Premier At Perry Village For Nursing And Rehab, Ll
Inspection history, citations, penalties and survey trends for this long-term care facility in New Bloomfield, Pennsylvania.
- Location
- 213 East Main Street, New Bloomfield, Pennsylvania 17068
- CMS Provider Number
- 395426
- Inspections on file
- 20
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Premier At Perry Village For Nursing And Rehab, Ll during CMS and state inspections, most recent first.
A resident with CHF and GERD was discharged home without confirmation of home health services, despite multiple unsuccessful referrals. The discharge summary lacked documentation of the resident's Foley catheter, oxygen needs, and education on catheter care, and did not include a post-discharge plan of care or instructions for follow-up.
The facility failed to maintain hazardous area doors within allowed gap margins and in good repair. Observations revealed that doors in the laundry and storage rooms had gaps greater than one-eighth of an inch and were damaged, with some repaired using unauthorized substances. These issues were confirmed by the Director of Maintenance.
The facility failed to ensure corridor doors positively latch and remain unobstructed. The Main Dining Room doors did not latch properly, and a decoration on the door knob of a resident's room impeded the door from closing. These issues were confirmed by the Director of Maintenance.
The facility failed to maintain battery back-up lighting for the generator transfer switch in one of four smoke zones. During an observation, the battery back-up light did not illuminate when tested, and this was confirmed by the Director of Maintenance. This deficiency indicates a failure to meet NFPA standards for essential electrical systems.
A resident with a history of metabolic encephalopathy and other conditions was found with a bag of Tylenol pills, which he ingested, claiming they were candy. The facility failed to notify the resident's physician until eight hours later, despite the potential risk of Tylenol toxicity. The delay in notification was due to the night shift nurses not contacting the physician immediately, although the resident showed no signs of toxicity. When informed, the physician ordered the resident to be sent to the ED for evaluation.
The facility failed to ensure accurate MDS documentation for two residents. One resident, with hypertension and anxiety, was administered oxygen therapy, but the MDS did not reflect this. Another resident, with major depressive disorder and dementia, had a bed alarm order, but the MDS inaccurately marked it as 'No'. These discrepancies were confirmed through clinical record reviews and interviews with the NHA.
The facility failed to develop comprehensive care plans for three residents, omitting critical focus areas such as smoking supervision and dementia care. A resident with major depressive disorder and hypertension did not have a smoking care plan, while another with dementia lacked a dementia care plan. Additionally, a resident with urinary retention and cancer did not have their smoking status reflected in their care plan. These deficiencies were confirmed by the NHA.
The facility failed to update care plans for three residents, resulting in discrepancies with current physician orders. One resident's care plan included Ativan for seizures, which was discontinued months earlier. Another resident's care plan did not reflect updated dietary orders, and a third resident's care plan inaccurately indicated a therapeutic diet. The Nursing Home Administrator confirmed these discrepancies.
A facility failed to provide appropriate respiratory care for a resident with obstructive sleep apnea and asthma by not obtaining a physician order for a BiPAP machine. Despite the resident's documented use of CPAP and BiPAP, there was no physician order in the clinical record since admission. The Nursing Home Administrator confirmed the oversight, highlighting a lapse in adhering to professional standards.
A resident with specific dietary equipment needs was not provided with a Kennedy cup during meals, despite physician orders and care plan requirements. Observations over three consecutive days confirmed the absence of the Kennedy cup, although a lipped plate was provided. The Nursing Home Administrator acknowledged the oversight.
A cook in the facility was observed handling food items such as hamburger buns, lettuce, and tomato with the same gloved hands that had touched non-food items like tray tickets and packaging. This unsanitary practice was confirmed by the NHA, who stated that dietary staff should avoid direct contact with food after touching non-food items.
The facility failed to provide evidence of a QA Committee meeting during the first quarter of 2024. The NHA stated that the meeting was held by the prior administration, but no documentation, such as a sign-in sheet, was provided to confirm this. Despite follow-up, the NHA could not produce evidence of the meeting.
A resident with Alzheimer's disease and muscle weakness suffered a scalp laceration and leg injury after falling from a litter chair during transport in a facility van. The transportation driver failed to ensure the resident was properly secured, as the safety belt was not fastened. The driver had not received competency training for the litter chair, and there was no written procedure for its use. The incident resulted in actual harm to the resident.
Failure to Ensure Safe and Documented Discharge Preparation
Penalty
Summary
The facility failed to ensure that a resident was adequately prepared for a safe and orderly discharge, and did not provide a complete discharge summary with a post-discharge plan of care. The resident, who had diagnoses including congestive heart failure and gastroesophageal reflux disease, was discharged home with physician orders for home health services, including physical therapy, occupational therapy, and skilled nursing. Multiple referrals to home health agencies were made, but all were unable to accept the resident prior to discharge. Despite this, the resident was discharged home without confirmation that home health services were in place, and there was no evidence that the physician was notified of the lack of services or that additional referrals were made at the time of discharge. The resident had an indwelling Foley catheter and was receiving oxygen at the facility, but the discharge summary did not mention the catheter, oxygen needs, or provide documentation of education on catheter management. There was also no instruction for follow-up with outside providers for catheter management or mention of the home health referrals in the discharge summary. The facility's policy required that residents and/or responsible parties receive teaching and discharge instructions, but there was no evidence that these requirements were met for this resident.
Deficiencies in Hazardous Area Door Maintenance
Penalty
Summary
The facility was found to have deficiencies in maintaining hazardous area doors within the allowed gap margins and in good repair. During an observation on December 16, 2024, it was noted that doors in three of four smoke zones had gaps greater than one-eighth of an inch. Specifically, the laundry's soiled-side and clean-side doors, as well as storage room doors across from the Nurses' Station and by Resident Room 418, all exhibited gaps exceeding the permissible size. This was confirmed through an interview with the Director of Maintenance. Additionally, the hazardous area doors were found to be damaged and repaired using unauthorized or unidentified substances. The laundry's soiled-side door was damaged on the surface and edge and filled with an unauthorized filler, while the clean-side door was also damaged on the surface and edge. These findings were again confirmed by the Director of Maintenance during the interview.
Plan Of Correction
1. The facility will request a TLW to correct K321, so that the facility can have adequate time to order and replace laundry soiled side door, laundry clean side door. The facility will also request TLW to have adequate time to repair gaps in the laundry soiled side door, laundry clean side door, Central Supply door, and Storage Room door by room 418. TKW request until 6/19/2025. 2. The Maintenance Supervisor will receive re-education by the Administrator on the allowed gap margins for interior doors. 3. The facility will complete an initial audit of all facility doors then audit 5 facility doors per week for 4 weeks to ensure that the door gap margins do not exceed the allowed gap margins, then quarterly for one year. 4. Audits will be reviewed at the next QAPI meeting.
Corridor Door Latching and Obstruction Deficiencies
Penalty
Summary
The facility failed to maintain corridor doors to positively latch and remain unobstructed from closing in two of four smoke compartments. During an observation on December 16, 2024, at 1:20 PM, it was noted that the Main Dining Room double doors, located directly in from the Main Entrance, did not positively latch when closed. This deficiency was confirmed through an interview with the Director of Maintenance at the same time. Additionally, at 1:40 PM on the same day, the corridor door to Resident Room 403 was found to be impeded from closing due to a decoration hanging on the door knob. This obstruction was also confirmed by the Director of Maintenance during an interview conducted at the time of the observation.
Plan Of Correction
1. The main dining room double door was repaired. The decoration was removed from the doorknob of room 403. 2. The Maintenance Supervisor will receive re-education by the administrator on indoor door closure and impeding door closures. 3. The facility will complete an initial audit of all facility doors then 5 random facility doors monthly for 1 year to ensure adequate door closure and no impeded door closures. 4. Audits will be reviewed at the next QAPI meeting. 5. The facility will be in substantial compliance by 2/14/2025.
Failure to Maintain Battery Back-Up Lighting for Generator Transfer Switch
Penalty
Summary
The facility failed to maintain battery back-up lighting for the generator transfer switch in one of four smoke zones. During an observation on December 16, 2024, at 12:50 PM, it was noted that the battery back-up light did not illuminate when tested. This deficiency was confirmed through an interview with the Director of Maintenance at the same time, who acknowledged the failure of the battery back-up light. The report indicates that the facility did not meet the requirements for maintaining essential electrical systems as outlined by NFPA standards. The deficiency was specifically related to the battery back-up lighting, which is crucial for ensuring the functionality of the generator transfer switch during power outages. The lack of proper maintenance and testing of this component led to the failure observed during the survey.
Plan Of Correction
1. Battery backup lighting was repaired. 2. The Maintenance Supervisor will receive re-education from the Administrator on maintaining the battery back up lighting for the generator transfer switch. 3. The facility will conduct an audit monthly of the battery back up lighting. 4. Audits will be reviewed in the next QAPI meeting. 5. The facility will be in substantial compliance by 2/14/2025.
Delayed Physician Notification of Potential Medication Ingestion
Penalty
Summary
The facility failed to promptly notify a resident's physician of an incident involving the potential ingestion of medication, which could have resulted in a negative outcome. The facility's policy requires immediate notification of the resident, their attending physician, and a representative in the event of changes in the resident's condition or status. However, in the case of a resident with a history of metabolic encephalopathy, anxiety disorder, depression, and low back pain, the physician was not notified until approximately eight hours after the incident occurred. The incident involved the resident being found with a bag of pills, which he claimed were candy, and taking an unknown amount of them. The pills were later identified as 500 mg Tylenol. Despite the potential risk of Tylenol toxicity, the resident's physician was not informed until the following morning, after the night shift had monitored the resident for symptoms of toxicity. The delay in notification was due to the night shift nurses not contacting the physician immediately after the incident. The deficiency was further highlighted by the fact that when the physician was finally informed, he ordered the resident to be sent to the emergency department for evaluation. The facility's Nursing Home Administrator and Director of Nursing acknowledged the delay but justified it by stating that the resident showed no signs of toxicity and that the facility's policy allowed for a 24-hour notification window. However, the staff involved in the morning shift felt that the physician should have been notified immediately after the incident occurred.
Plan Of Correction
1. The physician was notified of the incident for resident 44. 2. An initial audit of residents who have had incidents with potential for negative outcomes was completed to ensure the physician was notified. 3. Nursing staff were educated on the need to notify physicians timely of incidents with potential for negative outcomes. 4. Five audits of incidents for MD notification will be audited weekly for 4 weeks, then monthly for 2 months to ensure compliance by DON or designee. Results of these audits will be presented to the QAA committee for review. 5. The facility will be in substantial compliance by 1/7/25.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, leading to discrepancies in their Minimum Data Set (MDS) documentation. For one resident, who had diagnoses of hypertension and anxiety, there was a physician's order for oxygen therapy to maintain saturation above 91% as needed for shortness of breath. Despite being administered oxygen on multiple occasions, the MDS did not reflect the use of oxygen therapy, marking it as 'No'. This discrepancy was identified during a review of the clinical records and confirmed through an interview with the Nursing Home Administrator. Another resident, diagnosed with major depressive disorder and dementia, had a physician's order for a bed alarm. However, the MDS inaccurately marked the use of a bed alarm as 'No'. This error was also identified during a clinical record review and confirmed in an interview with the Nursing Home Administrator. Both instances highlight the facility's failure to ensure that the MDS accurately reflected the residents' current status and care needs, as required by regulations.
Plan Of Correction
1. Residents 8 and 60 had modifications of their MDS completed. 2. An initial audit of MDS completed in the past 30 days was completed to ensure accuracy of Section 00110 C1 and P0200 A. 3. Education was completed with MDS staff on ensuring accuracy of these sections of the MDS. 4. 5 audits of Section 00110 C1 and 5 audits of Section P0200 A will be completed weekly x 4, then monthly x 2 by DON or designee. Results of these audits will be shared with the QAA committee for review. 5. The facility will be in substantial compliance by 1/7/25.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents, addressing their medical, physical, mental, and psychosocial needs. Resident 10, diagnosed with major depressive disorder and hypertension, was identified as a smoker who required supervision. However, her care plan did not include a smoking care plan until it was added on December 4, 2024, after the deficiency was noted. Similarly, Resident 60, who was admitted with major depressive disorder and dementia, did not have a dementia care plan in place upon admission, which was only added on December 4, 2024. Resident 75, diagnosed with urinary retention and cancer, was also identified as a smoker. Despite having multiple smoking evaluations indicating their smoking status, their care plan did not reflect their desire to smoke until it was updated on December 4, 2024. These omissions in the care plans were confirmed by the Nursing Home Administrator, who acknowledged that the care plans should have included these focus areas prior to the survey findings.
Plan Of Correction
1. Residents 10, 60, and 75 had their care plans corrected to reflect smoking and dementia diagnosis. 2. An initial audit of residents who smoke and residents with dementia diagnosis was completed to ensure that their care plans reflect these items. 3. Education was completed with nursing staff, therapy staff, and IDT on ensuring that care plans are developed for residents who smoke and residents that have dementia diagnosis. 4. 5 audits of residents who smoke and 5 residents with dementia diagnosis will be conducted weekly x 4, then monthly x 2 by DON or designee. Results of these audits will be presented to the QAA committee for review. 5. The facility will be in substantial compliance by 1/7/25.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for three residents, leading to discrepancies between the care plans and the current physician orders. For Resident 1, the care plan included an intervention of intramuscular Ativan for seizure activity, initiated in July 2024. However, the physician orders did not include Ativan, as it had been discontinued in May 2024. This discrepancy was confirmed during an interview with the Nursing Home Administrator (NHA), who acknowledged that the care plan should have been updated at the time of discontinuation. Resident 11's care plan was not updated to reflect the current physician orders for a consistent, controlled carbohydrate, liberal renal diet with dysphagia advanced texture and thin consistency. The care plan had not been revised since June 2023, despite changes in dietary orders. Similarly, Resident 60's care plan inaccurately indicated a therapeutic altered diet related to diabetes, while the current physician orders specified a regular diet with regular texture and thin consistency. The NHA confirmed that Resident 60's care plan was incorrect and should have been updated to reflect the current diet.
Plan Of Correction
1. Residents 1, 11, and 60 had their care plans revised. 2. An initial audit of residents who had antianxiety medications discontinued in the past 30 days was completed to ensure accuracy, as well as an initial audit of residents who have had diet changes in the past 30 days has been conducted to ensure accuracy. 3. Education was completed with nursing staff and the IDT on ensuring that care plans are updated timely with any revision. 4. Five audits of residents with discontinued antianxiety medications and five audits of residents with diet changes will be conducted weekly for 4 weeks, then monthly for 2 months by the DON or designee. Results of these audits will be presented to the QAA committee. 5. The facility will be in substantial compliance by 1/7/25.
Failure to Obtain Physician Order for Respiratory Device
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident diagnosed with obstructive sleep apnea and asthma. Observations revealed the presence of a CPAP or BiPAP machine at the resident's bedside, but there was no physician order for either device in the resident's clinical record since their admission. Despite documentation in nursing progress notes indicating the resident's use of CPAP and BiPAP on multiple occasions, the necessary physician order was absent. The resident's care plan included the use of CPAP at bedtime per order, but the facility's records did not reflect an actual physician order for the device. An email from the Nursing Home Administrator confirmed that the resident used a BiPAP, not a CPAP, and acknowledged the lack of a physician order prior to the surveyor's inquiry. This oversight indicates a failure to adhere to the facility's policy and professional standards of practice regarding respiratory care.
Plan Of Correction
1. Resident 44 had orders revised to reflect BiPAP use. 2. An initial audit of residents who use BiPAPs was conducted to ensure accuracy with physician orders. 3. Education was completed with licensed nursing staff on ensuring that orders for BiPAPs are completed. 4. 2 new admissions will be audited for BiPAP orders weekly x 4, then monthly x 2 by DON or designee. Results of this audit will be presented to the QAA committee for review. 5. The facility will be in substantial compliance by 1/7/25.
Failure to Provide Adaptive Feeding Devices
Penalty
Summary
The facility failed to provide adaptive feeding devices for a resident, identified as Resident 53, who required them. According to the facility's policy on 'Assistance with Meals,' adaptive devices such as silverware with enlarged handles, plate guards, and specialized cups should be provided to residents in need. Resident 53's clinical record indicated a need for a lip plate and a Kennedy cup with meals, as per active physician orders dated September 10, 2024. The resident's care plan, revised on November 3, 2023, also specified the use of these devices. Observations conducted on December 2, 3, and 4, 2024, revealed that while Resident 53 was provided with a lipped plate during lunch, the Kennedy cup was consistently missing. This oversight was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the resident should have been served with a Kennedy cup. The deficiency was noted under the regulatory code 28 Pa code 211.6(a) - Dietary Services.
Plan Of Correction
1. Resident 53 had no adverse effect from not receiving kennedy cup with noon meal. 2. An initial audit of resident who use kennedy cups was completed to ensure that it was received as ordered. 3. Education was completed with dietary and nursing staff on ensuring that kennedy cups are provided as ordered. 4. 5 audits of residents who require kennedy cups will be conducted weekly x 4, then monthly x 2 by NHA or designee. Results of this audit will be presented to the QAA committee for review. 5. The facility will be in substantial compliance by 1/7/25.
Sanitation Breach in Food Service
Penalty
Summary
The facility failed to maintain sanitary conditions during food service, as observed during a tray line inspection in the kitchen. Employee 1, a cook, was seen wearing gloves on both hands while handling various items. The employee picked up a resident tray ticket from a cart and placed it on a resident tray, then opened a package of hamburger buns by tearing a hole in the bag. Using the same gloved hands, the employee removed a hamburger bun from the package and subsequently reached into a bin to remove lettuce and tomato, placing them on a resident plate. This process was repeated for three additional resident trays, with the employee continuing to touch tray tickets, hamburger buns, lettuce, and tomato without changing gloves. During an interview, the Nursing Home Administrator confirmed that dietary staff should not have direct contact with resident food items after touching non-food items such as tray tickets and food packaging.
Plan Of Correction
1. Employee 1 was provided education on not touching nonfood items with the same gloves as touching food items. 2. Observational audits of meal service (tray line) for 3 meals per day x 3 days to ensure appropriate sanitary service. 3. Education was provided to the dietary staff on proper procedure on performing tray line. 4. 2 weekly observations of tray line will be conducted weekly x 4, then monthly x 2 by NHA or designee. Results of this audit will be presented to the QAA committee for review. 5. The facility will be in substantial compliance by 1/7/25.
Lack of Documentation for QA Meeting in First Quarter
Penalty
Summary
The facility failed to provide evidence that a Quality Assurance (QA) Committee meeting was held during the first quarter of 2024. This deficiency was identified through a review of facility documentation and staff interviews. The Nursing Home Administrator (NHA) stated that the meeting was conducted by the prior administration, but she did not receive the sign-in sheet or any documentation confirming the meeting took place. Despite follow-up inquiries, the NHA was unable to provide any evidence of the meeting, confirming the lack of documentation for the first quarter of 2024.
Plan Of Correction
1. The facility was unable to find quarter 1 signature sheet for QAA meeting. 2. The facility has conducted monthly QAA meetings since April of 2024. Signature sheets were available for review. An audit of these signature sheets was completed to ensure that meetings were conducted monthly. 3. Education was provided to the QAA committee on the importance of conducting QAA meetings as scheduled. 4. QAA meeting will be audited monthly x 2 by NHA or designee. The results of these audits will be presented to the QAA committee for review. 5. The facility will be in substantial compliance by 1/7/25.
Resident Injury Due to Inadequate Supervision During Transport
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent accidents, resulting in harm to a resident. The incident involved a resident with Alzheimer's disease, unspecified lack of coordination, and generalized muscle weakness, who sustained a scalp laceration and a leg injury during transport. The resident fell from a litter chair while being transported in the facility van, leading to a 12 cm laceration on the head and a fracture of the distal femur, among other injuries. The deficiency was attributed to the transportation driver's failure to ensure the resident was properly secured in the litter chair. The driver, Employee 1, did not verify that the safety belt was fastened around the resident, assuming it was secured because it was not visible under the blankets. The incident occurred when the driver made a turn in the parking lot, causing the resident to roll off the litter chair. The facility's investigation revealed that Employee 1 had not received competency training for the use of the litter chair prior to the incident. Further investigation showed that there was no written procedure for staff to follow regarding the use of the litter chair, and other drivers also lacked competency training. The Nursing Home Administrator confirmed that the resident was not properly secured, and the transport driver failed to ensure the resident's safety, resulting in actual harm. The facility identified these issues during the survey and acknowledged the lack of proper training and procedures as contributing factors to the incident.
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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