Mountain Top Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mountain Top, Pennsylvania.
- Location
- 185 South Mountain Boulevard, Mountain Top, Pennsylvania 18707
- CMS Provider Number
- 395542
- Inspections on file
- 26
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Mountain Top Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
A resident with chronic respiratory failure, hypoxia, diabetes, and moderate cognitive impairment, who required two-person assistance for bed mobility, was left unattended on her side in bed by a nurse aide during incontinence care. The resident rolled out of bed and sustained a facial injury and nasal fracture. The bed was not in the lowest position, and the DON confirmed the resident should not have been left alone.
The facility failed to maintain two doors with self-closing devices, affecting one smoke compartment. Observations revealed that the doors at Nurse's Station 2 and Resident Room 62 did not positively latch into their frames. This issue was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility failed to maintain the sprinkler system, affecting one of two floors. Three sprinkler heads in the basement laundry were found loaded with lint. This was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility failed to ensure the right set of double doors in the Main dining room positively latched into the frame, as observed during a survey. This deficiency was confirmed in an interview with the Facility Administrator and Facilities Manager.
Mountain Top Rehabilitation and Healthcare Center failed to transmit MDS assessments to the CMS QIES ASAP System within the required 14-day timeframe for six residents. The assessments, including quarterly and end-of-stay evaluations, were not completed or submitted on time, as confirmed by the RNAC. This non-compliance was identified during a survey completed in April 2025.
A facility failed to accurately reflect a resident's hospice care status in their MDS assessment. The resident, admitted with Alzheimer's and malnutrition, was receiving hospice services, but the MDS assessment incorrectly noted otherwise. This was confirmed by the DON during an interview.
A resident with dementia experienced significant weight loss, but the facility failed to update the care plan to reflect this change. Despite nutritional interventions by the dietitian, the care plan had not been revised since the resident's admission, and the oversight was confirmed by the Nursing Home Administrator during a survey.
The facility did not document the accounting and disposition of medications for a resident upon discharge. The resident was admitted and later discharged, but by the time of the survey, there was no evidence in the clinical record regarding the medications' accounting or disposition. This was confirmed during an interview with the Nursing Home Administrator.
The facility failed to develop comprehensive care plans for three residents, omitting critical medical devices and treatments. A resident with cardiovascular conditions and wounds lacked a care plan for their pacemaker and wound treatment. Another resident's care plan did not include their cardiac pacemaker, and a third resident's use of TED stockings was not documented. The DON confirmed these deficiencies.
The facility failed to follow physician orders for two residents, leading to deficiencies in care. One resident did not receive the prescribed bowel protocol despite not having a bowel movement for six days, with no evidence of timely physician notification. Another resident was observed not wearing TED stockings as ordered for edema management. Staff interviews confirmed these oversights, indicating a lack of adherence to professional standards and physician orders.
The facility failed to address significant weight loss in two residents, with one losing 7.93% of body weight in 29 days and the other 10.7% over 180 days. The dietitian did not identify or act on these changes, and the care plans lacked necessary interventions. The physician and resident representatives were not notified, leading to a deficiency in maintaining nutritional health.
A resident with a prescription for a Lidocaine pain patch experienced delays in administration, with the patch often applied more than an hour late, causing significant pain. The facility's policy requires medications to be administered within one hour of the prescribed time, but this was not followed, as confirmed by staff and records.
The facility failed to follow pharmacy procedures for controlled drug reconciliation on two medication carts. The policy requires nurses to count and sign off on controlled medications at shift changes, but signatures were missing on several dates. Interviews confirmed the expectation for nurses to sign the logs, and the DON acknowledged this requirement.
A resident with acute systolic congestive heart failure experienced a significant weight gain, which was not reported to the physician as required by the facility's policy. The resident's weight increased by 8.8 pounds in one day, a 6.48% gain, but no re-weight was taken the next day, and the physician was not notified. The facility dietitian confirmed this failure to follow protocol.
Failure to Provide Required Assistance During Bed Mobility Resulting in Resident Fall
Penalty
Summary
A resident with chronic respiratory failure, hypoxia, and diabetes, who was moderately cognitively impaired and required extensive assistance for personal hygiene and bed mobility, was not provided the necessary care and services to prevent a fall from bed. According to the resident's care plan, two staff members were required to assist with bed mobility. However, during incontinence care, a nurse aide left the resident unattended on her side in bed to obtain washcloths, despite the resident's need for two-person assistance for bed mobility. As a result, the resident rolled out of bed and landed on her face, sustaining a raised bluish/purple area on the forehead and an acute fracture of the bony nasal septum, as confirmed by a CT scan. The bed was not in the lowest position at the time of the incident. The nurse aide involved confirmed leaving the resident alone, and the DON verified that the resident should not have been left unattended during care, which directly led to the fall.
Failure to Maintain Self-Closing Doors
Penalty
Summary
The facility failed to maintain two doors with self-closing devices, which affected one of six smoke compartments. During an observation on April 30, 2025, between 10:14 am and 10:21 am, it was noted that the doors did not positively latch into their frames. Specifically, the door at Nurse's Station 2 and the door of Resident Room 62, which is tied into the fire alarm system, were identified as not latching properly. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager at 11:00 am on the same day.
Plan Of Correction
The Nurse's Station 2 door and Resident Room 62 door assembly was adjusted to provide positive latching by facility maintenance department. The Maintenance Director/designee will conduct a facility wide audit to identify doors requiring adjustment to fully latch and coordinate repairs as identified. The Nursing home Administrator will provide re-education to the Maintenance Director on proper door latching requirement. The Maintenance Director will conduct audits on latching doors to verify compliance weekly x 4 weeks, then monthly x 2 months. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for compliance.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the sprinkler system in one location, specifically affecting one of two floors. During an observation on April 30, 2025, at 9:55 am, it was found that three sprinkler heads within the basement laundry area were loaded with lint. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 11:00 am.
Plan Of Correction
The 3 basement laundry sprinkler heads were thoroughly cleaned of lint. The Maintenance Director will conduct an audit of sprinkler heads within the basement laundry to verify that the sprinklers are lint free. The Nursing Home Administrator/designee will provide re-education to the Maintenance Director for the requirements for sprinkler heads being free from lint. The Maintenance Director/designee will conduct audits of random sprinkler heads to confirm that they are free of lint and verify compliance weekly audits x 4 weeks, then monthly x 2 months. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for compliance.
Failure to Maintain Corridor Door Latching
Penalty
Summary
The facility failed to maintain a corridor opening as required by regulations, specifically concerning the doors in the Main dining room. During an observation on April 30, 2025, at 10:46 am, it was noted that the right set of double doors in the Main dining room did not positively latch into the frame. This deficiency affects one of the two floors in the facility. The issue was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 11:00 am. The failure of the doors to positively latch is a violation of the requirements for corridor doors, which are supposed to resist the passage of smoke and have positive latching hardware, especially in fully sprinklered smoke compartments.
Plan Of Correction
The main dining room right set of double doors' door assembly was adjusted to provide positive latching by facility maintenance department. The Maintenance Director/designee will conduct a facility wide audit of double doors to identify doors requiring adjustment to fully latch and coordinate repairs as identified. The Nursing home Administrator will provide re-education to the Maintenance Director on proper door latching requirement. The Maintenance Director will conduct audits on latching doors to verify compliance weekly x 4 weeks, then monthly x 2 months. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for compliance.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
Mountain Top Rehabilitation and Healthcare Center was found to be non-compliant with the requirements of 42 CFR Part 483 Subpart B, specifically regarding the encoding and transmission of Minimum Data Set (MDS) assessments. The facility failed to transmit MDS assessments to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within the required 14-day timeframe for six residents. These residents' assessments, which included quarterly and end-of-stay evaluations, were not completed or submitted on time, as evidenced by the clinical record reviews and staff interviews. The Registered Nurse Assessment Coordinator (RNAC) confirmed that the MDS assessments for the residents were not completed and submitted within the mandated period. The assessments for Residents 70, 77, 58, 100, 78, and 47 were all delayed, with some remaining incomplete and unsubmitted through the survey's conclusion. This failure to adhere to the required timelines for MDS data submission was identified during the Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on April 18, 2025.
Plan Of Correction
F0640 - Encoding /Transmitting Resident Assessment A. Corrective action taken for residents identified: Residents #70, #77, #58, #100, #78, #47 - outstanding MDS completed and submitted. B. Registered Nurse Assessment Coordinator or designee will conduct an initial audit of open MDS assessments to review for timely completion. Findings will be addressed and corrected. C. Nursing Home Administrator or designee will re-educate on the required assessment completion and transmission timeframes per CMS regulations. D. Nursing Home Administrator or designee will complete an MDS tracking form weekly x6 weeks of completed assessments, to for timeliness. Any variances of completion or submission within regulatory timeframes will be addressed, and results will be shared with QA committee for review.
Inaccurate MDS Assessment for Hospice Care
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for a resident, leading to a deficiency. Resident 49, who was admitted with Alzheimer's disease and protein-calorie malnutrition, was receiving hospice services. However, the quarterly MDS assessment dated December 20, 2024, inaccurately indicated that the resident was not receiving hospice care. This discrepancy was confirmed during an interview with the Director of Nursing on April 17, 2025, who acknowledged that the resident was indeed receiving hospice care during the period in question.
Plan Of Correction
F0641 - Accuracy of Assessments A. Resident #49: MDS assessment modified and resubmitted to reflect the accurate assessment. B. Registered Nurse Assessment Coordinator will conduct an initial audit to identify other residents/MDS assessments with coding discrepancies for item 00110K1 (hospice). All findings will be addressed. C. Nursing Home Administrator or designee will re-educate the Registered Nurse Assessment Coordinator on RAI Manual guidelines related to 00110K1 coding. D. Nursing Home Administrator or designee will audit 00110K1 of completed MDS assessments, weekly x6 weeks, to ensure accuracy. Inaccurate coding will be addressed upon identification and results will be shared with QA committee for review.
Failure to Update Care Plan for Resident's Weight Loss
Penalty
Summary
The facility failed to review and revise the care plan for a resident who experienced significant weight loss. The resident, admitted with diagnoses including dementia, showed an 8.5% weight loss over 90 days as of March 18, 2025. Despite the registered dietitian implementing nutritional interventions, the care plan had not been updated since December 13, 2023, to reflect the resident's current nutritional status and needs. During a survey conducted in April 2025, it was found that the care plan did not include updates or new interventions addressing the resident's weight loss. The Nursing Home Administrator confirmed the oversight, acknowledging that the care plan should have been reviewed and revised in response to the significant change in the resident's condition.
Plan Of Correction
F Tag 0657: 1. Resident 91's plan of care was updated to reflect weight changes with implementation of appropriate interventions. 2. Director of Nursing or Designee will conduct an initial of residents with significant weight changes to verify that their individualized plans of care were completed addressing current weight significant changes and implementation of interventions as warranted. 3. Director of Nursing or Designee will be provided re-education to the Interdisciplinary Care Team on Comprehensive Plans of Care updating/reviewing reflecting weights. 4. Director of Nursing or designee will conduct audits on residents identified as having significant weight changes to verify care plans and implementation of interventions as warranted. The audits will be conducted weekly x 4 weeks and monthly x 3 months. Results of these audits will be brought to the QAPI Committee for review and recommendations.
Failure to Document Medication Disposition for Discharged Resident
Penalty
Summary
The facility failed to document the accounting and disposition of medications for Resident 109 upon discharge. Resident 109 was admitted on November 6, 2024, and discharged on January 29, 2025. However, by the time of the survey, which concluded on April 18, 2025, there was no documented evidence in the resident's clinical record regarding the accounting of remaining medications or their disposition at the time of discharge. This deficiency was confirmed during an interview with the Nursing Home Administrator on April 18, 2025, at 10:30 AM.
Plan Of Correction
P 5280 - Disposition of Medications 1. The facility cannot retroactively correct said deficiency. 2. Residents discharged within the last 14 days will be reviewed by the Director of Nursing or Designee to verify proper documentation for disposition of medications occurred. 3. Director of Nursing or Designee will re-educate licensed nurses on documentation of disposition of medications. 4. Director of Nursing or Designee will conduct audits of discharged residents daily x 2 weeks, weekly x 4 weeks and monthly x 2 months to ensure proper documentation of disposition of medications occurred. Results of these audits will be reviewed by the facility's QAPI Committee for review and recommendations.
Deficiency in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, leading to deficiencies in meeting their medical and treatment needs. Resident 53, who was admitted with multiple cardiovascular conditions and wounds, had a care plan that did not address the presence of an implantable pacemaker or the treatment for arterial and venous wounds on the lower extremities. Similarly, Resident 55's care plan did not include the presence of a cardiac pacemaker, despite the resident's admission with acute systolic congestive heart failure and other cardiovascular issues. Resident 64, with a history of venous thrombosis and embolism, had a physician's order for the use of TED compression stockings, which was not reflected in the care plan. The Director of Nursing confirmed that the facility did not ensure comprehensive care plans were developed to meet the residents' medical and treatment needs, as required by 28 Pa. Code 211.12 (d)(5) Nursing services.
Failure to Follow Physician Orders for Bowel Protocol and Compression Stockings
Penalty
Summary
The facility failed to adhere to physician orders for two residents, resulting in deficiencies in care. For one resident, the facility did not follow a prescribed bowel protocol, which included administering Milk of Magnesia, Dulcolax suppository, and a Fleet enema as needed for constipation. Despite the resident not having a bowel movement for six days, there was no documented evidence that the bowel protocol was administered, nor was there timely notification to the physician. The resident's clinical records showed multiple blank entries regarding bowel activity, indicating either incomplete tasks or failure to document by the staff. Another resident had a physician's order for the application of TED stockings to the right lower extremity to manage edema. Observations over several days revealed that the resident was not wearing the TED stocking as ordered. Interviews with staff confirmed the oversight, and the Nursing Home Administrator acknowledged that the staff did not follow the physician's order for the application and removal of the TED stocking. These failures indicate a lack of adherence to professional standards of practice and physician orders, as required by the facility's regulations.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to accurately and consistently assess the nutritional status of two residents, leading to significant weight loss that was not timely addressed. Resident 75 experienced a weight loss of 7.93% in 29 days and 6.19% in 43 days, which was not identified or acted upon by the dietitian. The dietitian confirmed that the significant weight loss in March 2024 was not recognized, and no nutritional support measures were developed or implemented at that time. Additionally, the physician and resident representative were not notified of the weight loss. Resident 51 also experienced significant weight loss, with a 10.7% decrease over 180 days. Despite the resident's history of weight loss and increased nutrient needs, the care plan did not include new interventions to address the ongoing weight loss. The dietitian did not address the weight loss until May 14, 2024, and there was no evidence that the physician or representative were notified of the weight loss. The resident's care plan did not include the intervention of sugar-free Healthshakes, which the resident was receiving three times a day. The Nursing Home Administrator confirmed that the facility was unable to demonstrate that the dietitian had identified the residents' weight loss and implemented timely measures to maintain acceptable nutritional parameters. The facility's failure to act upon the significant weight changes and notify the appropriate parties resulted in a deficiency in maintaining the residents' nutritional health.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident, identified as Resident 64, who was prescribed a Lidocaine External Patch for pain relief. The resident was scheduled to receive the patch at 9:00 AM daily, but records and interviews revealed that the administration of the patch was frequently delayed by one hour or more on multiple occasions throughout June 2024. The resident reported experiencing significant pain due to these delays, and an interview with the Assistant Director of Nursing confirmed that the patch was not applied as scheduled. The facility's policy on medication administration, which requires medications to be administered within one hour of their prescribed time, was not adhered to. The Nursing Home Administrator acknowledged that the late administration of the pain patch was inconsistent with professional standards for pain management. The deficiency was identified through a review of clinical records, facility policy, and interviews with the resident and staff, highlighting a repeated failure to provide person-centered pain management in accordance with professional standards.
Failure to Reconcile Controlled Drugs
Penalty
Summary
The facility failed to implement proper pharmacy procedures for the reconciliation of controlled drugs on two medication carts, Med cart A and Med cart D. According to the facility's policy on controlled substances, which was last reviewed on June 12, 2024, controlled medications are to be counted at the end of each shift by both the on-coming and off-going nurses, with any discrepancies reported immediately to the Director of Nursing (DON). However, during observations on June 26, 2024, it was found that the required signatures verifying the completion of the controlled drug count were missing on several dates for both medication carts. Specifically, for Med cart A, the signatures were absent on June 18, 23, and 24, 2024, and for Med cart D, the signatures were missing on June 21 and 24, 2024. Interviews with the involved staff, including an LPN and an RN, confirmed the absence of signatures and acknowledged the expectation that licensed nurses sign the count verification at shift changes. The DON also confirmed that it is the facility's expectation for nursing staff to sign the controlled substance logs at shift changes to ensure timely identification of any discrepancies. This deficiency was identified under the regulations 28 Pa. Code 211.19(a)(1)(k) Pharmacy services and 28 Pa. Code 211.12 (d)(3)(5) Nursing services.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to timely consult with the physician regarding a significant weight gain experienced by a resident. The resident, who was admitted with acute systolic congestive heart failure and had a cardiac pacemaker, showed an 8.8-pound weight gain in one day, which constituted a 6.48% increase. According to the facility's policy, any weight change of 5% or more should be retaken the next day for confirmation, and significant weight changes should be reported to the physician. However, there was no documented evidence that the physician was notified of this significant weight gain, nor was a re-weight taken the following day as required by the policy. The dietitian's note indicated that weight fluctuations were reviewed, and the physician was to be notified if a 5-pound weight gain in 7 days was noted. Despite this, the significant weight gain recorded on May 30, 2024, was not communicated to the physician, and the policy for re-weighing was not followed. An interview with the facility dietitian confirmed the failure to notify the physician in a timely manner. This oversight was a violation of the facility's policy and the state code 28 Pa Code 211.12 (d)(3)(5) regarding nursing services.
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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