penalty
Summary
The facility failed to implement individualized incontinence care and provide maintenance care as outlined in the care plans for two residents. One resident, admitted with overactive bladder and muscle weakness, was assessed as incontinent of bowel and bladder and determined not to be a candidate for retraining or scheduled toileting due to cognitive status. The care plan required the resident to be checked and changed every two hours and as needed, but there was no documented evidence in the clinical record that this care was provided as planned. Another resident, with diagnoses including dementia and muscle weakness, was also assessed as incontinent and not appropriate for retraining. The care plan similarly required checks and changes every two hours and as needed. Documentation revealed multiple dates across several months where the resident was not checked and changed according to the care plan. This resident also experienced hematuria and was treated for a urinary tract infection following a positive urine culture. Interviews with the Nursing Home Administrator confirmed the lack of documented evidence that scheduled incontinence care was provided for both residents.
Failure to Ensure Timely Acquisition and Administration of Prescribed Medication
Penalty
Summary
The facility failed to implement procedures to ensure the timely acquisition and administration of a prescribed medication for a resident admitted with hemiplegia following a cerebral infarction. Hospital discharge instructions and physician orders indicated the resident was to receive diazepam 2mg by mouth at bedtime for anxiety. However, review of the medication administration record showed that the medication was not administered on two consecutive days as ordered, with no documentation or nurse signatures indicating it was given. A nursing progress note confirmed that the medication was not available, and further review revealed the facility had not received the diazepam from the pharmacy in time for the scheduled doses. The Nursing Home Administrator acknowledged that adequate procedures were not in place to ensure timely medication acquisition and administration.
Failure to Ensure Call Bell Accessibility for Residents
Penalty
Summary
The facility failed to reasonably accommodate the needs of three residents by not ensuring their call bells were accessible. On November 5, 2024, Resident 42 was observed seated on the left side of her bed, facing the wall, with the call bell draped over the headboard on the right side, out of her reach. This was confirmed by a registered nurse, Employee 2, who acknowledged that Resident 42 did not have access to the call bell for assistance. Similarly, Resident 18 was found lying in bed with the call bell wrapped around the left bed rail, making it inaccessible. Resident 18 confirmed during an interview that she relies on the call bell to alert staff for assistance, and the Director of Nursing verified that call bells should be within reach at all times. Additionally, Resident 28 was observed seated in a wheelchair beside his bed, with the call bell hidden under the pillow and blankets, out of sight and reach. Resident 28 mentioned that this was not the first time he was unable to find his call bell. Employee 3, a registered nurse, confirmed the inaccessibility of the call bell for Resident 28. The Nursing Home Administrator also verified that call bells are required to be within reach of residents at all times. These observations and interviews indicate a failure to meet the residents' needs for call bell accessibility, as required by the relevant Pennsylvania codes on nursing services and resident rights.
Inconsistent Documentation of Controlled Medication Administration
Penalty
Summary
The facility failed to implement proper pharmacy procedures to ensure accurate accounting of controlled medications for a resident. A review of clinical records and controlled drug records revealed that a resident had a physician order for Oxycodone HCl 10 mg to be administered every 8 hours as needed for moderate pain. However, on two occasions, the nursing staff signed out doses of the medication, but the administration was not recorded on the resident's Medication Administration Record (MAR). This inconsistency in documentation was confirmed by the Nursing Home Administrator during an interview, highlighting a deficiency in the facility's pharmacy services.
Failure to Provide Timely Assistance and Dignified Care
Penalty
Summary
The facility failed to provide a dignified dining experience and timely assistance to residents, as evidenced by the experiences of several residents. Resident 18, who has moderate cognitive impairment and requires assistance due to an amputation and muscle weakness, was observed with her lunch tray out of reach and her call bell inaccessible. Despite being awake and waiting for assistance to be repositioned or moved to her wheelchair for lunch, no staff returned to help her for at least 45 minutes. Resident 18 also reported frequent long waits for call bell responses, sometimes resulting in incontinence due to the delays. Other residents, including Resident 28, reported similar issues with call bell accessibility and response times, with waits sometimes extending to two hours. During a group interview, five residents expressed ongoing concerns about long wait times for assistance, which had been raised in Resident Council meetings without resolution. The Nursing Home Administrator and Director of Nursing confirmed that residents should be treated with dignity and respect but could not explain the delays in staff responses, which negatively impacted residents' quality of life.
Failure to Implement Effective Fall Prevention and Safety Assessments
Penalty
Summary
The facility failed to implement effective interventions and timely re-evaluate the effectiveness of planned safety interventions for Resident 46, who had a history of falls and severe cognitive impairment. Despite being at risk for falls due to impaired cognition, decreased safety awareness, and incontinence, the facility did not adequately revise the resident's fall prevention plan. Over a period from July to October 2024, Resident 46 experienced nineteen falls, with many incidents involving incontinence and inadequate supervision. The facility's interventions, such as providing clear pathways and maintaining call lights within reach, were insufficient, and there was a lack of new interventions following repeated falls. Additionally, the facility failed to assess the safety of motorized wheelchair use for two residents, Resident 35 and Resident 25. Resident 35, who had moderate cognitive impairment, exhibited unsafe behaviors with his motorized wheelchair, such as operating it at excessive speeds and failing to maintain safe distances from peers. Despite a contractual license outlining actions for unsafe practices, the facility did not conduct a thorough assessment of Resident 35's safety while using the wheelchair. Similarly, Resident 25, who was cognitively intact, did not receive periodic safety assessments for their electric wheelchair use. The facility's lack of effective interventions and safety assessments resulted in repeated falls for Resident 46 and potential safety risks for Residents 35 and 25. The Director of Nursing and Nursing Home Administrator acknowledged the issues but did not provide adequate supervision or revise safety plans to address the residents' needs. The facility's failure to implement a comprehensive toileting program and review resident devices contributed to the ongoing safety concerns.
Deficiencies in Incontinence Management and Toileting Plans
Penalty
Summary
The facility failed to develop and implement individualized plans to meet the toileting needs of four residents, leading to deficiencies in incontinence management. Resident 16, who was cognitively intact but required extensive assistance, was identified as a candidate for scheduled toileting. However, there was no documented evidence that a scheduled bladder and bowel program was evaluated or implemented to determine a pattern of incontinence or to assess if more frequent checks and changes were necessary to keep the resident dry. Resident 7, with severe cognitive impairment and a history of urinary tract infections, was supposed to be on a two-hour check and change program with barrier cream application after each incontinence episode. Despite this plan, there was no consistent documentation that these interventions were performed, and the resident's Kardex did not include the necessary incontinence management needs. Similarly, Resident 28, who was moderately cognitively impaired and required extensive assistance, was identified as a potential candidate for a scheduled toileting program. However, there was no evidence that a two-hour check and change program was developed or implemented, despite frequent incontinence episodes. Resident 46, with severe cognitive impairment and a history of falls, was occasionally incontinent of bladder. There was no evidence of a three-day bladder diary or an assessment to determine the type of incontinence. Despite a physician's order to complete a bladder tracker for fall prevention, there was no evidence that this task was completed. The facility was unable to provide evidence that timely care for the resident's toileting needs was consistently provided, including incontinence management and the necessary physical assistance.
Failure to Implement Individualized Care Plan for Dementia-Related Behaviors
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia, who exhibited various behavioral symptoms. The resident, admitted with a history of dementia and falls, displayed behaviors such as wandering, delusions, inappropriate urination, and verbal aggressiveness. Despite these behaviors being documented in nursing notes, the care plan lacked specific interventions tailored to the resident's needs and preferences. The care plan for the resident was limited to general interventions such as administering medications, applying non-skid socks, and attempting to redirect the resident when agitated. However, it did not address the resident's specific behaviors or include individualized strategies based on the resident's history, preferences, or interests. The facility's documentation showed that the resident continued to exhibit challenging behaviors, including exit-seeking, medication refusal, and multiple falls, without evidence of effective behavioral management or modification interventions. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed the absence of a comprehensive, individualized plan to manage the resident's dementia-related behaviors. The facility's failure to provide evidence of consistent monitoring and tailored interventions for the resident's behavioral symptoms resulted in a deficiency in providing appropriate care and services for the resident's condition.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. Resident 35, who had a history of inappropriate sexual behaviors, was involved in an incident where he was found holding the hand of Resident 24 and rubbing his private parts and thigh over clothing with her hand. This incident occurred in the activity area and was unwitnessed, with no injuries noted. Resident 35 had a documented history of making sexually inappropriate statements and had moderate cognitive impairment, while Resident 24 had severe cognitive impairment due to Alzheimer's dementia. The facility's policy on abuse prevention required assessing, care planning, and monitoring residents with behaviors that could lead to conflict or neglect. However, the facility failed to follow up on a previous incident where Resident 35 made a nurse aide uncomfortable by caressing her arm. There was no documented evidence that social services followed up with Resident 35 or that his care plan was reviewed and revised to manage his sexual behaviors effectively. This lack of action contributed to the failure to prevent the subsequent incident involving Resident 24. Interviews with the Director of Nursing and the Nursing Home Administrator revealed that they were unaware of Resident 35's history of sexually inappropriate behaviors. The facility did not ensure proper staff supervision of Resident 35, which resulted in the failure to protect Resident 24 from sexual abuse. The facility also failed to fully investigate the incident and develop necessary interventions to prevent further occurrences of sexual abuse.
Failure to Investigate and Assess After Alleged Abuse
Penalty
Summary
The facility failed to promptly conduct a thorough investigation and implement established procedures following an alleged incident of sexual abuse involving two residents. Resident 35, who has a history of inappropriate sexual behaviors and moderate cognitive impairment, was observed by a nursing assistant engaging in inappropriate conduct with Resident 24, who has severe cognitive impairment and Alzheimer's dementia. The incident was unwitnessed, and no injuries were noted at the time. The facility's immediate response included separating the residents and placing Resident 35 under one-to-one supervision. However, the facility did not ensure that a registered nurse conducted a thorough assessment of Resident 24 following the incident, as required by the facility's abuse policy. This lack of assessment was a critical oversight in the facility's response to the alleged abuse. Furthermore, the facility did not complete a timely and comprehensive investigation into the incident, nor did it submit the results to the State Survey Agency within the required five working days. The Nursing Home Administrator confirmed these failures, acknowledging that the facility did not fully implement its abuse prohibition policy, which contributed to the deficiency.
Failure to Develop Policies for Medicare Health Plan Changes
Penalty
Summary
The facility failed to develop policies and procedures in accordance with CMS guidance to protect residents from being disenrolled from Medicare Health Plans without their request, consent, knowledge, and/or complete understanding. A review of clinical records, CMS guidance, and facility documentation, along with staff interviews, revealed that the facility did not have established policies and procedures to ensure that residents or their representatives were fully informed, both verbally and in writing, about the risks and impacts of changing their Medicare health plans. The Nursing Home Administrator confirmed that the facility may initiate discussions about making changes in Medicare Health plans for its residents but was unable to provide documentation of policies and procedures that outline the process of assisting beneficiaries with such changes and ensuring that residents possess the cognitive ability to make these changes at the given time. The CMS memo reviewed indicated that only a Medicare beneficiary, their authorized representative, or a party authorized under state law can request enrollment or disenrollment from a Medicare health or drug plan. The facility did not have documentation to support that enrollment actions were initiated by the beneficiary or their representative, nor did it have a process to ensure that residents understood the impact of changing their coverage. The lack of documentation and established procedures suggests that the facility did not comply with regulations regarding enrollment/disenrollment and resident rights, as required by CMS and state codes.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to implement effective fall prevention interventions and provide adequate supervision for a resident with a history of falls and unsafe behaviors. Resident B1, who was admitted with diagnoses of dementia, muscle weakness, and a history of repeated falls, was noted to be severely cognitively impaired and required extensive staff assistance. Despite being placed at the nurse's station for close observation, the resident attempted to self-transfer and fell, resulting in a right hip fracture. This incident occurred despite the presence of alarms and other planned interventions in the resident's care plan. Following hospitalization for the hip fracture, Resident B1 was readmitted to the facility and placed in a Broda chair near the nurse's station. The resident again fell, this time sustaining a hematoma on the left side of the forehead. The facility's intervention of placing the resident at the nurse's station proved ineffective in preventing falls, as evidenced by the repeated incidents. The facility's failure to provide individualized and effective fall prevention measures, including sufficient staff supervision, led to the resident's injuries. The facility was unable to provide evidence that effective safety measures and staff supervision were in place to prevent the resident's falls. The repeated use of the same ineffective intervention, despite the resident's known risk factors and previous falls, highlights the deficiency in the facility's fall prevention strategies. The report indicates that the facility did not demonstrate the provision of adequate supervision and individualized care to prevent the resident's falls and injuries.
Failure to Conduct Neurological Assessment After Unwitnessed Fall
Penalty
Summary
The facility failed to provide nursing staff with the necessary skills and competencies to fully assess and monitor a resident for signs of injury after an unwitnessed fall. Resident B2, who was admitted with diagnoses including type 2 diabetes, hypertension, and atrial fibrillation, experienced an unwitnessed fall. The resident was found on the floor with her head and left shoulder against the door, exhibiting confusion and not at her baseline. Although vital signs were obtained and emergency medical services were notified, there was no evidence that neuro checks were conducted or that a Registered Nurse assessed the resident for potential injury and neurological status before the transfer to the hospital. The LPN on duty, Employee 1, did not perform the necessary neurological assessments, which are outside the scope of practice for an LPN according to their practice act. The Director of Nursing (DON) was contacted but did not come to the facility to conduct a professional nursing assessment. The facility's documentation revealed that Employee 1 had signed off on orientation and was deemed proficient in nursing areas, including the care of head injuries, but failed to demonstrate competency in this instance. The DON confirmed that Employee 1 should have completed the neurological assessment and incident investigation, but this did not occur. The Nursing Home Administrator and DON acknowledged the failure in competency regarding neurological data collection after the unwitnessed fall.
Failure to Demonstrate Clinical Necessity for Antipsychotic Medication
Penalty
Summary
The facility failed to demonstrate the clinical necessity for the initiation of an antipsychotic drug for Resident B1. The resident, who was admitted with diagnoses of dementia, muscle weakness, and a history of repeated falls, displayed unsafe restless behaviors and had multiple falls shortly after admission. Despite these behaviors, there was no documented evidence of a clinical indicator or psychiatric diagnosis justifying the use of the antipsychotic medication Seroquel, which was prescribed and administered for anxiety and agitation following the resident's falls. The medication was given without proper documentation of clinical necessity or a supporting diagnosis, as required by regulations. The resident was severely cognitively impaired, requiring extensive assistance with activities of daily living, and had a history of unsafe behaviors leading to falls. After a fall resulting in a fractured hip, the resident was readmitted to the facility and experienced another fall the same day. A physician ordered Seroquel for the resident, but there was no documentation of the clinical justification for its use. The medication was administered twice daily without evidence of a supporting diagnosis or clinical necessity, leading to the deficiency noted in the survey.
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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