Normandie Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in York, Pennsylvania.
- Location
- 1700 Normandie Drive, York, Pennsylvania 17404
- CMS Provider Number
- 395902
- Inspections on file
- 19
- Latest survey
- September 26, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Normandie Ridge during CMS and state inspections, most recent first.
A resident with chronic respiratory failure and MSSA in the lungs was placed on droplet precautions, but a housekeeper failed to follow required infection control protocols, including improper removal of PPE, lack of hand hygiene, and not sanitizing equipment after use, contrary to facility policy and posted instructions.
A resident with complex cardiac conditions developed a pressure ulcer that was not assessed or documented by a Registered Nurse for nine days after initial identification by an LPN. During this period, the wound tracking form was not initiated, and no reassessment occurred after the resident's hospital transfer and return, resulting in delayed wound assessment and documentation.
The facility failed to ensure accurate MDS assessments for five residents, leading to discrepancies in clinical records. Errors included incorrect documentation of medical devices, diagnoses, and medications, confirmed by facility staff as coding inaccuracies.
The facility failed to update care plans for three residents, leading to deficiencies. A resident with a pacemaker lacked safety interventions in her care plan. Another resident's care plan incorrectly stated DNR status despite her wish for full treatment. A third resident's care plan did not reflect a reclassified stage 3 pressure ulcer and lacked pacemaker safety measures. The NHA acknowledged these issues.
A resident with specific care needs related to obesity and a urinary tract infection experienced delays in receiving assistance due to insufficient staffing. The facility's records showed prolonged call bell response times and failure to meet required nurse aide hours and ratios, as confirmed by the NHA and DON.
A facility failed to limit PRN psychotropic medications to 14 days or document rationale for extension for a resident with anxiety and depression. Another resident with Alzheimer's and hypothyroidism was not properly monitored for side effects of psychotropic medications, as evidenced by inaccurate documentation in the TARs. These deficiencies were acknowledged by the NHA and DON.
The facility failed to meet food safety standards, with undated and improperly stored food items, unsanitary food handling practices, and inadequate temperature control in kitchenettes. Observations revealed unlabeled food, moldy produce, and improper glove use, risking cross-contamination. Temperature logs showed repeated high readings without corrective actions.
A facility failed to include a focus area for antipsychotic medication use in a resident's care plan, despite the resident having an active order for Haloperidol to manage terminal agitation. The oversight was identified during a review of the resident's clinical records and confirmed by the Nursing Home Administrator.
A resident with hypertension and chronic atrial fibrillation did not receive consistent wound care for pressure ulcers as ordered. The Treatment Administration Record showed missed treatments for wounds on the mid and right back, with no progress notes explaining the omissions. The Nursing Home Administrator and DON expected documentation of completed treatments and notes if care was refused, leading to a deficiency in nursing services.
The facility failed to provide adaptive feeding devices for two residents. One resident, with atrial fibrillation and GERD, did not receive the required dycem under her plate, causing difficulty during meals. Another resident, with Parkinson's disease, was not given the prescribed Kennedy cup, instead receiving a sippy cup. Staff confirmed the unavailability of the required equipment.
Failure to Follow Droplet Precaution Protocols and Infection Control Policy
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident on droplet precautions due to chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and a diagnosis of methicillin susceptible Staphylococcus aureus (MSSA) in the lungs. Physician orders required droplet precautions with a respirator, all care and treatments to be completed in the room, and specific instructions for PPE use and hand hygiene. Facility policy also required handwashing before entering and after exiting the resident's room, and sanitizing reusable equipment. During observation, a housekeeper entered and exited the resident's room multiple times wearing a gown, gloves, face mask, and face shield, but failed to remove the face shield and mask prior to exiting the room as required. The housekeeper also did not perform hand hygiene after removing PPE and did not sanitize the mop handle used in the resident's room. These actions were inconsistent with both the facility's infection control policy and the posted droplet precaution instructions.
Failure to Timely Assess and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care and services consistent with professional standards to promote healing and prevent worsening of a pressure injury for a resident with significant medical conditions, including acute congestive heart failure and atrial flutter. Upon re-admission from a hospital stay, the resident's sacral area was documented as having intact, dry skin. However, an open area was identified on the left upper buttocks several days later, with documentation by an LPN noting the wound's size and characteristics. Despite this, there was no documented wound assessment or progress note completed by a Registered Nurse at the time of discovery, and the electronic wound assessment tracking form was not initiated until nine days after the wound was first identified. During this nine-day period, the resident was also transferred to and returned from the hospital, but no reassessment of the skin was documented upon return. The first comprehensive wound assessment was completed by a Registered Nurse only after this delay, at which point the wound had increased in size. Staff interviews confirmed the lack of documented wound assessments during this period, and the facility was unable to provide further information regarding the resident's wound care during the gap in documentation.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate resident assessments for five residents, leading to discrepancies in their clinical records and MDS documentation. Resident 20's MDS inaccurately indicated the presence of an indwelling catheter, which was not supported by clinical records. The Nursing Home Administrator confirmed this was a coding error. Resident 27's MDS assessments repeatedly failed to reflect accurate diagnoses, such as heart failure, depression, and the presence of a diabetic ulcer, despite the resident receiving medications for these conditions. The Director of Nursing confirmed these errors, acknowledging that the MDS should accurately represent the resident's status. Resident 29's MDS incorrectly documented the administration of anticoagulant medication, which was not supported by the Medication Administration Record. Similarly, Resident 49's MDS inaccurately indicated dialysis treatment, and Resident 56's MDS failed to reflect diagnoses of anxiety and depression, despite being prescribed related medications. These errors were confirmed by facility staff as coding inaccuracies.
Care Plan Deficiencies for Residents with Pacemakers and Inconsistent Code Status
Penalty
Summary
The facility failed to review and revise the care plans for three residents, leading to deficiencies in their care. Resident 19, diagnosed with atrial fibrillation and congestive heart failure, had a pacemaker but lacked safety interventions in her care plan. Despite having orders to ensure her pacemaker transmitter was operational every shift, the care plan did not address safety measures related to the pacemaker's presence. The Nursing Home Administrator (NHA) acknowledged the need for these safety measures but initially relied on staff's professional judgment. Resident 20's care plan was inconsistent with her wishes and physician orders. Although her POLST form indicated she wished to receive CPR and full treatment, her care plan incorrectly stated she was a DNR. This discrepancy was later confirmed by the NHA. Resident 27, with type 2 diabetes and a stage 3 pressure ulcer, had a care plan that failed to address the reclassification of her diabetic ulcer to a stage 3 pressure ulcer. Additionally, her care plan did not include safety interventions for her implanted pacemaker, similar to Resident 19. The NHA confirmed the need for revisions in Resident 27's care plan to reflect these changes.
Staffing Deficiency Leads to Resident's Unmet Needs
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of its residents, specifically impacting one resident who was reviewed. This resident had diagnoses including obesity and a urinary tract infection, and their care plan required limited assistance for toileting and ambulation due to impaired balance and fatigue. Despite these needs, the resident reported waiting extended periods for staff assistance, resulting in an incident where they soiled themselves while waiting for their call bell to be answered. The facility's Device Activity Report confirmed multiple instances where the resident's call bell went unanswered for significant durations, ranging from approximately 26 to 51 minutes. Additionally, staffing records indicated that on a specific day, the facility did not meet the required nurse aide hours and ratios based on the census, which was confirmed by the Nursing Home Administrator and Director of Nursing. This deficiency in staffing directly contributed to the resident's unmet needs and compromised their well-being.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medications were limited to 14 days or had documented rationale and duration for continuation beyond this period for one resident. Specifically, a resident with diagnoses of anxiety and depression had a PRN order for Lorazepam without a stop date, which was not accompanied by a documented rationale for extending the medication beyond 14 days, contrary to the facility's policy. This oversight was confirmed during an interview with the Nursing Home Administrator, who acknowledged the expectation for physicians to adhere to the policy. Additionally, the facility did not adequately monitor the effects and side effects of psychotropic medications for another resident diagnosed with Alzheimer's disease and hypothyroidism. The resident had multiple active orders for psychotropic medications, including Haloperidol and Lorazepam, with specific instructions to observe and document any side effects. However, the Treatment Administration Records (TARs) for several months showed only check marks, failing to accurately reflect whether the resident exhibited any side effects. There were no nurses' progress notes indicating the resident's response to the medications, and this documentation error was acknowledged by the Nursing Home Administrator and the Director of Nursing.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its kitchen and kitchenettes, as evidenced by multiple observations and interviews. During a tour of the kitchen, it was found that several food items in the walk-in production cooler and freezer were not dated or sealed properly, contrary to the facility's policy on labeling and dating. Additionally, the dry storage room contained opened packages without open dates, and the produce cooler had strawberries with visible mold, indicating a lack of proper monitoring and rotation of food items. Dented cans were also found on the canned goods rack, which should have been discarded upon receipt. In the Tulip kitchenette, improper food handling practices were observed. An employee was seen using the same pair of gloves to handle food and touch various surfaces, including a refrigerator door handle, without changing gloves in between tasks. This practice poses a risk of cross-contamination. Furthermore, the ice machine had a scoop stored inside, and an employee was observed retrieving ice without washing their hands, which is against sanitary protocols. The storage of utensils and dishes was also improper, with service sides facing upwards, increasing the risk of contamination. The facility's refrigerator temperature logs for the Tulip dining room kitchenette revealed several instances where temperatures exceeded the recommended 40 degrees Fahrenheit, with inadequate corrective actions documented. Despite the facility's policy requiring corrective actions when temperatures are out of range, the logs showed repeated high temperatures without appropriate follow-up. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that they expected proper labeling, dating, and storage of food, as well as adherence to sanitary serving practices, which were not met in these instances.
Failure to Implement Comprehensive Care Plan for Antipsychotic Use
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, identified as Resident 56, which resulted in a deficiency. The facility's policy on care plans, last revised in March 2022, mandates that care plans should describe the services necessary to maintain a resident's highest practicable physical, mental, and psychosocial well-being. Resident 56's clinical record indicated diagnoses of Alzheimer's disease and hypothyroidism, and an active physician's order for Haloperidol to manage terminal agitation. However, the resident's care plan did not include a focus area or intervention for the use of this antipsychotic medication, which was a required component of their care plan. This oversight was identified during a review of the resident's clinical records and confirmed in an interview with the Nursing Home Administrator.
Failure to Provide Consistent Wound Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing for a resident with pressure ulcers, as required by professional standards of practice. The resident, who had diagnoses including hypertension and chronic atrial fibrillation, had specific treatment orders for wounds on the mid and right back. The treatment for the mid back wound involved cleansing with normal saline, applying skin prep, medi honey, and securing with foam dressing daily. The treatment for the right back wound involved cleansing, applying skin prep, xeroform, and securing with a dry sterile dressing every two days. However, the Treatment Administration Record (TAR) for July 2024 showed that the mid back wound treatment was not completed on three occasions, and the right back wound treatment was not completed on two occasions. There were no progress notes in the resident's clinical record explaining why the wound treatments were not completed on the specified days. An interview with the Nursing Home Administrator and the Director of Nursing revealed that they expected staff to document completed treatments on the TAR and to write a progress note if the resident refused care. This lack of documentation and failure to provide consistent wound care led to the deficiency, as it did not align with the expected nursing services standards outlined in 28 Pa. Code 211.12(d)(1)(3)(5).
Failure to Provide Adaptive Feeding Devices
Penalty
Summary
The facility failed to provide adaptive feeding devices for two residents, leading to deficiencies in their care. Resident 19, who has diagnoses including atrial fibrillation and GERD, had a care plan that required the use of dycem under her plate during meals to assist with her self-care performance deficit. However, during an observation, it was noted that Resident 19 did not have dycem under her plate, causing her plate to slide and requiring her to reposition it multiple times while eating. The dietary staff was initially unable to provide the dycem, and it was only given to her after a delay. Similarly, Resident 27, diagnosed with Parkinson's disease and muscle weakness, had a physician's order for a Kennedy cup to assist with nutrition and hydration. Despite this, observations revealed that Resident 27 was consistently provided with a two-handled sippy cup with a straw instead of the prescribed Kennedy cup. Staff interviews confirmed the unavailability of the Kennedy cup, which was reportedly stored elsewhere. The Nursing Home Administrator and Director of Nursing acknowledged the expectation that residents should receive their adaptive equipment as ordered.
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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