Pleasant Ridge Manor East/west
Inspection history, citations, penalties and survey trends for this long-term care facility in Girard, Pennsylvania.
- Location
- 8300 West Ridge Road, Girard, Pennsylvania 16417
- CMS Provider Number
- 395361
- Inspections on file
- 27
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Pleasant Ridge Manor East/west during CMS and state inspections, most recent first.
Three residents did not receive respiratory care in accordance with physician orders and facility policy, including lack of documentation for nebulizer cleaning, incomplete or missing oxygen orders, and failure to specify oxygen flow rates. Staff confirmed these deficiencies in respiratory care and documentation.
A resident with multiple serious diagnoses was transferred to a hospital, but the facility failed to document or communicate the necessary clinical information to the receiving provider, as confirmed by the DON and a review of the clinical record.
A resident with hemiplegia, hyperlipidemia, and hypertension did not have a physician-ordered edema glove or Geri sleeve applied to their left hand/arm as required. Multiple observations showed the resident without the prescribed device, and an LPN confirmed the omission, resulting in a deficiency for not following physician's orders.
A resident with dementia, muscle contracture, and hypothyroidism did not receive physician-ordered bilateral resting hand splints as required. Documentation and direct observation showed the splints were not applied according to the prescribed schedule, and an LPN confirmed the omission. This resulted in the resident not receiving appropriate treatment to prevent further decrease in range of motion.
Surveyors found that controlled medications were not securely locked in the designated storage box, and expired antibiotics remained in the medication refrigerator past their discard date. Both an LPN and the DON confirmed these lapses, which were not in accordance with facility policy.
The facility failed to accurately code MDS assessments for two residents: one was incorrectly marked as having significant weight loss, and another was repeatedly coded as receiving an anticoagulant when actually receiving an antiplatelet medication. These errors were confirmed through clinical record review and staff interviews.
A resident with severe cognitive impairment and multiple medical conditions was physically abused by a nursing assistant during a transfer. The incident was witnessed by another staff member, but was not reported immediately as required by facility policy, resulting in a delay in notifying the DON and initiating an investigation.
A resident with severe cognitive impairment and total dependence for transfers was injured due to improper transfer methods. The resident, who required a Maxi lift with two-person assistance, was instead moved using a Sara lift by a single nursing assistant, resulting in a femur fracture. The facility's investigation confirmed the deviation from prescribed transfer orders.
A facility failed to provide a resident and/or their representative with a written notice of the bed-hold policy upon hospital transfer. Despite the facility's policy requiring such notification, there was no evidence that the resident, who had conditions including renal dialysis dependence and diabetes, received this information during transfers. The DON confirmed the oversight, acknowledging non-compliance with regulatory requirements.
The facility failed to ensure that two residents with limited range of motion received physician-ordered splint treatments. One resident with dementia and other conditions had a palm splint order without a posted wear schedule, leading to non-compliance with the prescribed schedule. Another resident with chronic conditions had a resting hand splint order, but observations showed the splint was not worn as scheduled, despite the schedule being posted. Staff interviews confirmed the splints were not applied as ordered.
A facility failed to provide proper urinary catheter care for a resident with an indwelling catheter. Observations showed the resident's drainage bag and tubing on the floor, contrary to facility policy requiring them to be off the floor and covered. An LPN confirmed the improper placement and coverage of the catheter equipment.
The facility failed to provide a clinical rationale for the continued use of PRN psychotropic medications beyond 14 days and did not attempt non-pharmacological interventions prior to administering these medications for two residents. One resident was prescribed Alprazolam for anxiety, and another was prescribed Lorazepam for agitation, both without required stop dates or clinical rationales for extended use. The Director of Nursing confirmed these deficiencies.
The facility failed to properly clean a blood glucometer between uses on two residents, using a 70% isopropyl alcohol prep pad instead of the manufacturer's approved cleaning agents. An LPN assumed the alcohol prep pad was appropriate, but the DON confirmed it was not compliant with guidelines.
The facility failed to provide written summaries of baseline care plans and order summaries to several residents or their representatives. This deficiency affected residents with complex medical conditions such as COPD, diabetes, dementia, and heart failure. The Director of Nursing confirmed the absence of these documents in the clinical records, highlighting a lapse in ensuring residents and their representatives are informed of initial care plans.
The facility failed to follow professional standards for G-tube care, resulting in a resident being sent to the emergency room due to a clogged G-tube with a broken-off Q-tip lodged in it. The Director of Nursing confirmed that facility policies were not adhered to.
Failure to Provide and Document Proper Respiratory Care and Oxygen Administration
Penalty
Summary
The facility failed to provide and maintain respiratory care, including oxygen administration and nebulizer equipment, according to physician orders and facility policy for three residents. For one resident with Alzheimer's disease and functional quadriplegia, the clinical record showed a physician's order for nebulized medication four times daily, but there was no documentation of cleaning or maintaining the nebulizer equipment. Observations revealed the resident's nebulizer mask was left on the nightstand with dried secretions and solid matter inside, and staff confirmed there was no evidence of when the mask was last cleaned or changed. Another resident with prostate cancer, diabetes, altered mental status, and dementia was found to be receiving supplemental oxygen without a physician's order specifying its use. Progress notes indicated oxygen was started after a potential seizure, but there was no documentation of continued use, flow rate, or route in the clinical record. Staff confirmed the lack of complete orders and documentation for the resident's oxygen therapy. A third resident with Parkinson's disease, dementia, and heart failure had physician's orders for oxygen via nasal cannula for comfort and as needed per oximetry, but the orders did not specify a flow rate. The DON confirmed that the oxygen orders were incomplete and should have included the flow rate. These findings demonstrate the facility's failure to follow professional standards and its own policies regarding respiratory care and documentation.
Plan Of Correction
R32's nebulizer mask was immediately replaced by the Registered Nurse Supervisor upon notification. An initial audit was conducted to determine that all residents with orders for nebulizer had a clean and dated mask or T-pipe. All licensed nursing staff will be educated by the Director of Nursing/Designee on proper cleaning, storing, and dating of nebulizer supplies. A weekly audit will be conducted by the third shift Licensed Practical Nurse to ensure nebulizer supplies remain clean, are dated, and stored properly. Weekly audits by the third shift Licensed Practical Nurse will continue for four weeks, then monthly for four months, then quarterly. Results of these audits will be reviewed at the Quality Assurance Committee monthly for review until audits meet 100% compliance for three consecutive quarters. The Director of Nursing/designee will be responsible for compliance. Completion Date: 7/31/25. R153's oxygen order was changed to reflect rate, route, and diagnosis. Orders involving titration of oxygen now have supplemental documentation requirements of rate and oxygen saturation level. R195's oxygen order was changed to reflect rate, route, and diagnosis. Standing admission order for "oxygen per oximetry prn/as needed" order was removed from the admission order sets. Oxygen can be applied as a nursing measure. Once prn oxygen is initiated, the Registered Nurse will obtain a physician order to reflect the flow rate, route, and rationale for use. The Assistant Director of Nursing did an initial audit to ensure as needed oxygen orders contained a rate, route, and rationale for oxygen use in the physician order. The Director of Nursing and Assistant Director of Nursing conducted an audit of all routine oxygen orders today to ensure they contain rate, route, and diagnosis. All nursing staff will be educated by the Director of Nursing/designee on documenting oxygen saturation and flow rate in the resident record for as needed oxygen orders involving titration orders. Ward Clerks will be educated by the Director of Nursing/Designee on adding supplementary documentation of saturation and liter flow to the electronic medication administration record system for as needed oxygen orders involving titration of oxygen. Registered Nurses will be educated by the Director of Nursing/Designee on ensuring that all as needed oxygen orders contain rate of flow, route of administration, and indications for use. Registered Nurse Supervisor will run a weekly report of physician orders to ensure rate, route, rationale are captured in orders for oxygen. Weekly audits will continue for four weeks, then monthly for four months, then quarterly. Results of these audits will be reviewed at the Quality Assurance Committee monthly for review until audits meet 100% compliance for three consecutive quarters. The Director of Nursing/designee will be responsible for compliance. Completion Date: 7/31/25. F 0695
Failure to Communicate Required Clinical Information During Resident Transfer
Penalty
Summary
Pleasant Ridge Manor West was found to be noncompliant with federal and state regulations regarding the discharge process for residents. The facility's policy requires that, upon transfer or discharge, necessary resident information must be communicated to the receiving health care provider and documented in the resident's medical record. However, a review of the clinical record for one resident revealed that this process was not followed. The resident in question had an admission date of 12/12/24 and diagnoses including respiratory failure, congestive heart failure, and obstructive sleep apnea. On 5/15/25, a progress note indicated that the resident was transferred to the hospital. Despite this transfer, the clinical record did not contain evidence that the necessary clinical information was communicated to the receiving health care provider as required by both facility policy and federal regulations. During an interview, the DON confirmed that there was no documentation showing that the required clinical information was provided to the hospital at the time of transfer. The DON also acknowledged that it is the facility's expectation and policy to provide and document such information during resident transfers. This failure constituted a deficiency in meeting the requirements for safe and effective resident discharge and transfer communication.
Plan Of Correction
Preparation and/or evaluation of the following Plan of Correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the Statement of Deficiency. The Plan of Correction is prepared and/or executed solely because it is required by the provisions of federal and state law. Registered Nurse's User Defined Assessment/Transfer Assessment was created to ensure that all pertinent information is relayed to the receiving provider. All Registered Nurse Supervisors will be educated on completing this assessment and documenting that Physician/Resident Representative were notified. All licensed staff will be educated on the requirements on the completing the e-interact transfer form, copy of current Medication Administration record, and sending the summary of episode note form. All requirements are captured in the e-interact and/or summary of episode note. The Director of Nursing/Designee will audit daily any resident transfers to ensure all pertinent information is relayed to the receiving provider. Audit will be completed daily for thirty days and if compliant will audit weekly for thirty days and then change to quarterly. Results of these audits will be reviewed at the Quality Assurance Committee meeting monthly for review until audits meet 100% compliance for three consecutive quarters. The Director of Nursing/designee will be responsible for compliance. Completion Date: 7/31/25
Failure to Follow Physician's Orders for Compression Device Application
Penalty
Summary
A deficiency was identified when a facility failed to follow physician's orders for a resident with hemiplegia, hyperlipidemia, and hypertension. The physician had ordered an edema glove to be applied to the resident's left hand to reduce swelling. However, review of the clinical record and task documentation showed a task to apply a Geri sleeve to the left upper extremity in the morning and remove it at bedtime, but there was no evidence that either the glove or sleeve was consistently applied as ordered. Multiple observations over several days revealed that the resident was repeatedly seen without the prescribed glove or sleeve on their left hand or arm, both while in bed and in a wheelchair. During an interview, an LPN confirmed that the resident did not have the glove or sleeve on and acknowledged that, according to the physician's orders, the resident should have had it applied. This failure to follow physician's orders constituted a deficiency under the cited regulations.
Plan Of Correction
R197's sleeve/glove were placed on resident upon notification. Initial audit was completed for residents with geri sleeve or edema glove orders. All were available and being worn per physician orders. Geri sleeves/edema gloves were documented by the nursing assistant in Point Click Care point of care. Geri sleeves/edema gloves will be added to the Licensed Practical Nurse treatment administration record to ensure they are being worn per physician order. All nursing staff will be educated on following the physician orders. Certified Nursing Assistant will be educated on the importance of applying geri sleeves/edema gloves as ordered. Ward clerks will be educated on adding these orders to the Licensed Practical Nurse treatment administration record. All Licensed Practical Nurses will be educated on ensuring residents with orders for sleeves/gloves are wearing as ordered and documenting in the treatment administration record. A daily audit will be conducted by the Registered Nurse Supervisor on each shift to ensure all geri sleeves/edema gloves are on per orders and documented in the resident record. Results of these audits will be reviewed at the Quality Assurance Committee monthly for review until audits meet 100% compliance for three consecutive quarters. The Director of Nursing/designee will be responsible for compliance. Completion Date: 7/31/25
Failure to Apply Physician-Ordered Hand Splints for Resident with Limited ROM
Penalty
Summary
A deficiency was identified when a resident with a history of dementia, muscle contracture, and hypothyroidism did not receive physician-ordered bilateral resting hand splints as prescribed. The facility's policy required nursing staff to follow physician orders and recommendations for splinting devices, but documentation in the clinical record lacked evidence that the splints were applied according to the specified schedule. Observations on multiple occasions confirmed that the resident was not wearing the resting hand splints at times when they should have been, as per the physician's order. During interviews, an LPN confirmed that the resident did not have the splints on and acknowledged that they should have been applied according to the physician's instructions. The failure to follow the prescribed splinting schedule and lack of documentation demonstrated that the resident did not receive appropriate treatment and services to prevent further decrease in range of motion, as required by federal and state regulations.
Plan Of Correction
Therapy replaced bilateral missing hand splints of R120 on 6/26/25. Therapy will do an initial audit of all residents with orders for splints to ensure all are available for use. Nursing staff will be educated on informing therapy immediately if resident splints are missing or unavailable. The Director of Therapy will continue to educate all nursing staff/therapy staff on applying resident splints per physician orders/splinting schedule. The Director of Nursing/designee will educate all nursing staff on informing therapy immediately if resident splints are missing, damaged, or unavailable. The Director of Therapy/designee will conduct a weekly audit to ensure all splints are available to residents. A Unit Licensed Practical Nurse will conduct a daily audit to ensure all splints are being worn per the resident schedule. Daily audits will continue for four weeks, then weekly for four weeks, then monthly for four months, then quarterly. Results of these audits will be reviewed at the Quality Assurance Committee monthly for review until audits meet 100% compliance for three consecutive quarters. The Director of Nursing/designee will be responsible for compliance. Completion Date: 7/31/25
Failure to Secure Controlled Medications and Timely Discard Expired Drugs
Penalty
Summary
The facility failed to ensure that controlled medications were securely stored and that expired medications were discarded in a timely manner. During an observation of the H Unit medication storage refrigerator, Ativan injection syringes, a controlled medication, were found in a red plastic box designated for controlled substances, but the box lacked a lock or secure device. This was confirmed by both an LPN and the Director of Nursing, who acknowledged that the controlled medication box should have been secured according to facility policy. Additionally, in the A Unit medication storage refrigerator, expired antibiotics, including multi-dose bottles of Cefpodoxime and a bag of Meropenem IV solution, were found past their discard date. An LPN confirmed that these medications were expired and should have been discarded or returned to the pharmacy. The Director of Nursing also confirmed that expired medications should not have remained in storage. These findings were based on direct observations, staff interviews, and a review of facility policies.
Plan Of Correction
Refrigerator on Unit H was secured with a lock on the red narcotic box inside the refrigerator. Pharmacy conducted an audit of all medication refrigerators to ensure all had a double locking system. Unit Licensed Practical Nurse will conduct daily audits to ensure narcotic medications are double locked. Audits will continue for four weeks, then weekly for four weeks, then monthly for four months, then quarterly. All licensed nursing staff will be educated by the Director of Nursing/Designee on the need for double locks of narcotic medications. Results of these audits will be reviewed at the Quality Assurance Committee monthly for review until audits meet 100% compliance for three consecutive quarters. The Director of Nursing/designee will be responsible for compliance. Completion Date: 7/31/25. And medication rooms expired or discontinued medications. Results of these audits will be reviewed at the Quality Assurance Committee monthly for review until audits meet 100% compliance for three consecutive quarters. The Director of Nursing/designee will be responsible for compliance.
Inaccurate MDS Coding for Weight Loss and Medication Classification
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. For one resident with diagnoses including bipolar disorder, anxiety, and chronic pain, the MDS was incorrectly coded to indicate significant weight loss in the Swallowing/Nutritional Status section, despite confirmation from the Registered Dietitian that no such weight loss had occurred. This error was identified through a review of the resident's clinical record and MDS instructions, which specify the criteria for coding weight loss. For another resident with diagnoses such as Type 2 diabetes, bipolar disorder, long-term kidney disease, and adult failure to thrive, the MDS was repeatedly coded to indicate the use of an anticoagulant in multiple assessments. However, the resident was actually receiving ticagrelor, an antiplatelet medication, not an anticoagulant. The Registered Nurse Assessment Coordinator confirmed that the MDS coding for anticoagulant use was incorrect across several quarterly and annual assessments. These inaccuracies were identified through clinical record review and staff interviews.
Plan Of Correction
Resident R13's Minimum Dataset assessment dated 4/1/25 was corrected with the removal of weight loss, and resubmitted 7/8/25. Resident R43's Minimum Dataset assessments dated 8/29/24, 11/21/24, 2/13/24, 5/8/25, and 6/3/25 were corrected to reflect the resident was receiving an antiplatelet and not an anticoagulant on 7/8/25 and resubmitted. The Utilization Review Director provided education to all staff that complete Section N and K of the Minimum Dataset Assessment. The Utilization Review Director or designee will conduct weekly audits of a minimum of 25% of the comprehensive and quarterly Minimum Dataset assessments for accurate documentation of medication classification of antiplatelet vs. anticoagulant. The Utilization Review Director or designee will conduct weekly audits of a minimum of 25% of the comprehensive and quarterly Minimum Dataset assessments for accurate documentation of weight loss. All residents' most recent Minimum Dataset assessments will be audited on Section K and N, and errors will be corrected and resubmitted. Audits will be forwarded to the Quality Assurance review monthly until 100% compliance is achieved for three consecutive months, then quarterly. Completion Date: 7/31/25
Failure to Timely Report Alleged Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported in a timely manner for one resident. According to facility policy, any suspicion or incident of abuse, neglect, mistreatment, or misappropriation of property must be reported immediately to designated authorities within the facility. However, an incident occurred during a mechanical lift transfer in which a nursing assistant was observed to physically abuse a resident by pulling the resident's fingers off the lift, bending them backwards, and subsequently punching and pinching the resident. Another staff member witnessed the abuse, instructed the perpetrator to stop, and was told to remain silent. The witness did not report the incident to a nurse before leaving the facility at the end of the shift, resulting in a delay in notification. The incident was not discovered until the following day when the DON received a call regarding the allegation of abuse. The resident involved had severe cognitive impairment, dementia, a tracheostomy, and diabetes, and was unable to advocate for themselves. Facility leadership acknowledged that the delay in reporting did not comply with their policy, which requires immediate reporting of suspected abuse. The deficiency was identified through review of facility policy, clinical records, facility documents, and staff interviews.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to provide a safe transfer for a resident, resulting in actual harm. The resident, who was severely cognitively impaired and totally dependent on assistance for transfers, was supposed to be moved using a Maxi lift with the assistance of two staff members, as per the physician's orders. However, a nursing assistant used a Sara lift, which is a sit-to-stand lift, and performed the transfer alone, contrary to the prescribed method. The resident, who had a history of falling and was diagnosed with Alzheimer's disease and dementia, suffered an acute fracture of the femur during the transfer. The incident was discovered when the resident exhibited swelling and bruising on the right knee and upper thigh. Subsequent x-rays confirmed a displaced fracture of the right distal femur, necessitating hospital evaluation. The facility's investigation revealed that the nursing assistant did not adhere to the resident's transfer orders, leading to the injury. The assistant admitted to using the incorrect lift and performing the transfer without the required second person. This deviation from the prescribed transfer method directly resulted in the resident's injury.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide a resident and/or their representative with a written notice of the bed-hold policy upon transfer to a hospital. This deficiency was identified during a review of the facility's policy and clinical records, as well as through staff interviews. The facility's policy, dated January 26, 2024, mandates that residents and/or their representatives be informed in writing of the bed-hold policy upon admissions, transfers, and therapeutic leaves. However, for Resident R65, who was admitted with diagnoses including renal dialysis dependence, diabetes, and obstructive and reflux uropathy, there was no evidence in the clinical record that the bed-hold policy was provided during transfers to the hospital on October 3, 2023, and February 2, 2024. The Director of Nursing confirmed during an interview that there was no evidence that Resident R65 and/or their representative received a copy of the bed-hold policy, which should have included the cost per day. This oversight was acknowledged as a failure to comply with the facility's policy and the regulatory requirements outlined in 28 Pa. Code 201.18(e)(1) and 28 Pa. Code 201.29(c.3)(2), which pertain to management and resident rights, respectively.
Failure to Adhere to Splint Wearing Schedules for Residents
Penalty
Summary
The facility failed to provide appropriate care for residents with limited range of motion by not adhering to physician-ordered treatment and services. Specifically, two residents, identified as R79 and R43, did not receive the prescribed use of splints to prevent further decrease in their range of motion. The facility's policy required that a specific program be written onto the CNA flow sheet and a copy of the splint/orthotic wearing schedule be placed in the resident's closet, which was not followed in these cases. Resident R79, who had diagnoses including dementia, diabetes, and chronic obstructive pulmonary disease, had a physician's order for a palm splint on the left hand with a non-standard wear schedule. However, the clinical record lacked a wear schedule, and the splint was observed not being worn during multiple observations. Interviews with staff revealed confusion about the wearing schedule, and the Director of Nursing confirmed that the schedule was not posted as required and that refusals to wear the splint were not documented. Resident R43, with diagnoses including chronic respiratory failure, intracranial injury, and peripheral vascular disease, had a physician's order for a left resting hand splint to be worn per a standard wear schedule. Despite the schedule being posted in the resident's closet, observations showed that the splint was not worn during the specified times. An LPN confirmed that the splint was not applied as ordered during their shifts, indicating a failure to follow the prescribed care plan for the resident.
Inadequate Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate urinary catheter care for a resident with an indwelling catheter due to urinary retention. The facility's policy required that catheter tubing and drainage bags be kept off the floor and covered at all times. However, observations revealed that the resident's urinary drainage bag was on the floor, with the catheter cover only partially covering the bag. Later, the drainage bag was found lying flat on the floor, with the tubing also on the floor and the catheter cover completely off the bag and wrapped around the tubing. A Licensed Practical Nurse confirmed that the catheter tubing and bag should not be on the floor and that the catheter cover should fully cover the urinary drainage bag.
Failure to Provide Clinical Rationale and Non-Pharmacological Interventions for PRN Psychotropic Medications
Penalty
Summary
The facility failed to provide a clinical rationale for the continued use of PRN psychotropic medications beyond 14 days and did not attempt non-pharmacological interventions prior to administering these medications for two residents. Resident R87, diagnosed with anxiety, hypertension, and respiratory failure, was prescribed Alprazolam for anxiety without a required stop date or clinical rationale for its continued use beyond 14 days. The medication was administered multiple times in July 2024 without evidence of non-pharmacological interventions being attempted first. Similarly, Resident R17, with diagnoses including dementia, arthritis, and transient ischemic attack, was prescribed Lorazepam for agitation. The medication was used numerous times from April to July 2024 without a stop date or clinical rationale for extended use. Additionally, there was a lack of evidence that non-pharmacological interventions were attempted before administering Lorazepam on most occasions. The Director of Nursing confirmed these deficiencies during interviews.
Improper Cleaning of Blood Glucometer
Penalty
Summary
The facility failed to properly clean and prevent potential cross-contamination during the use of a blood glucometer for two residents during medication administration. The facility's policy, dated 1/26/24, required cleaning and disinfecting reusable equipment between uses according to the manufacturer's instructions and current infection control standards. However, the Licensed Practical Nurse (LPN) used a 70% isopropyl alcohol prep pad to clean the blood glucose meter, which was not an approved cleaning agent according to the manufacturer's guidelines. The guidelines specified that only certain EPA-registered wipes, such as Clorox Germicidal Wipes and CaviWipes, were approved for cleaning and disinfecting the device. During the observation, the LPN used the blood glucose meter on two residents, wiping it with the alcohol prep pad before and after each use, and then placed it back in the medication cart. When questioned by the surveyor, the LPN admitted to assuming that the alcohol prep pad was an approved cleaner, as it was what they always used. The Director of Nursing later confirmed that the use of the 70% isopropyl alcohol prep pad was not in compliance with the manufacturer's approved cleaning agents for the blood glucose meter.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to seven out of nine residents reviewed for baseline care plans. This deficiency was identified during a review of clinical records and staff interviews. The residents affected included individuals with various medical conditions such as chronic obstructive pulmonary disease, diabetes, Hodgkin lymphoma, dementia, atrial fibrillation, dysphagia, end-stage renal disease, heart failure, chronic kidney disease, anxiety, hearing loss, hypertension, and obstructive and reflux uropathy. Despite these complex medical needs, there was no evidence in the clinical records that the required documentation was provided to the residents or their representatives. The Director of Nursing confirmed during an interview that the clinical records for these residents lacked the necessary written summaries. This oversight was noted for residents who had been admitted with significant health issues, requiring immediate and comprehensive care planning. The absence of these documents indicates a failure in the facility's process to ensure that residents and their representatives are informed of the initial care plans and orders, which are crucial for addressing their immediate health needs upon admission.
Failure to Follow G-Tube Care Protocols
Penalty
Summary
The facility failed to provide care in accordance with professional standards for the care of a gastrostomy tube (G-tube) for one resident. The facility's policies on administering medications via enteral feeding tube and irrigation of feeding tubes were not followed. Specifically, a nurse's progress note indicated that the resident was sent to the emergency room due to a foreign object stuck in the G-tube. The emergency department provider note revealed that upon the resident's arrival, the G-tube was removed and replaced, and a broken-off Q-tip was found lodged in the tube. This incident was confirmed by the Director of Nursing, who stated that a foreign object should never be placed in a G-tube or used to unclog it. The resident involved had a medical history that included dysphagia, diabetes, and gastroesophageal reflux. The resident was admitted to the facility and later transferred to the emergency room due to the clogged G-tube. The emergency room documentation confirmed the presence of a foreign object in the G-tube, which necessitated its removal and replacement. The Director of Nursing confirmed that the facility's policies were not followed, leading to the deficiency in care.
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.
Trusted data from CMS and state health departments
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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