Northampton Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Easton, Pennsylvania.
- Location
- 4100 Freemansburg Avenue, Easton, Pennsylvania 18045
- CMS Provider Number
- 396077
- Inspections on file
- 24
- Latest survey
- May 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Northampton Post Acute during CMS and state inspections, most recent first.
A resident was left without a meal for over 20 minutes while others in the dining room were served and eating, leading to visible frustration and verbal complaints. The DON confirmed that all residents should be served simultaneously to maintain dignity.
A resident with a recent stroke and limited mobility was repeatedly found without access to a call bell, despite care plan instructions for it to be within reach. The call bell was observed on the nightstand or floor, and the resident reported being unable to use it, relying instead on a roommate for help. Staff confirmed the call bell should have been clipped to the bed and accessible.
A resident with a history of subarachnoid hemorrhage, torticollis, and left hemiplegia was not accurately assessed in the MDS, as their upper extremity impairment was not documented in section GG despite clinical and therapy records indicating such limitations.
A resident with end stage renal disease and heart failure received midodrine for hypotension on multiple occasions despite a physician's order specifying it should not be given if systolic blood pressure was above 130 mm/Hg. The DON confirmed the medication was administered outside the prescribed parameters.
A resident with a history of neurological and musculoskeletal conditions experienced a decline in range of motion in the left upper extremity, as observed and reported by the resident. Despite this decline, no interventions or restorative programs were implemented to prevent further loss of function or to improve mobility, resulting in a deficiency related to nursing services.
A resident with an indwelling urinary catheter, diagnosed with urinary obstruction and enlarged prostate, was observed on multiple occasions with the catheter drainage bag positioned above bladder level while sitting in a recliner. Facility policy and care plans required the drainage bag to be kept below the bladder, but staff failed to follow these instructions, as confirmed by the DON.
A resident with significant medical needs did not receive the prescribed amount of enteral nutrition due to the tube feeding being stopped and not resumed as ordered. Observation showed the feeding pump was off and only a partial amount of formula had been infused, with staff and DON confirming the feeding was not restarted per the physician's order.
The facility did not ensure that food was served at a palatable and safe temperature, as required by its policy. Several residents reported receiving undercooked and cold food, and a test tray evaluation confirmed that a hot food item was served below the required temperature, with the center remaining cold and unpalatable. The Dietary Manager acknowledged that the food did not meet preparation and serving guidelines.
The facility did not meet the required nurse aide (NA) to resident ratios for 18 out of 21 days reviewed. The day shift ratio of one NA for ten residents, the evening shift ratio of one NA for 11 residents, and the night shift ratio of one NA for 15 residents were not maintained on multiple dates. The Nursing Home Administrator confirmed these staffing deficiencies.
The facility did not provide the required 3.2 hours of direct care per resident on 19 out of 21 days reviewed. Nursing schedules showed care hours ranging from 2.56 to 3.18 per resident, falling short of the regulatory requirement. This was confirmed by the Nursing Home Administrator.
The facility failed to maintain sanitary conditions during food preparation and service. Uncooked beef was found on the floor and shelf under a food preparation table, near clean cutting boards and food bins. A dietary employee was observed handling resident meal trays without changing gloves or performing hand hygiene after obtaining food items from the oven.
A facility failed to monitor and assess a significant weight change for a resident at risk for weight loss. Despite a policy requiring nutritional assessments for residents at risk, a resident with dementia and depression lost 8.9% of their weight in less than 30 days without being assessed by a dietitian until several months later. The Administrator confirmed the lack of timely assessment.
A facility failed to complete necessary dialysis communication forms for a resident with end-stage renal disease and anemia, as required by their policy. The forms, which should have included medications, vital signs, and shunt site status, were not filled out on several occasions. The Administrator acknowledged the oversight.
Delayed Meal Service Compromises Resident Dignity
Penalty
Summary
During a lunch meal observation on the 2nd floor nursing unit, several residents were seated in the dining room, and all except one resident were served their meals and began eating. One resident was left without a meal for over 20 minutes, during which time the resident was observed throwing his hands in the air and verbally expressing frustration about not receiving food. The resident did not receive his lunch tray until significantly after the others had been served. The DON later confirmed that all residents in the dining room should be served at the same time.
Call Bell Inaccessibility for Resident with Stroke
Penalty
Summary
A deficiency was identified when a resident with a recent stroke, who had limited control of his left leg and no control of his left arm, was repeatedly observed without access to a call bell. Clinical records indicated the resident was alert, oriented, able to make his needs known, and at risk for falls, with a care plan intervention requiring the call bell to be within reach and reminders to use it for assistance. On multiple occasions, the call bell was found out of the resident's reach, either on the nightstand or on the floor, while the resident was in bed. The resident reported being unable to find or use the call bell because it kept falling off the bed and stated he relied on his roommate for assistance. Staff interviews confirmed the call bell should have been clipped to the bed and accessible at all times.
Inaccurate MDS Assessment of Resident Functional Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's current status. Clinical record review showed that the resident had diagnoses including non-traumatic subarachnoid hemorrhage, torticollis, and left hemiplegia, with documented impairments in strength and range of motion in the left upper extremity according to an occupational therapy evaluation. However, the MDS assessment did not identify the resident as having an upper extremity impairment in functional limitation in range of motion under section GG, Functional Status. This discrepancy was confirmed during an interview with the Administrator, who acknowledged that the MDS was not coded to accurately reflect the resident's condition.
Failure to Follow Physician's Orders for Blood Pressure Medication
Penalty
Summary
Staff failed to follow a physician's order for a resident with end stage renal disease and heart failure, which required administration of midodrine three times daily for hypotension, with the specific instruction not to administer the medication if the resident's systolic blood pressure (SBP) exceeded 130 mm/Hg. Clinical record review showed that the medication was given on three separate occasions when the resident's SBP was above the prescribed threshold. The Director of Nursing confirmed that the medication was administered outside of the established parameters for this resident.
Failure to Implement Interventions for Declining Range of Motion
Penalty
Summary
A resident with a history of non-traumatic subarachnoid hemorrhage, torticollis, and left hemiplegia was identified as having limited range of motion (ROM) in the left upper extremity. The resident was dependent on staff for personal hygiene and dressing, and initial occupational therapy (OT) assessments did not note functional limitations due to contracture. However, a subsequent OT evaluation documented a functional limitation due to contracture, and observations over several days confirmed that the resident's left hand and wrist were slightly contracted. The resident reported that her hand had worsened and she was experiencing increased difficulty moving it. Despite the documented decline in ROM and the resident's own report of worsening condition, there were no interventions implemented to prevent further decline or to improve ROM. The OT discharge summary did not include any recommendations or restorative nursing program, and staff confirmed that no interventions had been put in place following the decline. This failure to implement appropriate care and interventions led to the deficiency cited under 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Failure to Maintain Catheter Drainage Bag Below Bladder Level
Penalty
Summary
The facility failed to provide adequate catheter care for one resident with an indwelling urinary catheter. According to facility policy, the urinary drainage bag should be kept below the level of the bladder at all times to prevent backflow of urine. Clinical records showed that the resident had diagnoses including urinary obstruction and enlarged prostate, and physician orders and care plans specified that the catheter be maintained below bladder level. However, on two separate occasions, the resident was observed sitting in a recliner with the catheter drainage bag hanging on the armrest above the level of the bladder, with urine visible in the tubing. The DON confirmed that the drainage bag should have been kept below the bladder at all times.
Failure to Administer Enteral Nutrition as Ordered
Penalty
Summary
A deficiency was identified when a resident with a history of brain injury, seizure disorder, and quadriplegia, who was dependent on staff for activities of daily living and unable to express needs, did not receive enteral nutrition as ordered by the physician. The physician's order specified that Jevity 1.2 should be administered at a rate of 55 ml per hour starting at 8:00 p.m. until a total of 935 ml was infused. However, observation revealed that the tube feeding was not connected to the resident, the pump was turned off, and only 300 ml had been infused by the following morning. Staff interviews confirmed that the tube feeding had been stopped for care and was not resumed according to the physician's order. The LPN on duty stated that the tube feeding was typically started on the night shift and continued until early afternoon, but had not disconnected the feed during her shift. The Director of Nursing verified that the feeding had not been restarted as required, resulting in the resident not receiving the prescribed amount of nutrition.
Failure to Serve Palatable and Properly Heated Food
Penalty
Summary
The facility failed to provide food that was palatable and at an appetizing temperature on one of its nursing units. According to the facility's policy, hot foods such as fish should be cooked to a minimum of 165 degrees Fahrenheit and served between 145 and 165 degrees Fahrenheit. However, multiple residents reported that food was often served undercooked and cold. During a test tray evaluation on the second floor, the baked breaded fish was found to be only 140 degrees Fahrenheit, with the center of the fillet being liquid, cold to the touch, and unpalatable. The Dietary Manager confirmed that this did not meet the facility's guidelines for preparation and serving of hot foods.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios for 18 out of 21 days reviewed, as evidenced by a review of nursing schedules from December 12, 2024, through January 1, 2025. Specifically, the facility did not maintain the minimum NA to resident ratio of one NA for ten residents during the day shift on multiple dates in December 2024. Additionally, the evening shift ratio of one NA for 11 residents was not met on several dates in December 2024. Furthermore, the night shift ratio of one NA for 15 residents was not achieved on numerous dates in December 2024 and January 1, 2025. The Nursing Home Administrator confirmed these staffing deficiencies during an interview conducted on January 2, 2025.
Plan Of Correction
1. The facility has reviewed past reported staffing information including ratios. 2. Facility will review schedules and ratios during the daily labor meetings for Nurse Aides. A variety of methods for staffing and recruitment will be utilized in order to fill vacant positions. Methods will be reviewed for effectiveness during daily labor review and adjusted according to facility need. 3. The Administrator / Designee re-educated the staffing coordinator on the policy regarding staffing, schedules, and ratios for Nurse Aides. 4. The Administrator / Designee will audit schedules and ratios 2 times per week for 2 weeks, then weekly for 4 weeks. Results of audits will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on previous audit findings.
Facility Fails to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per day for each resident. A review of nursing schedules over a 21-day period from December 12, 2024, to January 1, 2025, revealed that the facility did not meet this requirement on 19 of those days. Specific days showed care hours as low as 2.56 per resident, with the highest being 3.18, still below the mandated minimum. This deficiency was confirmed by the Nursing Home Administrator during an interview on January 2, 2025.
Plan Of Correction
1. The facility has reviewed past reported staffing information including PPDs. 2. Facility will review schedules and PPDs during the daily labor meetings. A variety of methods for staffing and recruitment will be utilized in order to fill vacant positions. Methods will be reviewed for effectiveness during daily labor review and adjusted according to facility need. 3. The Administrator / Designee re-educated the staffing coordinator on the policy regarding staffing, schedules, and PPD requirements. 4. The Administrator / Designee will audit schedules and PPDs 2 times per week for 2 weeks, then weekly for 4 weeks. Results of audits will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on previous audit findings.
Sanitation Deficiency in Food Preparation and Service
Penalty
Summary
The facility failed to maintain sanitary conditions during food preparation and service in the kitchen. During an observation of the tray line service, uncooked beef was found on the floor and on a shelf under a food preparation table, alongside clean cutting boards and bins of food products such as flour and powdered mashed potatoes. Dietary Employee 2 (DE 2) was observed preparing resident meal trays and repeatedly turned away from the tray line to obtain food items from the oven. DE 2 then returned to handling resident plates and ready-to-eat food items without changing gloves or performing hand hygiene.
Failure to Monitor and Assess Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and assess a significant weight change for a resident at risk for weight loss. The facility's policy on Nutritional Assessment, last reviewed on January 1, 2024, required staff to conduct a nutritional assessment when a change in condition placed a resident at risk for impaired nutrition. A clinical record review revealed that the resident, who had diagnoses including dementia and depression, experienced a significant weight loss of 8.9 percent in less than 30 days, dropping from 142.4 pounds to 129.6 pounds between September 12, 2023, and October 6, 2023. This weight loss was confirmed on October 9, 2023, when the resident weighed 129.4 pounds. Despite this significant weight change, there was no evidence that the dietitian assessed the resident until February 16, 2024. The Administrator confirmed in an interview on May 30, 2024, that the resident was not assessed by the dietitian prior to February 16, 2024.
Incomplete Dialysis Transfer Documentation
Penalty
Summary
The facility failed to provide dialysis services consistent with professional standards of practice for a resident with end-stage renal disease and anemia who required hemodialysis. The facility's policy, last reviewed on January 1, 2024, mandated that appropriate medical, social, administrative, and other information accompany residents during transfers to the dialysis center. This information was to include medical records detailing the resident's illness history, current treatments, medications, and any changes in condition. However, a review of the resident's dialysis communication forms revealed that section one, which should have been completed prior to transfer and included medications, vital signs, and the status of the shunt site, was not filled out on multiple dates in April and May 2024. The Administrator confirmed that these forms should have been completed before the resident's transfer on the identified dates.
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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