Premier Washington Rehabilitation And Nursing Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Washington, Pennsylvania.
- Location
- 36 Old Hickory Ridge Rd, Washington, Pennsylvania 15301
- CMS Provider Number
- 395577
- Inspections on file
- 38
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Premier Washington Rehabilitation And Nursing Ctr during CMS and state inspections, most recent first.
Surveyors identified that the facility did not maintain its automatic sprinkler system in accordance with NFPA standards when electrical MC wire conduit was found resting directly on sprinkler piping above ceiling tiles in the elevator lobby areas on two separate floors, affecting two of fifteen smoke compartments. The Facility Administrator and Director of Maintenance acknowledged these sprinkler system deficiencies during interview.
Surveyors found that oxygen cylinders were stored in crash cart rooms in two separate cores without the required precautionary signage on the doors indicating oxidizing gas storage and no smoking. Observations in two smoke compartments showed oxygen cylinders present in the 3 East and 2 East core crash cart rooms, yet the doors lacked the mandated "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING" signage. The facility administrator and maintenance leadership confirmed that the proper oxygen storage signs were not posted on these doors.
Surveyors identified that a room equipped with an FM-200 non-water-based fire protection system lacked the required warning sign indicating the presence of this extinguishing system. This deficiency affected one of the facility’s smoke compartments and was confirmed during an interview with the facility’s administrator and maintenance leadership.
Multiple grievances and resident council concerns were documented regarding unclean resident bathrooms. Despite staff claims of daily cleaning, observations found several bathrooms visibly soiled, with stained toilets and dust-blocked vents. Interviews with two residents confirmed inconsistent cleaning, and inspections revealed unsanitary conditions, including feces and urine left in toilets. The DON acknowledged the failure to maintain a homelike environment in several units.
A facility failed to maintain proper hazardous area enclosures when a storage room door in the Inventory Control room was found secured open with a rope, preventing it from closing and latching. This deficiency was confirmed by the Assistant Facility Administrator and Maintenance Director, affecting one of fifteen smoke compartments.
The facility failed to maintain the automatic sprinkler system, leading to deficiencies in two smoke compartments. Observations revealed a gap around sprinkler heads in a storage room and a hangar wire attached to a sprinkler branch line above smoke doors. These issues were confirmed by the Assistant Facility Administrator and Maintenance Director.
The facility failed to ensure that a fire extinguisher in the staff break room had the required annual inspection, as observed during a survey. This deficiency was confirmed by the Facility Administrator and Maintenance Director, who acknowledged the lapse in compliance with NFPA 10 standards.
The facility failed to maintain electrical wiring as required by NFPA 70, with an open electrical junction box found in the ceiling of the transfer switch room. This deficiency was confirmed through an interview with the Facility Administrator and Maintenance Director.
The facility failed to maintain proper use of electrical power cords and extension cords, affecting two smoke compartments. A microwave was plugged into an extension cord in the Supervisor's office, and a coffee pot and microwave were plugged into a power strip in the Pharmacy break room. These issues were confirmed by the Assistant Facility Administrator and Maintenance Supervisor.
The facility's main kitchen had sanitation issues, including ice build-up on a freezer fan affecting food items and improperly covered ground beef showing oxidation. These conditions were confirmed by the Dietary Manager.
The facility failed to store insulin pens in a safe and sanitary manner, with observations revealing unbagged insulin pens in three medication carts, posing a risk of cross-contamination. LPNs confirmed the pens were not bagged and were unaware of the reason for bagging them. The Director of Nursing acknowledged the facility's failure to prevent cross-contamination.
The facility failed to properly dispose of expired medications and biologicals in one of its medication rooms. Expired heparin lock flush syringes and a partially used bottle of vitamin E supplement were found, contrary to the facility's policy requiring the return or destruction of such items. The Unit Nurse Manager and DON confirmed these findings.
The facility did not post the required contact information for Adult Protective Services (APS) on the nursing units, making it inaccessible to residents, families, and visitors. This was confirmed by the DON during an interview.
The facility did not provide the required 3.2 hours of direct resident care per resident in a 24-hour period on multiple occasions. A review of nursing schedules and census data showed that the hours per patient day (PPD) were below the required threshold on 15 out of 21 days. The Nursing Home Administrator confirmed this deficiency.
The facility failed to serve meals at scheduled times on one nursing unit, with lunch trays consistently arriving late. Staff and resident interviews confirmed the issue, and an observation showed significant delays in meal delivery. The Regional Food Service Director acknowledged the problem and mentioned efforts to address it.
The facility failed to provide sufficient dietary staff, resulting in delayed and incorrect meal deliveries. Residents reported receiving cold food and missing items, with some meals arriving hours late. The Food Service Director acknowledged staffing shortages and unreliable equipment, contributing to ongoing issues documented in meeting minutes and grievance logs.
The facility failed to serve meals at scheduled times over three days, with significant delays reported by staff and residents. Meals were often late, cold, and missing requested items. The Food Service Director cited staffing shortages and equipment issues as contributing factors. This deficiency violated dietary service regulations.
The facility failed to respect residents' rights in handling personal property, affecting eleven residents. Observations revealed piles of soiled and clean personal items in the laundry area, and staff interviews confirmed that an afternoon shift staff member refused to deliver personal items. The DON acknowledged the facility's failure in this regard.
The facility failed to follow the posted menu and provide residents with their preferred dietary choices during a lunch meal. Observations and interviews revealed discrepancies between the posted and actual menu, leading to residents not receiving meals as per their preferences. Staff and residents reported ongoing issues with late food delivery and missing items on trays, which were confirmed by the Food Service Director.
The facility failed to maintain a clean and homelike environment in five of six nursing units, affecting 33 residents. Observations showed dirty hallways, lounges, and dining areas, with debris and sticky substances. Resident rooms and shared bathrooms had soiled floors, broken sinks, and unsanitary conditions. The Housekeeping/Laundry Supervisor confirmed these issues.
The facility failed to store medications and biologicals properly and securely in three of six medication carts. Medication carts were observed unlocked and unattended, with resident medical information accessible and personal items improperly stored. These actions violated the facility's policies on medication storage and administration.
The facility failed to provide an environment that promoted dignity during medication administration for five residents. Medications were administered in a public area with other residents nearby, compromising the residents' dignity. The Director of Nursing confirmed this failure.
The facility failed to meet professional standards of quality when staff improperly administered insulin to a resident using a syringe instead of the Kwik Pen as per manufacturer's instructions. Both an LPN and an RN admitted to this practice, which was confirmed by the DON.
The facility failed to notify physicians and assess two residents for hyperglycemia and hypoglycemia despite multiple instances of abnormal blood glucose levels. The care plans were not followed, and the physician was not notified of the changes in condition.
Improper Support of Sprinkler Piping by Electrical Conduit in Two Smoke Compartments
Penalty
Summary
Surveyors found that the facility failed to properly maintain its automatic sprinkler system in accordance with NFPA 25 and NFPA 101 requirements. During observations on April 27, 2026, an electrical MC wire conduit was seen resting directly on sprinkler piping above the ceiling tiles in the elevator 4 lobby on the 3 East unit at 9:15 a.m. A similar condition was observed at 9:35 a.m. above the ceiling tiles in the elevator 4 lobby on the 2 East unit, where another electrical MC wire conduit was resting on sprinkler lines. These deficiencies affected two of fifteen smoke compartments. In an interview on April 28, 2026, at 1 p.m., the Facility Administrator and Director of Maintenance confirmed the identified automatic sprinkler system deficiencies. No residents or specific patient conditions were mentioned in the report, and the deficiency pertains solely to the physical environment and maintenance of the sprinkler system components in the identified areas.
Plan Of Correction
1. On April 27, 2026, the electrical MC wire conduit resting on the sprinkler piping above the ceiling tiles in the Elevator 4 Lobby on 3 East was removed and Elevator 4 Lobby on 2 East was removed and properly supported to eliminate contact with the sprinkler system piping. The Director of Maintenance verified that no damage occurred to the sprinkler piping or system 2. The Director of Maintenance conducted a facility-wide inspection above accessible ceiling spaces to identify any additional instances of electrical conduit, wiring, or other materials resting on sprinkler piping. Any additional findings identified during the inspection were immediately corrected at the time of discovery. 3. The Director of Maintenance educated maintenance department on requirements prohibiting any item from being supported by or resting on sprinkler piping. 4. The Director of Maintenance or designee will conduct weekly inspections x4 weeks and then monthly after, of a minimum of five random above-ceiling locations throughout the facility to verify compliance. Findings will be documented and reviewed during the facility's (QAPI) meetings monthly for three months
Failure to Post Required Oxygen Storage Signage in Crash Cart Rooms
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. The code requires that storage rooms or areas containing oxidizing gases, such as oxygen cylinders, have precautionary signage on each door or gate that is readable from 5 feet and includes, at a minimum, the wording "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." During the survey, the facility was evaluated for compliance with these standards, which apply to various quantities of stored gas and require proper construction, separation from combustibles, and appropriate labeling of storage locations. On the survey date, observations showed that oxygen cylinders were stored in two separate crash cart rooms, one in the 3 East core and one in the 2 East core, without any signage indicating oxygen storage on the doors. These observations occurred at 10:13 a.m. in the 3 East core crash cart room and at 11:03 a.m. in the 2 East core crash cart room. The Facility Administrator and Director of Maintenance confirmed during an interview that the doors to these rooms did not have the required oxygen storage signage. The deficiency affected two of fifteen smoke compartments in the facility.
Plan Of Correction
1. On April 27, 2026, propersignage for oxygen was placed onthe 3 east crash cart room and the 2east crash cart room. 2. On April 27th, 2026 the Directorof Maintenance conducted afacility-wide inspection of all oxygencylinder storage locations and crashcart rooms to verify that requiredoxygen signage was present and nooxygen cylinders were improperlystored. 3. The maintenance staff wereeducated to ensure that propersignage for oxygen storage is postedfor all rooms where oxygen is stored. 4. The Director of Maintenance ordesignee will conduct weekly auditsx4 weeks and monthly after for 3months of oxygen storage areas toverify proper signage. Auditfindings will be documented andreviewed during the facility'smonthly QAPI meetings
Missing Warning Sign for FM-200 Fire Suppression System
Penalty
Summary
Surveyors found that the facility failed to maintain a non-water-based fire protection system in accordance with NFPA 99 (2012) 15.12.2. During an observation conducted at 11:40 a.m. on April 28, 2026, it was noted that a room equipped with an FM-200 extinguishing system did not have a required warning sign indicating the presence of this system. This omission was identified in one of 15 smoke compartments. In an interview held at 1:00 p.m. the same day, the Facility Administrator and Director of Maintenance confirmed the absence of the warning signage, thereby confirming the deficiency. No residents or specific patient conditions were mentioned in the report, and no additional contextual details beyond the missing warning sign for the FM-200 system and the staff confirmation of this issue were provided.
Plan Of Correction
1. On April 28, 2026, the required warning signage indicating the room was equipped with an FM-200 extinguishing system was installed at the entrance to the affected room. The Director of Maintenance verified the signage was properly posted and visible in accordance with applicable Life Safety Code and NFPA requirements. 2. On April 28, 2026, the Director of Maintenance conducted a facility-wide inspection of all rooms containing clean agent fire suppression systems, including FM-200 systems, to verify required warning signage was present. Any additional deficient areas identified during the inspection were corrected immediately. 3. Maintenance staff were re-educated regarding NFPA requirements for identification and warning signage associated with clean agent extinguishing systems. 4. The Director of Maintenance or designee will conduct monthly inspections for 3 months of all extinguishing system rooms to verify required signage remains in place and legible. Inspection findings will be documented and reviewed during the facility's (QAPI) meetings.
Failure to Maintain Clean and Homelike Resident Bathrooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents, specifically in the 3 South nursing unit bathrooms. Facility policy guarantees residents the right to a dignified existence and a safe, homelike environment. However, review of grievance logs over several months revealed multiple complaints regarding dirty resident rooms and bathrooms. Resident council minutes also documented concerns about housekeeping services. Despite staff interviews indicating that resident rooms and bathrooms are cleaned daily, observations on the 3 South unit found several bathrooms visibly soiled with debris and stains on the floors, toilets with stains of unknown origin, and ventilation units blocked with dust. Interviews with residents confirmed that bathrooms were not always cleaned, with one resident stating their shared bathroom was never cleaned and was not used by any of the occupants. Inspection of this bathroom revealed feces and urine in the toilet. Another resident also reported inconsistent cleaning, and their bathroom was found unclean upon inspection. The DON confirmed the poor conditions in multiple bathrooms and acknowledged that the facility failed to maintain a homelike environment on three of four observed nursing units.
Hazardous Area Enclosure Deficiency
Penalty
Summary
The facility failed to maintain proper hazardous area enclosures, as evidenced by an observation on April 14, 2025. During this observation, it was noted that the door to a storage room within the Inventory Control room was improperly secured open with a rope or string, preventing it from closing and latching as required. This deficiency was confirmed through an interview with the Assistant Facility Administrator and the Maintenance Director on April 15, 2025. The deficiency affected one of the fifteen smoke compartments in the facility.
Plan Of Correction
Inventory control room door was open with a rope/string, and was unable to close and latch. The rope/string was removed from the door and closed properly. Maintenance audited throughout the facility with no other door issues found. Education to be completed with all maintenance staff making sure all doors are closed properly throughout the facility. Audits will be completed by maintenance to ensure all doors are not propped open and closed properly, Weekly X4 weeks and monthly X 2. All audits will be reported to QAPI.
Automatic Sprinkler System Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system, resulting in deficiencies in two of the 15 smoke compartments. During an observation on April 14, 2025, two specific issues were identified: a gap larger than 1/8 inch was found around two sprinkler heads with escutcheons in a storage room inside the Inventory Control room, and a ceiling tile track hangar wire was attached to a sprinkler branch line above the smoke doors near the 2 South Supervisor's office. These deficiencies were confirmed through an interview with the Assistant Facility Administrator and Maintenance Director on April 15, 2025.
Plan Of Correction
Large gap around two sprinkler pipes with escutcheons in the inventory control storage room. Ceiling hanger wire attached to sprinkler branch line above smoke door near 2 south supervisors office. Maintenance adjusted hanger in ceiling to raise the sprinkler head and escutcheon closer to the ceiling tile and replaced the ceiling tile. Maintenance removed hanger from sprinkler. Maintenance conducted audit of facility with no other issues with sprinklers or escutcheons. The maintenance department will be educated on Sprinkler system compliance. Audits will be completed by maintenance to ensure sprinkler system is in compliance, Weekly X4 weeks and monthly X 2. All audits will be reported to QAPI.
Fire Extinguisher Annual Inspection Deficiency
Penalty
Summary
The facility failed to maintain compliance with NFPA 101 standards regarding portable fire extinguishers. During an observation on April 14, 2025, it was noted that the inspection tag on the fire extinguisher located in the 2 core staff break room did not have the required annual inspection. This deficiency was confirmed through an interview with the Facility Administrator and Maintenance Director on April 15, 2025, who acknowledged that the portable fire extinguisher had not undergone the necessary annual inspection as mandated by NFPA 10 standards.
Plan Of Correction
Inspection tag on the fire extinguisher in the 2 core breakroom did not have the annual inspection. Maintenance has ordered new fire extinguishers through Johnson Controls to be delivered. Maintenance conducted an audit of all fire extinguishers in the facility with no other issues found. Maintenance to be educated on compliance for all fire extinguishers. Audits will be completed by maintenance to ensure all fire extinguishers are within compliance, Weekly X4 weeks and monthly X 2. All audits will be reported to QAPI.
Electrical Wiring Deficiency in Transfer Switch Room
Penalty
Summary
The facility failed to maintain electrical wiring in accordance with NFPA 70, National Electric Code, as evidenced by an open electrical junction box found in the ceiling of the transfer switch room. This deficiency was observed during a survey on April 14, 2025, at 10:17 a.m. The issue was confirmed through an interview with the Facility Administrator and Maintenance Director on April 15, 2025, at 1:30 p.m. The deficiency was identified in one of the 15 smoke compartments within the facility.
Plan Of Correction
An open electrical junction box on the ceiling of the transfer switch room was identified. The cover for the box was immediately put back on. Maintenance completed an audit throughout the facility with no other junction box issues. The maintenance department will be educated to make sure all junction boxes are covered. Audits will be completed by maintenance to ensure all junction boxes are covered, Weekly X4 weeks and monthly X 2. All audits will be reported to QAPI.
Improper Use of Electrical Cords in Facility
Penalty
Summary
The facility failed to maintain proper use of electrical power cords and extension cords, affecting two of 15 smoke compartments. During an observation on April 15, 2025, it was noted that a microwave was plugged into an extension cord in the second floor Supervisor's office. Additionally, a coffee pot and microwave were plugged into a power strip in the Pharmacy break room. These deficiencies were confirmed during an interview with the Assistant Facility Administrator and Maintenance Supervisor on the same day.
Plan Of Correction
Appliances cited were removed from power strip to an appropriate outlet. Maintenance completed audit with no other issues with power strips were identified in the facility. Maintenance staff in serviced on what can and can't be plugged into a power strip. Audits will be completed by maintenance to ensure all power strips are used properly, Weekly X4 weeks and monthly X 2. All audits will be reported to QAPI.
Sanitation Issues in Main Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen, which could potentially lead to cross-contamination or foodborne illness. During an observation, condensation and ice build-up were noted on the fan in the freezer, causing ice formation on multiple boxes of frozen goods, as well as on trays of cauliflower and broccoli wrapped in tin foil. Additionally, a metal tray containing approximately half of a ten-pound tube of ground beef was found loosely and partially covered with plastic wrap, showing signs of oxidation on the exposed end. These findings were confirmed by the Dietary Manager during an interview.
Improper Storage of Insulin Pens in Medication Carts
Penalty
Summary
The facility failed to store medications in a safe and sanitary manner, specifically concerning the storage of insulin pens in medication carts. During observations, it was noted that insulin pens were stored unbagged in three of the four medication carts reviewed, which included the Three South front cart, Three East front cart, and Two East back cart. This practice posed a risk of cross-contamination. Licensed Practical Nurses (LPNs) responsible for these carts confirmed the insulin pens were not bagged and expressed unawareness of the reason for storing them in bags. The Director of Nursing confirmed the facility's failure to prevent the risk of cross-contamination by not storing insulin pens in bags. The facility's policies on Infection Prevention Control Program Core Practices and Medication Storage, both reviewed on March 4, 2025, indicated the need for maintaining medication storage in a clean, safe, and sanitary manner. However, the observations and interviews revealed a lack of adherence to these policies, leading to the identified deficiency.
Improper Disposal of Medications in Medication Room
Penalty
Summary
The facility failed to ensure proper disposal of medications and biologicals in one of its medication rooms, specifically Unit 1 [NAME] medication room. During an observation, five heparin lock flush syringes with an expiration date of 9/30/24 and an opened, partially used bottle of vitamin E supplement with an expiration date of 3/25 were found. The facility's policy on the storage of medications, dated 3/4/25, mandates that discontinued, outdated, or deteriorated drugs or biologicals should be returned to the dispensing pharmacy or destroyed. The Unit Nurse Manager and the Director of Nursing confirmed these observations, indicating a failure to adhere to the facility's medication disposal policy.
Failure to Post APS Contact Information
Penalty
Summary
The facility failed to comply with the requirement to post contact information for Adult Protective Services (APS) in areas accessible to residents, families, and visitors. During observations conducted on April 10, 2025, at 8:30 a.m., it was noted that the APS contact information, including name, address, email, and phone number, was not posted on the first, second, and third floor nursing units. This deficiency was confirmed during an interview with the Director of Nursing at 8:51 a.m. on the same day, who acknowledged that the APS contact information was not available in the required areas.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period on 15 out of 21 days. This deficiency was identified through a review of nursing time schedules and staff interviews. The specific dates where the facility did not meet the required hours were documented, with the provided nursing schedules and census information revealing that the hours per patient day (PPD) fell below the required 3.2 hours on these days. The Nursing Home Administrator confirmed the failure to meet the required nursing hours during an electronic communication.
Plan Of Correction
1. Facility did not meet minimum required PPD for the dates of (12/23/24, 12/24/24, 12/25/24, 12/26/24, 12/27/24, 12/28/24, 1/12/25, 1/13/25, 1/15/25, 1/16/25, 1/17/25, 1/18/25, 2/17/25, 2/19/25 and 2/21/25). 2. Review of PA Code 211.12 completed by NHA and DON. Education then provided to scheduler by DON. 3. Facility contracts with multiple staffing agencies. Additionally, the facility also has an active recruitment and retention committee in an attempt to retain staff. There are also consistent advertisements on both Apploi and Indeed and often has a running ad in local paper. The facility currently offers sign on bonus, referral bonus for recruiting new staff, extra shift bonuses when we are projecting low, flexible scheduling, and nursing management staff rotate extra shifts. 4. NHA, DON, and facility Staff Scheduler will review projected current day's PPD, weekly projection as able, and previous day actual PPD 5 x week for 4 weeks.
Delayed Meal Service on Nursing Unit
Penalty
Summary
The facility failed to ensure that meals were served at regularly scheduled times for one of its nursing units, specifically the 1 [NAME] nursing unit. The facility's Meal Delivery Policy, dated 2/28/24, indicated that meals should be served at designated times. However, a review of the [NAME] Meal Delivery Log, revised 8/24/24, showed that lunch trays were consistently delivered late, with the first tray cart arriving at 12:52 p.m. and the second at 12:59 p.m. Staff interviews revealed that food carts were never on time for all three meals, with some deliveries delayed until 2:00 or 3:00 p.m. An observation on 11/14/24 confirmed that the first tray cart arrived at 1:33 p.m., 41 minutes late, and the second at 1:43 p.m., 44 minutes late. Resident interviews corroborated these findings, with one resident expressing dissatisfaction with the timing and quality of the meals. The Regional Food Service Director acknowledged awareness of the issue and mentioned ongoing efforts to address it through staff education and training. The Nursing Home Administrator and the Regional Food Service Director confirmed the facility's failure to adhere to scheduled meal times, as required by 28 Pa. Code: 211.6 (c) Dietary services.
Insufficient Dietary Staff Leads to Meal Delivery Issues
Penalty
Summary
The facility failed to provide sufficient dietary staff to perform essential kitchen duties, leading to significant delays and issues with meal delivery. Observations and interviews revealed that food trucks were consistently late, resulting in residents receiving meals hours after the scheduled time. Staff reported that trays were often incorrect, and residents complained about receiving cold food, missing items, and poor taste. The Food Service Director acknowledged the staffing shortages and the challenges in managing the kitchen effectively, noting that equipment such as hotplate warmers were unreliable. Residents expressed dissatisfaction with the meal service, citing late deliveries and inadequate food quality. One resident reported having to purchase their own condiments due to missing items on trays. The Dietary Council Meeting Minutes and Grievance logs from May to July 2024 documented ongoing issues with late and cold food, as well as complaints about not receiving ordered items. The Food Service Director confirmed the facility's failure to maintain adequate dietary staffing, which contributed to these deficiencies.
Failure to Serve Meals on Time
Penalty
Summary
The facility failed to ensure that meals were served at regularly scheduled times over a period of three days. The Meal Delivery policy, dated 2/28/24, allowed for a ten-minute delay in food truck delivery times, but required an explanation if the delay exceeded this period. Despite this policy, staff and residents reported significant delays in meal delivery, with some meals arriving two to three hours late. Staff Employee E2 noted that food trucks were consistently late, and residents did not receive the meals they requested. Resident R5 reported receiving cold food, particularly at breakfast, and mentioned that dinner was served as late as 9:00 p.m. Resident R7 echoed these concerns, stating that trays were consistently late, lacked condiments, and often had missing items. The Food Service Director, Employee E3, acknowledged the issues with meal delivery, citing staffing shortages and malfunctioning hotplate warmers as contributing factors. During an observation, the lunch cart delivery was noted to be fifteen minutes late, further confirming the facility's failure to adhere to scheduled meal times. The Director of Nursing, Nursing Home Administrator, and Lucent Regional Manager confirmed the facility's inability to serve meals on time for the identified days. This deficiency was in violation of 28 Pa. Code: 211.6 (c) Dietary services.
Failure to Respect Residents' Rights in Handling Personal Property
Penalty
Summary
The facility failed to respect the residents' rights in handling and protecting their personal property and clothing, as observed during a survey. Eleven out of thirteen residents interviewed reported issues with the management of their personal items. During an observation of the facility's laundry areas, surveyors noted multiple heaping piles of soiled and clean personal items on carts, indicating a backlog and mishandling of residents' belongings. Interviews with staff revealed that the afternoon shift staff member refused to deliver personal items, despite being written up several times. The Laundry Housekeeping Manager expressed an inability to replace this staff member due to staffing shortages. The Director of Nursing confirmed the failure to deliver personal clothing, acknowledging the facility's failure to respect residents' rights in this regard.
Failure to Follow Menu and Provide Preferred Dietary Choices
Penalty
Summary
The facility failed to adhere to the posted menu and provide residents with their preferred dietary choices during a lunch meal. Observations and interviews revealed that the facility did not follow the displayed menu for one of the three observed meals, specifically the lunch meal on 7/23/24. The posted menu on the 3 East and 3 South Nursing Units was not the menu being used, as confirmed by the Diet Clerk, who stated that the facility was actually in week 1 of the menu cycle. This discrepancy led to residents not receiving the meals as per their preferences. Interviews with staff and residents highlighted ongoing issues with meal service, including late food delivery and missing items on trays. Staff Employee E2 mentioned that food trucks were consistently late, resulting in residents receiving meals as late as 8:00 p.m. Additionally, Resident R7 expressed frustration over the lack of condiments and the need to purchase their own sugar and salt. The Food Service Director confirmed that the trays did not contain all the requested items for three residents, further indicating the facility's failure to meet dietary needs as per the posted menu.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, homelike environment across five of six nursing units, affecting 33 out of 52 residents. Observations revealed that the main entrance hallways leading to various nursing units and the main dining room were spoiled with black substances and debris. The main resident lounges on multiple nursing units were cluttered with wheelchairs, staff equipment, and littered with paper, food debris, and sticky substances. Additionally, the main hallways and dining room floors were found to be dirty and covered with debris. Specific resident rooms and shared bathrooms were observed to have soiled floors, broken sinks with sharp edges, and other unsanitary conditions. For instance, shared bathrooms and rooms had brown and black substances, sticky floors, soiled linens, and full garbage cans. Some residents' wheelchairs were heavily soiled, and several rooms had broken sinks with sharp edges. The Housekeeping/Laundry Supervisor confirmed these findings, acknowledging the facility's failure to provide a clean, comfortable, and homelike environment for the affected residents.
Improper Storage and Security of Medications and Biologicals
Penalty
Summary
The facility failed to store medications and biologicals properly and securely in three of six medication carts. Specifically, the One Front Hall medication cart was observed unlocked with the Electronic Health Record (EHR) visible on the laptop screen and four medication cups labeled with resident room numbers left on top of the cart. An LPN confirmed that the cart was left unattended and unlocked with resident medical information accessible to unauthorized individuals. Similarly, the Three East Back Hall medication cart was also left unattended and unlocked, as confirmed by another LPN. Additionally, the Three South Front Hall medication cart contained unlabeled personal items such as hand cream, hand sanitizer, and lip moisturizer, which were confirmed by an LPN to be improperly stored biologicals. Further observations revealed that the Three East Front Hall medication cart was left unattended and unlocked in the hall outside a resident's room, making it accessible to residents, staff, and visitors. An RN confirmed that she left the medication cart unattended and unlocked. These actions are in violation of the facility's policies on medication storage and administration, which require medication carts to be securely locked when out of the nurse's view and medications to be stored properly to prevent unauthorized access.
Failure to Promote Dignity During Medication Administration
Penalty
Summary
The facility failed to provide an environment and care that promoted dignity during medication administration for five residents. Observations revealed that medications were administered in a public area, specifically at tables in the middle of the nursing unit, with other residents seated nearby or walking around. This practice was inconsistent with the facility's policy on medication administration, which emphasizes safe and timely administration, and the policy on resident rights, which mandates treating all residents with kindness, respect, and dignity. Resident R226, diagnosed with dementia, depression, and muscle weakness, was observed receiving medications at a table in the middle of the nursing unit. Similarly, Resident R178, with diagnoses including dementia, anxiety, and depression, was also administered medications in the same public setting. Resident R119, who has diabetes, high blood pressure, and schizoaffective disorder, was observed receiving medications at a table in the middle of the unit, surrounded by other residents. Resident R131, diagnosed with schizoaffective disorder, diabetes, and anxiety, and Resident R214, with diabetes, COPD, and chronic atrial fibrillation, were also administered medications in the same undignified manner. Notably, Resident R214 was asked about insulin injection preferences in a public setting, which compromised his dignity. The Director of Nursing confirmed the failure to provide an environment that promotes dignity during medication administration for these residents.
Improper Insulin Administration
Penalty
Summary
The facility failed to ensure that the services provided met professional standards of quality for Resident R214. The resident, who was admitted with diagnoses including diabetes, depression, and muscle weakness, had a physician order for Lantus Kwik Pen insulin administration. However, during an observation of medication administration, an LPN was seen drawing insulin from the Kwik Pen using a syringe, which is against the manufacturer's instructions. The LPN admitted to using this practice frequently, as did another RN, indicating a systemic issue within the facility. The facility's policy on employee competence requires staff to demonstrate the knowledge and skills necessary to perform their duties correctly. Despite this, the staff's improper use of the insulin pen was confirmed by the Director of Nursing, who acknowledged that the facility failed to meet professional standards of quality in this instance. This deficiency was identified through a combination of clinical record reviews, staff interviews, and direct observation, highlighting a significant lapse in adherence to proper medication administration protocols.
Failure to Notify Physicians and Assess Residents for Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia and hypoglycemia for two residents. Resident R14 had a diagnosis of diabetes and was prescribed Lispro insulin with specific instructions to notify the physician if blood sugar levels were less than 60 or greater than 450. On multiple occasions, Resident R14's CBG levels were significantly above the threshold, but the facility did not assess for hyperglycemia, monitor the effectiveness of treatment, follow care plan interventions, or notify the physician of the abnormal results. Similarly, Resident R229, who also had a diagnosis of diabetes, had physician orders to notify the physician if blood glucose levels were greater than 400. Despite several instances where Resident R229's CBG levels exceeded this threshold, the facility did not assess for hyperglycemia, recheck blood sugar levels, follow care plan interventions, or notify the physician of the abnormal results. The care plans for both residents included specific instructions to monitor and report signs and symptoms of hyperglycemia, which were not followed. Interviews with various nursing staff, including LPNs and RNs, revealed that they were aware of the procedures for handling abnormal blood glucose levels but failed to execute them. The Director of Nursing confirmed that the facility did not notify the doctor of changes in condition related to blood glucose, did not follow care plan interventions, and did not recheck blood sugars for the affected residents.
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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