Passavant Retirement And Healt
Inspection history, citations, penalties and survey trends for this long-term care facility in Zelienople, Pennsylvania.
- Location
- 105 Burgess Drive, Zelienople, Pennsylvania 16063
- CMS Provider Number
- 395001
- Inspections on file
- 20
- Latest survey
- September 9, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Passavant Retirement And Healt during CMS and state inspections, most recent first.
A resident who was dependent on staff for transfers and required a Hoyer lift with two-person assistance sustained an abrasion to the forehead and a right tibial plateau fracture when staff failed to properly secure a lift pad loop during transfer. Both an LPN and a nurse aide participated in the transfer but did not ensure all loops were attached, resulting in the resident falling and sustaining actual harm.
A resident with significant mobility limitations and multiple diagnoses was being transferred with a Hoyer lift by two staff members when the front right pad loop was not properly secured, causing the resident to fall and sustain a forehead abrasion and a right tibial plateau fracture. Both staff members had received mechanical lift training, but failed to ensure all loops were attached, resulting in actual physical harm.
Staff failed to report and investigate multiple incidents where a resident with severe cognitive impairment physically struck another resident. Although staff intervened and no injuries were observed, the DON did not notify authorities or conduct an investigation, citing the absence of injury as the reason for not reporting.
A resident with anemia, dementia, and Parkinson's disease was observed self-administering medications without a documented assessment or physician order, contrary to the facility's policy. An LPN confirmed the resident's practice but was unaware of any formal assessment or orders, indicating a failure to follow the facility's medication self-administration policy.
The facility failed to provide a non-institutional dining experience by administering medications during breakfast for two residents. An LPN was observed giving medications to residents in the dining room, contrary to facility policy, which requires medications to be administered separately to ensure privacy and a homelike environment. The affected residents had various medical conditions, including anemia, dementia, hypertension, and diabetes.
The facility failed to ensure that the medication regimens for two residents were free from unnecessary psychotropic medications. Both residents, diagnosed with dementia and depression, were prescribed Quetiapine, which is not indicated for their conditions. The Director of Nursing confirmed the oversight, indicating a lapse in adherence to the facility's medication management policy.
The facility failed to properly label and store medications in three medication rooms and a resident's medication cabinet. Undated multi-dose vials and improperly stored insulin pens were found, along with expired catheters. These issues were confirmed by nursing staff and the DON, indicating non-compliance with facility policies and state regulations.
A facility failed to ensure a resident with moderate cognitive impairment understood a binding arbitration agreement. The resident, diagnosed with Non-Alzheimer's Dementia, diabetes, and Parkinson's disease, signed the agreement despite a BIMS score indicating moderate impairment. The care plan noted limitations in daily activities and confusion. The Marketing Coordinator confirmed the oversight.
A facility failed to implement droplet precautions for a resident with respiratory symptoms and did not update the care plan accordingly. Additionally, the facility did not maintain a sanitary environment in the Mountain Laurel Neighborhood kitchen, where items were improperly stored under the sink, risking cross-contamination.
A resident with a history of fractures and mental health conditions fell during a transfer to the commode due to inadequate supervision, as only one NA assisted instead of the required two. The fall resulted in an impacted proximal humerus fracture, highlighting a failure in following prescribed transfer protocols.
A resident with a history of Parkinson's disease and anxiety, initially assessed as not at risk for elopement, managed to leave the facility after asking a visitor to open a door. Despite having a wander guard, the resident exited through an unsupervised area and fell from their wheelchair, though they were not injured. Staff interviews revealed a lack of supervision and inadequate signage, contributing to the incident.
The facility failed to have a physician's order and care plan for a resident's indwelling catheter and did not provide appropriate catheter care for two residents. One resident had a Foley catheter without necessary documentation, while two others had issues with uncovered and improperly positioned urinary drainage bags.
The facility failed to conduct ongoing accurate assessments for bedrail usage for five residents, despite physician orders and care plans indicating their use. Staff interviews and clinical record reviews confirmed the lack of ongoing assessments, as required by regulations.
The facility failed to maintain the confidentiality of residents' medical information on the second floor Tionesta household. A medication cart/portable computer unit was left unattended with the screen open, displaying identifiable information. An LPN confirmed the breach of confidentiality, which violated the facility's policies on protecting resident information.
The facility failed to ensure that residents received neurological assessments after incidents involving falls. One resident with a history of high blood pressure and hemiplegia had incomplete neurological checks after a fall, and another resident with Alzheimer's and PTSD also had incomplete checks after being found with abrasions. The DON and an LPN confirmed the deficiencies.
The facility failed to ensure a physician order and care plan for a resident using a Bi-PAP/CPAP machine, despite the resident's diagnoses of obstructive sleep apnea, diabetes, and high blood pressure. The deficiency was confirmed by the Director of Nursing and observed in the resident's records and progress notes.
The facility failed to provide trauma-informed care to a resident with PTSD, as required by their policy. The resident's care plan did not include goals or interventions for PTSD, despite the diagnosis being documented. The Social Worker admitted to not including a PTSD-specific care plan, believing it would be redundant.
The facility failed to properly secure a medication drawer on four occasions in one of six households. Observations revealed that the portable computer unit medication drawer was left open, unattended, and out of sight of the medication nurse. LPNs and the Clinical Nurse Manager confirmed the failure to follow the facility's policy, and the DON confirmed the requirement to keep the drawer shut and locked.
The facility failed to follow infection control measures during blood sugar monitoring for two residents. An LPN did not allow the glucometer to air dry for the required two minutes after cleaning and did not perform hand hygiene after a finger stick blood sampling before preparing and administering insulin.
Failure to Ensure Safe Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure a safe transfer for a resident who required total assistance with mobility and was ordered to be transferred using a Hoyer lift with the assistance of two staff members. The resident, who had diagnoses including diabetes, Parkinson's disease, and depression, was dependent on staff for all transfers and positioning. During a transfer from wheelchair to bed, the right front loop of the Hoyer lift pad was not properly secured to the lift, resulting in the resident falling forward from the lift. The incident led to the resident sustaining an abrasion to the right forehead and a right nondisplaced tibial plateau fracture, accompanied by pain and visible deformity of the leg. Documentation and staff interviews revealed that both staff members involved in the transfer, an LPN and a nurse aide, participated in attaching the Hoyer lift pad but failed to ensure all loops were properly secured. Neither staff member could confirm who attached which straps, and both had received prior education on mechanical lift use. The facility's investigation determined that the root cause of the incident was the failure to secure the right front Hoyer pad loop before lifting the resident. Observations and interviews with other staff confirmed the correct procedure for securing the lift pad, which was not followed during the incident. The facility's policies clearly prohibit neglect and require that all residents be protected from harm, including ensuring safe transfers. The failure to properly secure the Hoyer lift pad directly resulted in actual harm to the resident, as evidenced by the injuries sustained during the fall. The deficiency was confirmed by the DON and supported by witness statements, clinical documentation, and the facility's own investigation.
Failure to Secure Hoyer Lift Pad Results in Resident Injury During Transfer
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident was free from a preventable accident during a transfer using a Hoyer lift. The resident, who had diagnoses including diabetes, Parkinson's disease, and depression, was assessed as totally dependent for transfers and required the use of a Hoyer lift with the assistance of two staff members. Physician orders and the care plan both specified this requirement. During a transfer from wheelchair to bed, the front right loop of the Hoyer lift pad was not properly secured, resulting in the resident falling forward from the lift, striking her face and leg. The incident was witnessed by two staff members, an LPN and a nurse aide, who both participated in attaching the Hoyer lift pad. Neither staff member could confirm who was responsible for securing the specific loop that failed. Documentation and interviews revealed that the right front Hoyer pad loop was not properly attached to the lift prior to the transfer. As a result, the resident sustained an abrasion to the right forehead and a right nondisplaced tibial plateau fracture, accompanied by pain and abnormal leg positioning. The facility's policy required a safe environment and proper use of mechanical lifts, and both staff members involved had received prior education on mechanical lift safety. Despite this, the failure to ensure all loops were securely fastened directly led to the resident's fall and subsequent injuries. Observations and interviews with other staff confirmed the correct procedure for securing the Hoyer lift pad, highlighting the deviation from protocol during the incident.
Failure to Report and Investigate Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to report and investigate allegations of physical abuse involving two residents. Clinical record review and staff interviews revealed that a resident with severe cognitive impairment, including diagnoses of non-traumatic brain dysfunction, Alzheimer's disease, and a psychotic disorder, was observed on multiple occasions following, yelling at, and physically striking another resident. On two separate dates, staff documented that the resident slapped another resident in the face, and in one instance, attempted to do so again shortly after being redirected. In both cases, staff intervened, redirected the resident, and noted that the other resident did not sustain injuries or complain of pain. Despite these documented incidents of resident-to-resident physical abuse, the facility did not report the events to the State Agency as required, nor did they conduct an investigation into the allegations. The Director of Nursing confirmed during an interview that these incidents were not reported or investigated because there were no injuries, indicating a misunderstanding of reporting requirements. The facility only reported a later incident involving a push, not the slapping incidents, which were omitted from required notifications and follow-up.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to determine the ability of a resident to self-administer medications, as required by their policy. The policy states that residents have the right to self-administer medications if it is deemed safe, and a licensed nurse must complete an assessment for self-administration, with the attending physician being notified within 24 hours. However, for one resident, this process was not followed. The resident, who was diagnosed with anemia, dementia, and Parkinson's disease, was observed taking medications from a cup on his breakfast tray without an order for self-administration or an assessment being completed. During an interview, an LPN confirmed that the resident takes his medications with breakfast but was unaware if there were orders to leave the medications at the bedside or if an assessment had been completed. This oversight indicates that the facility did not adhere to its own policies regarding medication self-administration, as there was no documented assessment or physician order for the resident to self-administer his medications.
Medication Administration During Meal Service
Penalty
Summary
The facility failed to provide a non-institutional dining experience by administering medications during the breakfast meal service for two residents. This was observed during a survey where Licensed Practical Nurse (LPN) Employee E11 was seen giving medications to two residents, R3 and R66, while they were seated in the dining room for breakfast. The facility's policy on medication administration requires that if residents are not in their rooms or otherwise unavailable, the medication administration record (MAR) should be flagged, and the nurse should return to administer the medication after completing the medication pass. However, this procedure was not followed, leading to the administration of medications during meal service, which compromised the residents' right to a homelike dining environment. Resident R3, who has diagnoses of anemia, dementia, and anxiety, and Resident R66, who has anemia, hypertension, and diabetes, were both affected by this practice. The LPN confirmed during an interview that the residents received their medications with breakfast, acknowledging the failure to adhere to the facility's policy and the residents' rights to privacy and a non-institutional dining experience. This incident highlights a deficiency in the facility's adherence to its own policies and the regulations governing resident rights.
Failure to Ensure Medication Regimen Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the medication regimens for two residents were free from unnecessary psychotropic medications. Resident R46, who was diagnosed with dementia and depression, was prescribed Quetiapine for delirium, despite the medication's indications being for schizophrenia and bipolar disorder. Similarly, Resident R86, also diagnosed with dementia and depression, was prescribed Quetiapine for delusions-behavior, which is not aligned with the medication's approved uses. The facility's policy on medication management requires the interdisciplinary team to review residents' medication regimens for efficacy and potential medication-related problems on an ongoing basis, but this was not adhered to in these cases. During an interview, the Director of Nursing confirmed that the diagnoses of dementia and depression for Residents R46 and R86 were not included in the indications for Quetiapine, highlighting a failure to ensure the residents' medication regimens were free of unnecessary psychotropic medications. This deficiency was identified through a review of facility policy, clinical records, and staff interviews, indicating a lapse in the facility's adherence to its own medication management policy.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols across multiple medication rooms and a resident's medication cabinet. In the Mountain Laurel medication room, two tuberculin multi-dose vials were found opened without a date, which was confirmed by RN Employee E7. Similarly, in the Trillium medication room, another tuberculin multi-dose vial was observed opened and undated, verified by RN Employee E9. In the Tionesta medication room, a Novolog flex pen was found without a label or resident name and was not stored in a box or individual bag as required. Additionally, six Coude foley catheters were discovered past their expiration date, as confirmed by LPN Employee E8. In a resident's room, specifically Resident R77's medication cabinet, a multi-dose nasal spray and eye drop container were found undated when opened, verified by LPN Employee E10. The Director of Nursing 2 confirmed these deficiencies, which included the failure to date opened medications, properly store and label medications in the medication rooms, discard expired nursing supplies, and properly store medications in the resident's medication cabinet. These findings indicate non-compliance with the facility's policies and state regulations regarding pharmacy and nursing services.
Failure to Ensure Resident Capacity for Arbitration Agreement
Penalty
Summary
The facility failed to ensure that Resident R67 had the capacity to understand the terms of a binding arbitration agreement. Resident R67, who was admitted to the facility, signed the arbitration agreement despite having a diagnosis of Non-Alzheimer's Dementia, diabetes, and Parkinson's disease. The Minimum Data Set (MDS) assessment indicated a Brief Interview for Mental Status (BIMS) score of 12, suggesting moderate cognitive impairment. Additionally, the resident's care plan noted limitations in performing activities of daily living due to Parkinson's disease and dementia, as well as issues with confusion and wandering. During an interview, the Marketing Coordinator, Employee E13, confirmed that the facility did not ensure Resident R67's capacity to comprehend the arbitration agreement. This oversight was identified as a deficiency in the facility's responsibility to ensure residents' understanding of legal agreements, as outlined in the relevant Pennsylvania Code sections.
Failure to Implement Droplet Precautions and Maintain Sanitary Kitchen Environment
Penalty
Summary
The facility failed to ensure droplet precautions were ordered and a care plan implemented for a resident who exhibited symptoms consistent with a respiratory infection. The resident, who had a history of coronary artery disease, hypertension, and diabetes, was noted to have a heavy wet nonproductive cough. Despite the physician being notified and new orders being initiated, including a rapid COVID test, PCR test, and chest x-ray, the resident's current physician orders did not include droplet precautions. Additionally, the resident's care plan was not updated to reflect the need for droplet precautions, as confirmed by the Director of Nursing. Furthermore, the facility did not maintain a safe and sanitary environment in one of its household kitchen areas, specifically the Mountain Laurel Neighborhood. During an observation, it was found that 15 boxes of disposable gloves and 15 compact disk cases were stored under the kitchen sink, contrary to the facility's infection control policy for household dining rooms. This was confirmed by the Household Coordinator and the Nursing Home Administrator, indicating a failure to prevent potential cross-contamination in the kitchen area.
Inadequate Supervision During Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision during a transfer for one of six residents, resulting in a fall. The resident, who was admitted to the facility with diagnoses including a right fibula fracture, anxiety, and depression, had physician orders indicating that toilet transfers should be completed with the assistance of two staff members. However, during a transfer to the commode, the resident slipped and fell, hitting the back of her head on a railing. Although no bleeding or lumps were noted, subsequent medical evaluations revealed an impacted proximal humerus fracture. The incident occurred when a Nurse Aid (NA) was transferring the resident alone, contrary to the prescribed assistance level. The NA's statement indicated that the resident slid while the NA was moving the wheelchair, and although the fall was partially broken, the resident still sustained injuries. The NA involved in the incident is no longer working at the facility and did not respond to follow-up communications. The Nursing Home Administrator confirmed the facility's failure to provide adequate supervision during the transfer, which led to the resident's fall.
Plan Of Correction
1) 12/30/24 R1 transfer status was reviewed with CNA's and Charge Nurses on R1 Nursing Household by Clinical Nurse Manager/DON. The CNA that was involved in the incident was interviewed, sent home, and terminated from the facility. 2) 12/31/24 Education was initiated by Clinical Coordinator/Designee to Charge Nurses and CNA's on all shifts regarding the transfer status, weight bearing status, resident profile, and Physician transfer orders. 3) 12/31/31/24 CNA's and Charge Nurses on each Nursing Household were interviewed by Clinical Nurse Manager/DON on the current transfer status order of each resident. 4) The Charge Nurse/Designee will monitor between the three shifts five residents on each nursing household for adequate supervision to ensure transfer status orders are being followed three times a week for three months or until substantial compliance is met.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident, identified as Resident R1. The resident, who was admitted to the facility with diagnoses including benign prostatic hyperplasia, Parkinson's disease, and anxiety, was initially assessed as not being at risk for elopement. However, after an incident on July 12, 2024, where the resident was found attempting to exit the facility, a subsequent assessment on July 13, 2024, identified the resident as being at risk for elopement, and a wander guard was applied. Despite these measures, on September 2, 2024, Resident R1 managed to leave the facility after asking another resident's family member to open a door. The resident exited through the employee entrance and fell out of their wheelchair but was not injured. The resident was later found by staff and escorted back into the facility. The incident report noted that the resident's wander guard was in place and functioning, and the resident expressed a desire to enjoy fresh air. Interviews with facility staff revealed that at the time of the elopement, there was no staff present in the area to supervise the resident. Additionally, there was a lack of signage on the inside of the exit door to prevent unauthorized exits. The Nursing Home Administrator acknowledged the failure to provide adequate supervision, which resulted in the elopement incident.
Deficiencies in Catheter Care and Documentation
Penalty
Summary
The facility failed to have a physician's order and a care plan for the use of an indwelling catheter for one resident and failed to ensure appropriate treatment and services for two residents with indwelling urinary catheters. Resident R193 had an indwelling urinary catheter without a physician's order or a care plan, as confirmed by the Director of Nursing (DON) and a Registered Nurse (RN). The resident was observed with a Foley catheter connected to a drainage bag, but the necessary documentation was missing from the clinical records and care plan. Additionally, Resident R67 and Resident R73 did not receive appropriate catheter care. Resident R67's urinary drainage bag was observed uncovered and laying on his bed, and Resident R73's urinary drainage bag was attached to the bed frame above the level of the bladder, both of which were confirmed by an LPN. Furthermore, Resident R73's physician order did not specify a catheter size, and the privacy cover for the urinary drainage bags was not utilized for both residents. These deficiencies were confirmed by the DON and an LPN during interviews.
Failure to Conduct Ongoing Bedrail Assessments
Penalty
Summary
The facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and to evaluate the risks associated with bedrail usage for five residents. According to Title 42 Code of Federal Regulations (CFR) S483.25(n), the facility must assess the resident for risk of entrapment from bed rails prior to installation and perform ongoing assessments. However, the clinical records for Residents R6, R14, R31, R32, and R34 did not reveal any ongoing assessments of the mobility bars, despite their continuous use as indicated by physician orders and care plans. Observations confirmed the presence of mobility bars on the beds of these residents, and staff interviews corroborated the lack of ongoing assessments. Resident R6, diagnosed with diabetes, overactive bladder, and spinal stenosis, had physician orders for continuous mobility bars, but no ongoing assessments were found in the clinical record. Similarly, Resident R14, with high blood pressure, heart failure, and coronary artery disease, had a left-side mobility bar for bed mobility without ongoing assessments. Resident R31, diagnosed with Alzheimer's Disease, anxiety, and depression, also had bilateral mobility bars without documented ongoing assessments. Resident R32, with a history of falling, anemia, and dementia, required substantial assistance with bed mobility and had bilateral mobility bars without current assessments. Resident R34, with high blood pressure, a history of falling, and Alzheimer's Disease, also had bilateral mobility bars without current assessments. Interviews with staff, including Nurse Aides and the Director of Nursing (DON), confirmed the lack of quarterly mobility bar assessments. The DON acknowledged that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and to evaluate the risks associated with bedrail usage for the five residents mentioned. This deficiency was observed through clinical record reviews, staff interviews, and direct observations of the residents' beds with mobility bars.
Failure to Maintain Confidentiality of Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information on the second floor Tionesta household. During an observation, a medication cart/portable computer unit was left unattended outside of a resident's room with the computer screen open, displaying identifiable personal and medical information. This occurred on two separate occasions within a short time frame, allowing any passerby to view the confidential information. Licensed Practical Nurse Employee E7 confirmed during an interview that the computer screen was left open and that the facility did not maintain the confidentiality of resident information as required by their policies. The facility's policies on the use of laptops and medication administration clearly state that computer screens should be closed or turned away when not in use to protect resident privacy. The failure to adhere to these policies resulted in a breach of confidentiality for the residents in the Tionesta household.
Failure to Complete Neurological Assessments After Falls
Penalty
Summary
The facility failed to ensure that residents received neurological assessments after incidents involving falls for two residents. Resident R9, who had a history of high blood pressure, hemiplegia, and previous falls, experienced a fall on 9/19/23 after sliding out of a mechanical lift in the shower. Despite sustaining multiple lacerations and an abrasion, only nine out of the required 15 neurological checks were completed. The Director of Nursing (DON) confirmed that the neurological checks were not completed per facility policy and was unable to locate additional checks in the resident's clinical record. Similarly, Resident R69, who had diagnoses of high blood pressure, Alzheimer's Disease, and PTSD, was found with abrasions on her forehead and nose on 2/6/24. Due to a language barrier, the cause of the abrasions was unclear, and neurological checks were initiated based on a presumed fall. However, only 11 out of the required 15 neurological checks were completed. An LPN confirmed the inability to locate additional neurological checks in the resident's clinical record and acknowledged that the facility failed to complete the assessments as required by policy.
Failure to Document and Plan Respiratory Care
Penalty
Summary
The facility failed to ensure a physician order for the use and cleaning of a Bi-PAP/CPAP machine and did not develop a plan of care for a resident (R58) who required this therapy. The facility's policies on respiratory care documentation and equipment changes were not followed. Specifically, the policy required nurses to complete the electronic treatment administration record (eTAR) for residents with physician orders for CPAP/Bi-PAP therapy and outlined maintenance procedures for the equipment. However, a review of Resident R58's records revealed no physician order for Bi-PAP/CPAP therapy and no corresponding care plan, despite the resident using the machine at night for breathing, as confirmed by both the resident and the Director of Nursing (DON2). The resident's progress notes and observations further confirmed the use of the Bi-PAP/CPAP machine without proper documentation or care planning in place. Resident R58, who was admitted to the facility with diagnoses including obstructive sleep apnea, diabetes, and high blood pressure, was observed using a Bi-PAP/CPAP machine. Despite this, there was no physician order or care plan documented for the use of the machine. The facility's failure to adhere to its own policies and ensure proper documentation and care planning for the resident's respiratory therapy was confirmed by the Director of Nursing. This deficiency was identified during a review of the facility's policies, resident observations, clinical records, and staff interviews.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to Resident R69, who has a diagnosis of Post Traumatic Stress Disorder (PTSD). The facility's policy on Trauma-Informed Care, dated 1/23/24, mandates culturally competent, trauma-informed care to mitigate potential triggers for residents with past or present trauma. However, a review of Resident R69's care plan on 3/28/24 revealed that it did not include any goals or interventions related to PTSD, despite the resident's diagnosis being documented in the Minimum Data Set (MDS) dated 1/18/24. The resident's diagnoses also included high blood pressure and Alzheimer's Disease. During an interview on 3/28/24, the Social Worker (Employee E3) admitted to not including a PTSD-specific care plan for Resident R69, believing it would be redundant since the resident was already care planned for mood and behaviors. Employee E3 also mentioned that the PTSD diagnosis might be related to an incident involving the resident's daughter. The failure to provide a trauma-informed care plan was confirmed by Employee E3, indicating a lapse in adhering to the facility's policy and potentially exposing the resident to re-traumatization triggers.
Failure to Secure Medication Drawer
Penalty
Summary
The facility failed to properly secure a medication drawer on four occasions in one of six households (Tionesta household). The facility policy, last reviewed on 1/23/24, indicates that during the administration of medications, the medication cart/portable computer unit is to be kept closed and locked when out of sight of the medication nurse. However, observations on 3/26/24 and 3/27/24 revealed that the portable computer unit medication drawer was left open, unattended, and out of sight of the medication nurse on four separate occasions. These observations were confirmed by Licensed Practical Nurses (LPNs) Employee E7 and Employee E8, who acknowledged the failure to secure the medication drawer as per the facility's policy. During interviews, LPN Employee E8 admitted to not knowing the specific policy concerning the medication drawer, while the Clinical Nurse Manager stated that the drawer is usually not closed when in sight but should be shut and locked if leaving the area. The Director of Nursing (DON2) confirmed that the medication drawer on the portable computer units is to be shut and locked, and the computer screen is to be closed. The facility's failure to secure the medication drawer was confirmed to be a deficiency in one of the six households, violating the 28 Pa. Code: 211.9(a)(1)(h)(k)(l)(1) Pharmacy services and 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
Infection Control Deficiency During Blood Sugar Monitoring
Penalty
Summary
The facility failed to implement proper infection prevention and control measures during finger stick blood sugar monitoring for two residents. During an observation, an LPN did not allow the glucometer to remain wet for the required two minutes after cleaning it with a Sani-cloth wipe before placing it back into its case. This action was observed after obtaining a blood glucose reading from one resident. Additionally, the same LPN did not perform hand hygiene after completing a finger stick blood sampling and before preparing and administering insulin to another resident. The facility's policies on hand hygiene and the use of glucometers were not followed. The hand hygiene policy requires staff to wash hands before and after performing tasks that include invasive procedures, such as finger stick blood sampling. The glucometer policy mandates disposing of the lancet, gloves, and used strip in a designated container, washing hands, and wiping the glucometer with a germicidal wipe, allowing it to air dry for two minutes. The LPN confirmed during an interview that these steps were not followed, leading to potential cross-contamination risks.
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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