Providence Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Beaver Falls, Pennsylvania.
- Location
- 900 Third Ave, Beaver Falls, Pennsylvania 15010
- CMS Provider Number
- 395682
- Inspections on file
- 37
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 40
Citation history
Health deficiencies cited at Providence Health & Rehab Center during CMS and state inspections, most recent first.
A resident with diabetes, hypertension, and a history of falls did not receive three ordered bedtime medications (Seroquel, Atorvastatin, and Lantus) after a verbal altercation with an agency RN over access to a kitchenette. The MAR documented the medications as not administered/resident refused, but the resident later reported that the nurse never came to give the medications and denied leaving the facility during the relevant time. An RN supervisor reported witnessing the argument and offering to pass the medications, which the agency RN refused, while another staff member stated that the agency RN asked other nurses to administer the medications but they declined. Conflicting accounts about the resident’s whereabouts and the refusal status, combined with the lack of medication administration as ordered, led surveyors to determine that the facility failed to provide necessary goods and services to the resident.
A resident with diabetes, hypertension, and a history of falls did not receive ordered bedtime doses of Seroquel, Atorvastatin, and Lantus on an evening shift. Facility policy required verification and administration of medications as ordered, and the resident’s care plan directed staff to give medications per MD orders. The MAR showed the agency RN documented the medications as refused, but the resident later reported he had not been offered or given them. Staff interviews and facility documentation described a verbal altercation between the agency RN and the resident over access to a kitchenette, the RN’s refusal of assistance from the RN supervisor to pass the medications, and conflicting accounts about whether and when the resident left and returned to the unit, resulting in the missed administration of significant medications.
A resident with hypertension, osteoporosis, and diabetes had physician orders for showers twice weekly during the 3 p.m. to 11 p.m. shift, but review of electronic Point of Care documentation over several months showed only six showers were completed. The admission materials stated that residents have the right to have their personal needs and preferences provided for, yet the ordered shower frequency was not followed. The DON confirmed that the resident received only six showers during the review period, demonstrating a failure to accommodate the resident’s shower needs and preferences.
A resident with anemia, diabetes, and late-onset Alzheimer’s disease, identified as a fall risk, experienced two unwitnessed falls with head strike, back pain, and a 4 x 4 cm head laceration. A provider ordered neurochecks with vital signs at frequent, specified intervals over a 24-hour period, but documentation showed these assessments were performed only a few times and did not follow the ordered schedule. The DON confirmed that staff failed to complete the neurochecks and vital signs as ordered, resulting in a failure to provide appropriate post-fall care and treatment.
A resident with a history of stroke and hemiplegia had a physician order for a left shoulder subluxation sling to be applied in the morning and removed in the evening, but the device was not included in the resident's care plan and was not in use during multiple observations. The resident reported that staff never applied the splint, did not know where it was, and stated that it helped reduce pain. An LPN confirmed the splint was not in place as ordered, and the DON acknowledged that the facility failed to provide the necessary services, equipment, and assistance to maintain or improve the resident's mobility.
Several residents with dementia, depression, diabetes, and neurocognitive disorders did not have individualized, measurable care plans addressing their specific medical and psychosocial needs. Care plans were missing for residents receiving psychotherapy, insulin therapy, and those exhibiting behavioral symptoms, despite documented diagnoses and physician orders. Staff interviews and record reviews confirmed these omissions.
The facility failed to notify physicians of abnormal blood glucose readings for a resident with diabetes, did not provide comprehensive skin assessments or timely wound care for two residents with skin conditions, and did not follow physician orders for vital sign monitoring or medication continuation for a resident with a seizure disorder. Staff interviews and record reviews confirmed lapses in documentation and adherence to care protocols.
The facility did not properly identify or assess two residents for smoking safety, omitting required risk assessments and care plan interventions, even though both were known to smoke. Additionally, after a resident eloped from the facility, staff failed to reassess the resident for elopement risk, update the care plan with appropriate interventions, or include the resident's information in the elopement binder, despite the resident being cognitively intact and non-compliant. Staff interviews and documentation confirmed these lapses in required procedures.
The facility did not maintain accurate care plans or conduct ongoing assessments for bedrail or enabler bar use for three residents, despite their medical conditions and physician orders. Clinical records lacked documentation of ongoing assessment, goals, and interventions related to bedrail use, and observations confirmed the use of bedrails or enabler bars without proper care plan updates.
Surveyors identified multiple failures in medication storage and labeling, including expired medications, unlocked and improperly monitored medication refrigerators, missing temperature logs, and insulin pens without open dates or with expired use on a medication cart. Staff confirmed these deficiencies, which involved improper storage, lack of security, and inadequate documentation for medications and biologicals.
The facility failed to prevent cross contamination by storing milk in a medication refrigerator and did not follow proper infection control practices during a dressing change for a resident with multiple diagnoses. An LPN did not cleanse the bedside table, used gloves from her pocket, and did not perform hand hygiene or change gloves between steps. Additionally, the facility did not conduct infection surveillance for four months, as confirmed by the Infection Preventionist.
A resident with multiple chronic conditions was not offered the influenza vaccine, and two residents with significant medical histories did not have documentation that the pneumococcal vaccine was offered, administered, or declined. Facility policy required proper documentation and offering of these vaccines, but clinical records and staff interview confirmed these steps were not completed.
A resident with multiple medical conditions, including a pressure ulcer, did not have their dignity maintained when an LPN wrote on a dressing after it was applied during wound care. This action was confirmed by the LPN and was found to be inconsistent with the resident's right to dignity and respect.
Residents repeatedly raised concerns about call bells, food, and staffing during council meetings, but the facility did not provide feedback or resolve these issues. Staff confirmed that these topics were discussed at every meeting without action taken by the facility.
A resident with a history of falls and cognitive impairment was provided with bilateral bolsters in bed, but the facility did not assess or document whether these bolsters acted as a physical restraint. The required comprehensive review and ongoing evaluation were not completed, and the DON confirmed the lack of assessment during the survey.
Two residents received psychotropic medications without proper documentation of non-pharmacological interventions, monitoring for medication effectiveness, or side effect and behavior monitoring, and one antipsychotic order lacked a diagnosis, contrary to facility policy.
The facility did not report two separate allegations of neglect to the local state field office within 24 hours as required. In one case, a resident with a seizure disorder did not receive a necessary anti-epileptic medication after a hospital order expired, and in another, a resident with dementia was given medications intended for another resident. Both incidents were confirmed by staff interviews and review of records, but were not reported to authorities in a timely manner.
The facility did not conduct thorough investigations into two separate incidents involving medication errors and alleged neglect. In one case, a resident with a seizure disorder did not receive a necessary anti-epileptic medication for several months, and the issue was only identified after the family raised concerns. In another case, a resident with dementia was given medications intended for another resident, and the facility's documentation of the event was incomplete, lacking key details and analysis. The DON and ADON confirmed that investigations were not thorough or complete.
The facility did not document communication of essential resident information to receiving health care providers and failed to notify residents or their representatives of the bed-hold policy during two hospital transfers. This deficiency was confirmed by record review and staff interviews.
Two residents had inaccurate MDS assessments: one was documented as receiving insulin injections without a corresponding physician order, and another was not coded as receiving hospice care despite a physician order for hospice services. These discrepancies were confirmed by the RN Assessment Coordinator.
On two observed days, residents in a memory care unit did not receive scheduled activities as posted on the activity calendar. Staff interviews confirmed that activities were delayed, changed, or not provided due to activity staff shortages, resulting in residents not receiving engagement as required by facility policy.
Two residents with complex medical needs did not have individualized care plans addressing their specific nutritional concerns, including dysphagia and prescribed hydration. The facility also failed to consistently monitor and document weights as required by policy, and care plans were not updated to reflect physician orders or changes in condition.
A resident with ESRD and multiple diagnoses did not have consistent or complete communication between the facility and the dialysis center, as required by facility policy. Several communication forms were missing or incomplete, and the care plan lacked specific details about dialysis scheduling and facility information.
Two residents experienced significant medication errors when one did not receive a prescribed anti-epileptic medication for several months, resulting in a seizure and hospitalization, and another was given medications intended for a different resident, missing her own routine medications. Facility leadership confirmed these errors and acknowledged that required medication administration procedures were not followed.
Two residents receiving hospice care did not have their care plans updated to include required hospice agency contact information or instructions for accessing the hospice's 24-hour on-call system, as required by facility policy. This lack of coordination between hospice and facility services was confirmed by a social worker.
The facility did not accurately or promptly document the offering of the COVID-19 vaccine for two residents, both of whom had medical conditions and were not up to date on vaccination. Required records of whether the vaccine was offered, administered, or declined were missing from their clinical files, as confirmed by the Infection Preventionist.
An LPN was found to have removed and signed out controlled medications, including alprazolam, oxycodone, tramadol, and lorazepam, in quantities that did not match what was documented as administered to multiple residents. Facility records and witness statements revealed that medications were signed out but not given, or removed in excess of what was documented, and the LPN appeared impaired while on duty. These actions resulted in the misappropriation of resident property, as residents did not receive their prescribed medications as ordered.
An LPN did not receive current abuse, neglect, and misappropriation training, with documentation showing the last training occurred in 2022. The Nursing Home Administrator confirmed the lack of up-to-date training.
An LPN was observed removing two Xanax tablets from a resident's medication card and discrepancies were found in the narcotic log, indicating probable diversion. The incident was reported internally and to police, but the facility failed to report the suspected misappropriation to the State Survey Agency as required.
The facility did not document, resolve, or provide responses for ten out of thirteen resident grievances, as required by its policy, with no evidence that residents or their responsible parties were informed of findings or outcomes.
Hot beverage carts containing coffee and hot water were left unsupervised in two hallways where residents with Alzheimer's and dementia resided. Staff confirmed that residents accessed the carts on their own throughout the day, contrary to facility policy requiring supervision for hot beverages. The DON acknowledged the failure to maintain a hazard-free environment.
The facility failed to implement an effective QAPI program for LPN staffing, as evidenced by not meeting the required staffing ratios. On multiple occasions, the facility did not have the necessary number of LPNs per resident census, which was confirmed by the Assistant Director of Nursing.
A resident experienced verbal abuse from a Nurse Aide, who criticized her for incontinence, leading to the aide's termination. Additionally, 29 residents on the Memory Impaired Unit did not receive their medications as required, due to a nurse's inability to manage the workload for 45 residents, resulting in unattended medications being found at the bedside.
The facility failed to investigate allegations of abuse and neglect for 30 residents, including a resident with dementia who was injured by a Hoyer lift and multiple residents who did not receive their medications. The facility did not conduct thorough investigations, as only directly involved staff were interviewed, violating several Pennsylvania Code regulations.
The facility failed to communicate necessary resident information to the receiving health care provider for five residents during transfers. Despite having significant medical conditions, essential details such as care plan goals and advanced directives were not documented or conveyed, as confirmed by the DON.
The facility failed to notify the Office of the LTC Ombudsman Division about the hospital transfers of five residents, as required by policy. These residents had various medical conditions, including diabetes, depression, and end-stage renal disease. The Director of Nursing confirmed the oversight, acknowledging the lack of documented evidence of notifications being sent.
The facility failed to notify residents or their representatives about the bed-hold policy during hospital transfers for five out of six cases reviewed. Despite the facility's policy requiring a bed-hold notice with the discharge-transfer letter, the clinical records lacked evidence of such notifications. The residents involved had various medical conditions, and the deficiency was confirmed by the DON.
The facility failed to update care plans for four residents, resulting in deficiencies such as missing safety measures, dietary updates, skin integrity issues, fluid restrictions, and cardiac care management. These omissions were confirmed by staff and violated Pennsylvania Code regulations.
The facility failed to supervise 29 residents in the Memory Impaired Unit, leading to unadministered medications and residents wandering unsupervised. Additionally, a resident with cognitive decline was not assessed for elopement risk, lacked a physician order for a wander guard, and had no care plan interventions for elopement prevention.
The facility did not conduct QAA meetings with all required members for three out of four quarterly meetings. The Medical Director was absent from meetings in October 2023, February 2024, and April 2024, as confirmed by QAPI attendance records and the Nursing Home Administrator. This is a violation of CFR S483.75(g), which requires the Medical Director's participation.
A long-term care facility failed to implement effective infection prevention and control measures, including improper dressing change procedures by an LPN, lack of tracking for Enhanced Barrier Precautions for residents, and improper PPE usage. Additionally, the facility did not maintain an effective infection control program, with no surveillance for infections over ten months and missing care plans for residents' infection precautions.
A facility failed to convey a deceased resident's funds in accordance with State law, leaving an account with a balance of $8,480 open beyond the 60-day period required by their policy. The resident, who had diagnoses including congestive heart failure, passed away, but the account closure was delayed due to the need for corporate approval, as confirmed by the Business Office Manager.
A resident with dementia, stroke, and high blood pressure experienced a medication error when scheduled medications were found at their bedside, indicating they were not taken. The facility failed to notify the physician or the resident's representative, as required by policy. This deficiency was confirmed by the DON and violated resident care policies.
A facility failed to ensure a resident with moderate cognitive impairment understood the Notice of Medicare Non-Coverage (NOMNC) form. The resident, who had colon cancer and heart failure, signed the form without adequate explanation. The resident wanted more therapy and asked the facility to contact their son for an appeal, but the facility only left a message without confirming understanding. This was acknowledged by the NHA.
The facility failed to ensure accurate assessments for two residents. One resident's MDS did not reflect continuous oxygen therapy, despite documentation in physician orders and care plans. Another resident's MDS omitted several diagnoses, only reflecting non-traumatic brain dysfunction. These inaccuracies were confirmed by staff interviews.
A facility failed to notify a physician about abnormal glucose readings for a resident with diabetes, despite specific orders to do so. Additionally, another resident with a cerebral infarction did not receive documented wound care for a toe abrasion, as required by their care plan. These deficiencies were confirmed by the DON and RNAC.
A facility failed to accurately document a resident's pressure ulcer in the MDS and did not develop a comprehensive care plan for its treatment. Despite physician orders for daily wound care, the resident's care plan lacked details on the pressure ulcer, which was confirmed by staff interviews.
The facility failed to provide appropriate catheter care for two residents. One resident with obstructive uropathy, diabetes, and heart failure was observed with an uncovered drainage bag attached to a wheelchair, while another resident with obstructive uropathy, Alzheimer's, and sepsis had a drainage bag on the floor without a cover. These deficiencies were confirmed by staff and acknowledged by the DON.
The facility failed to provide proper respiratory care for three residents. A resident with Alzheimer's and respiratory failure had an oxygen cannula not attached to the concentrator and outdated. Another resident's oxygen cannula was not stored properly, and a third resident's nebulizer tubing was not bagged or dated. These issues were confirmed by staff and the NHA.
The facility failed to provide adequate nursing staff in the Memory Impaired Unit, affecting 29 residents. Observations and staff interviews revealed that the facility did not maintain sufficient staffing levels, as required by their policy. A nurse reported being the only one on the floor for 45 patients, making it difficult to administer medications and provide quality care. Nurse aides also reported being understaffed, leading to delays in essential care. The Director of Nursing confirmed the facility's failure to provide adequate nursing services, impacting residents' well-being.
Failure to Administer Ordered Medications After Staff–Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary medications to a resident as ordered, constituting neglect under the facility’s abuse and neglect policy. The facility’s policy defined neglect as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and required staff to verify correct medication, dose, route, rate, time, and resident with each administration. The resident involved had an MDS dated 11/26/25 showing diagnoses including a history of falls, diabetes, and hypertension, and a care plan directing that medications be administered per physician orders. On a specific evening shift, the resident’s January MAR showed that three ordered medications—Seroquel 150 mg, Atorvastatin 10 mg at bedtime, and Lantus Solostar 28 units subcutaneous at bedtime—were not administered. The MAR entries for that date documented these medications as “not administered/resident refused” by an agency RN. However, the following day, the resident reported to nursing staff that he had not received his scheduled medications for that shift. This discrepancy between the MAR documentation and the resident’s report prompted a facility investigation. During the investigation, multiple staff statements described a verbal altercation between the resident and the agency RN after the RN told the resident he was not permitted in the kitchenette. The RN supervisor reported witnessing the altercation and offering to pass the resident’s medications, but the agency RN refused this assistance. A nurse aide stated that the agency RN asked another nurse or the RN supervisor to provide the medications because the resident was being rude and calling her names, but nursing staff refused to assist. The agency RN stated that after the argument, the resident sat near the nurse station, called her the B-word, then left the unit; she reported she intended to have another nurse administer or witness the medications when the resident returned, but the resident did not return until early morning and did not request medications. In a later interview, the resident stated the nurse was not around between approximately 8 and 9 p.m., that he went to his room, and that she never came to give his medications, and he denied being out of the facility until 1 a.m. These events led surveyors to determine that the facility neglected to provide required goods and services to the resident when his ordered medications were not administered as required.
Failure to Administer Ordered Bedtime Medications After Staff–Resident Altercation
Penalty
Summary
Facility staff failed to ensure that significant medications were administered as ordered for one resident. The facility’s medication administration policy required staff to verify the correct medication, dose, route, rate, time, and resident with each administration. The resident, who had a history of falls, diabetes, and hypertension, had care plans directing staff to administer medications per physician orders. Review of the January MAR showed that on the evening shift of 1/6/26, the resident did not receive ordered doses of Seroquel 150 mg, Atorvastatin 10 mg at bedtime, and Lantus Solostar 28 units subcutaneously at bedtime. These medications were documented in the MAR by an agency RN as not administered due to resident refusal. Subsequent documentation and interviews conflicted with the refusal notation. A clinical progress note the next day recorded that the resident approached staff and reported not receiving his scheduled medications for the 3–11 p.m. shift. Facility investigation statements indicated that during the shift, the agency RN and the resident had a verbal altercation after the RN told the resident he was not permitted in the kitchenette, and the RN supervisor intervened. The RN supervisor reported offering to pass the resident’s medications, but the agency RN refused this assistance. Another staff statement indicated the agency RN asked another nurse or the RN supervisor to give the medications because the resident was being rude, but nursing staff refused to assist. The agency RN stated she intended to have another nurse witness medication administration when the resident returned to the unit, but documented that the resident left and did not return until early morning. In a later interview, the resident stated the nurse was not around between approximately 8 and 9 p.m., that he went to his room and did not receive his medications, and that he did not leave the facility until about 1 a.m., and reported having no ill effects.
Failure to Provide Ordered Twice-Weekly Showers for a Resident
Penalty
Summary
The facility failed to reasonably accommodate a resident’s shower needs and preferences as outlined in the admission notice packet, which states that residents have the right to have their personal needs and preferences provided for as long as they do not interfere with the rights of others. The resident, who was admitted on an unspecified date, had an MDS dated 11/19/25 reflecting diagnoses of hypertension, osteoporosis, and diabetes, and had current physician orders for showers twice weekly on Sunday and Thursday during the 3:00 p.m. to 11:00 p.m. shift. Review of the Point of Care History from 9/1/25 through 1/5/25 showed only six showers documented as completed on 9/4/25, 10/4/25, 10/5/25, 10/26/25, 11/23/25, and 12/28/25, despite the standing order for twice-weekly showers. During an observation on 1/5/26, the resident was on the telephone and declined interaction with the survey agency, and in a subsequent interview the Director of Nursing confirmed that the resident had received only six showers during the review period, confirming the failure to accommodate the resident’s ordered shower schedule.
Failure to Follow Ordered Post-Fall Neurochecks and Vital Signs
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered post-fall neurological monitoring and vital signs for a resident following two unwitnessed falls with head impact. The resident had diagnoses including anemia, diabetes, and late-onset Alzheimer’s disease, with a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment, and was care planned as a fall risk related to impaired cognition, decreased safety awareness, Alzheimer’s, age-related cognitive decline, and sarcopenia. Facility documentation showed that on 12/27/25 the resident was found lying on the bedroom floor between the recliner and the bed after an unwitnessed fall, with moderate pain to the right side of the back and head, and later the same day had another unwitnessed fall with moderate head pain and an abrasion. A Third Eye Health note documented that the resident had two unwitnessed falls with head strike, reported back pain, and a 4 x 4 cm head laceration, and included specific provider orders for neurochecks with vital signs every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, and then every four hours for 24 hours. Review of the Continuity of Care Document showed that neurochecks and vital signs were only completed at 2:41 p.m. and 8:48 p.m. on 12/27/25, and at 12:23 a.m., 8:13 a.m., and 3:53 p.m. on 12/28/25, which did not meet the ordered frequency. In interviews, the Director of Nursing confirmed that the facility did not complete the neurochecks and vital signs as ordered by the provider and acknowledged that the facility failed to provide appropriate care and treatment post fall for this resident.
Failure to Implement and Care Plan Ordered Shoulder Subluxation Splint
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility as ordered. Facility policy required that splints be issued or fabricated with a provider's order, that a therapist evaluate the patient for need, fit, and issuance, and that the splint schedule be communicated to the multidisciplinary team and documented in the care plan. The resident in question had diagnoses including high blood pressure, stroke, and hemiplegia, and had a physician's order to wear a left shoulder subluxation sling on with morning care and off with evening care, as tolerated twice a day. However, the resident's current care plan did not include management and treatment of the left shoulder subluxation splint. During observations, the resident was seen in a wheelchair without the ordered left shoulder subluxation splint in place. The resident reported that staff never put the splint on, was unsure of its location, and stated that the splint reduced pain. An LPN confirmed that the splint was not in place as ordered. Later observation showed the resident still in the wheelchair without the splint, and the resident indicated that staff could not find it. The DON confirmed that the facility failed to ensure the resident with limited mobility received the appropriate services, equipment, and assistance to maintain or improve mobility.
Failure to Develop Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents with complex medical and psychosocial needs. Specifically, care plans for residents with diagnoses such as dementia, depression, diabetes, and neurocognitive disorders did not include individualized instructions or measurable goals and timetables as required by facility policy and regulatory standards. For example, residents with dementia or related symptoms did not have care plans addressing appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. Additionally, a resident with ongoing psychotherapy for anxiety and depression did not have a care plan addressing their psychosocial concerns or monitoring for depressive symptoms, despite multiple psychiatry visits and recommendations. Another resident receiving insulin for diabetes lacked a care plan that included the use of insulin and protocols for managing hyperglycemia and hypoglycemia, even though physician orders and medication administration records indicated ongoing insulin therapy. Furthermore, a resident with a neurocognitive disorder and behavioral issues did not have a care plan addressing their cognitive decline, behavioral symptoms, or interventions to manage these behaviors. These deficiencies were confirmed through staff interviews and review of clinical records, demonstrating a pattern of incomplete or missing care plans for residents with significant medical and behavioral needs.
Failure to Follow Physician Orders and Provide Comprehensive Care
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for multiple residents. For one resident with diabetes, the facility did not notify the physician of abnormal capillary blood glucose (CBG) readings as required by the physician's order. Specifically, there were instances of both hyperglycemia and hypoglycemia where the clinical records did not show any physician notification or documented interventions, despite clear orders to do so. Interviews with nursing staff confirmed a lack of consistent understanding and adherence to the notification protocol for abnormal blood glucose levels. Two residents with skin condition concerns did not receive comprehensive skin assessments or appropriate care and treatment. One resident had wounds that were not assessed or had dressings changed for several days, resulting in the wounds increasing in size and worsening. Documentation was lacking regarding wound care between dressing changes, and staff interviews confirmed that the wounds were not addressed as needed. Another resident at risk for pressure ulcers did not have a Braden Scale assessment completed for several months, and when fluid-filled blisters were observed, there was no comprehensive skin assessment, care, or notification to appropriate parties documented in the clinical record. Additionally, the facility failed to follow physician orders for vital sign monitoring for a resident with a history of seizures and recent hospitalization. The hospital discharge instructions required vital signs to be taken every four hours, but the clinical record did not show that this was done. The resident's family reported concerns about the discontinuation of an anti-epileptic medication (Keppra) after a 30-day order expired, and the facility did not continue the medication or document a reason for not following the order. Interviews with facility leadership confirmed these failures to follow physician orders and provide the required care.
Failure to Identify, Assess, and Care Plan for Smoking and Elopement Risks
Penalty
Summary
The facility failed to properly identify, assess, and care plan for residents who smoke and those at risk for elopement, as required by facility policy. For two residents, the facility did not timely identify or assess for smoking safety. One resident was not recognized as a smoker during admission, had no completed Smoking Risk Assessment, and lacked a care plan addressing safe smoking, despite being observed smoking in the designated area. Another resident, known by staff to smoke daily and with a diagnosis of nicotine dependence, was not included on the facility's list of current smokers and did not receive required quarterly Smoking Risk Assessments after a certain date. Additionally, the facility failed to reassess a resident after an elopement event and did not develop a comprehensive care plan with interventions to address the risk of elopement. This resident, who was cognitively intact and had a history of non-compliance, was found outside the facility on a motorized scooter without staff knowledge. Although a wanderguard was ordered, the care plan did not include interventions related to the device or address elopement risk, and the resident's information was not included in the elopement binder accessible to staff. Interviews with staff and residents confirmed these deficiencies, with staff acknowledging the lack of timely assessments and care planning. Facility documentation and policy reviews further substantiated that required procedures for identifying, assessing, and care planning for smoking and elopement risks were not followed for the affected residents.
Failure to Maintain Accurate Care Plans and Assessments for Bedrail Use
Penalty
Summary
The facility failed to maintain accurate resident care plans and conduct ongoing assessments regarding the use of bedrails for three residents. For each resident, the clinical records did not include ongoing assessments for bedrail or enabler bar usage, nor did they contain the development of goals and interventions related to this equipment in the care plans. Observations confirmed the presence of bedrails or enabler bars in use, but physician orders were either missing or not reflected in the care plans. Specifically, one resident with diagnoses including high blood pressure, hemiplegia, and depression was observed with enabler bars on the bed, but there was no physician order or care plan documentation for their use. Another resident with cancer, high blood pressure, and anxiety had a physician order for bilateral assistive handrails, but the care plan lacked ongoing assessment and interventions. A third resident with high blood pressure, dementia, and anxiety also had physician orders for assistive handrails, but again, the care plan did not include ongoing assessment or related interventions. Facility policy required evaluation of potential risks associated with bedrail use, including entrapment, prior to installation, and ongoing assessment using a safety checklist. However, review of the clinical records and staff interviews confirmed that these requirements were not met for the three residents in question. The deficiencies were identified through observations, policy review, clinical record review, and staff interviews, and were communicated to the facility's Director.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and management of medications and biologicals in multiple medication rooms and a medication cart. Observations revealed expired medications, such as a bottle of stool softener and niacin, were present in the medication storage cabinet. The medication refrigerator was found unlocked and operating above the recommended temperature range, and there were no temperature logs maintained for the refrigerator during specific months. Additionally, the medication room refrigerator on the third floor had missing temperature recordings for several days, and another medication refrigerator was noted to be operating below the recommended temperature range. Staff interviews confirmed these findings, including the lack of temperature monitoring and failure to secure medication storage areas. Further deficiencies were identified on a medication cart, where expired insulin pens and medications without documented open dates were found for several residents. Staff confirmed that these medications were not properly stored or labeled according to facility policy and professional standards. These actions and inactions demonstrate a failure to comply with regulations regarding the secure storage, labeling, and temperature control of medications and biologicals within the facility.
Failure to Prevent Cross Contamination and Maintain Infection Control Surveillance
Penalty
Summary
The facility failed to prevent potential cross contamination in one of three medication refrigerators by allowing an eight-ounce container of milk to be stored in the 2B Nurses Station medication refrigerator, as confirmed by an LPN. This action was not in accordance with the facility's policy, which prohibits food storage in areas designated for medications and biologicals. Additionally, the facility did not implement proper infection control practices during a dressing change for a resident with diagnoses including high blood pressure, COPD, and hypothyroidism. During the dressing change, the LPN did not cleanse the resident's bedside table before setting up the clean field, used gloves stored in her scrub pocket, failed to place a clean field between the resident's wound and bed linens, and did not perform hand hygiene or change gloves between critical steps of the procedure. The bedside table was also not cleansed after the procedure. Furthermore, the facility failed to maintain an infection control program that included consistent surveillance for communicable diseases or infections. Review of infection control documentation revealed that surveillance for tracking resident infections was not conducted for four months within an eleven-month period. The Infection Preventionist confirmed the absence of surveillance for these months, indicating a lapse in the facility's infection prevention and control program.
Failure to Offer and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that required immunizations for influenza and pneumococcal disease were offered and documented for certain residents, as identified through policy review, clinical record review, and staff interview. Specifically, one resident with diagnoses including dementia, high blood pressure, and hyperlipidemia was not offered the influenza vaccine during the current vaccination season, with documentation indicating the vaccine was not offered and no record of administration or refusal. Additionally, two residents with medical histories including high blood pressure, depression, anxiety, hemiplegia, and a history of falls did not have documentation in their clinical records that the pneumococcal vaccine was offered, administered, or declined. The facility's vaccination policy required that influenza, pneumococcal, and COVID vaccines be administered per orders, with consents, refusals, or medical ineligibility documented in the electronic health record. However, review of the Minimum Data Set (MDS) and clinical records for the affected residents showed missing documentation regarding the offering and administration or refusal of these vaccines. The Infection Preventionist confirmed that the facility did not ensure the required immunizations were offered as mandated.
Failure to Maintain Resident Dignity During Wound Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) provided wound care to a resident who had been admitted with diagnoses including high blood pressure, COPD, and hypothyroidism, and who had developed a pressure ulcer on the outer right ankle. During the wound care observation, the LPN wrote on the dressing after it had already been placed on the resident's ankle. This action was confirmed by the LPN during an interview and was determined to be a failure to maintain the resident's dignity, as required by facility policy and resident rights documentation. The report specifically notes that residents are entitled to privacy and to be treated with dignity and respect, and this standard was not upheld in this instance.
Failure to Respond to Resident Council Grievances
Penalty
Summary
The facility failed to respond to ongoing concerns and grievances raised by residents during resident council meetings. Residents consistently discussed issues related to call bells, food, and staffing at each meeting, but reported that these concerns were not addressed and no feedback was provided. Staff interviews confirmed that these topics were repeatedly brought up without resolution, and the facility did not act upon or respond to the resident group's ongoing concerns. This failure to address and respond to resident group grievances is in violation of federal regulations requiring facilities to consider and act promptly on the views and recommendations of resident groups regarding care and life in the facility.
Failure to Assess Bolsters as Potential Restraint
Penalty
Summary
The facility failed to identify and assess the use of bolsters as a potential physical restraint for a resident. According to the facility's own restraint policy, any device that restricts a resident's freedom of movement and cannot be easily removed by the resident should be evaluated as a possible restraint. In this case, a resident with a history of falls, decreased safety awareness, altered cognition, and impulsivity was observed lying in bed with bolsters on both sides. The resident's care plan included the use of bilateral bolsters and other fall prevention interventions, but there was no documentation of an assessment or ongoing evaluation to determine if the bolsters functioned as a restraint for this individual. Review of the clinical record and staff interviews confirmed that the facility did not conduct the required comprehensive review or use the Enabler Restraint Observation tool to assess whether the bolsters restricted the resident's movement. Additionally, there was no evidence that the interdisciplinary team evaluated the risks and benefits, considered alternatives, or involved the resident and family in decision-making regarding the use of bolsters. This lack of assessment and ongoing evaluation was acknowledged by the DON during the survey process.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from unnecessary psychotropic medications for two residents. For one resident with a history of left hip fracture, diabetes mellitus, and chronic kidney disease, physician orders included antianxiety, antipsychotic, and antidepressant medications. The antipsychotic medication order lacked an associated diagnosis, and the clinical record did not contain documentation of non-pharmacological interventions, monitoring for effectiveness of pharmacological interventions, or evidence of side effect or behavior monitoring as required by facility policy. The care plan referenced monitoring and documentation, but the clinical record did not reflect these actions. Another resident with dementia, a history of falls, and dysphagia was prescribed antianxiety and antipsychotic medications. The clinical record for this resident also lacked documentation of non-pharmacological interventions, effectiveness of pharmacological interventions, and monitoring for side effects or behaviors. During staff interviews, it was confirmed that the required clinical documentation and monitoring were not present for these residents, and that one antipsychotic medication order did not include a diagnosis.
Failure to Timely Report Allegations of Neglect to Authorities
Penalty
Summary
The facility failed to report allegations of neglect within 24 hours to the local state field office for two residents. For one resident with a history of epilepsy and anxiety disorder, the facility did not continue a prescribed anti-epileptic medication (Keppra) after a 30-day hospital order expired, despite the resident's known seizure history. The lapse in medication was only discovered when the resident's family brought it to the attention of the Director of Nursing, and the incident was not reported to the appropriate authorities within the required timeframe. In a separate incident, another resident with dementia, anxiety disorder, and hypothyroidism was administered medications intended for another resident, including Trazodone, Senna, Zyprexa, and Tramadol. The error was documented in the clinical record, and the resident did not exhibit acute distress or adverse effects. However, the facility did not report this medication error, which constituted an allegation of neglect, to the local state field office within 24 hours as required by policy. Staff interviews confirmed the failure to report both incidents in a timely manner.
Failure to Conduct Thorough Investigations into Alleged Neglect and Medication Errors
Penalty
Summary
The facility failed to initiate thorough investigations into allegations of neglect for two residents. For one resident with a history of epilepsy and anxiety disorder, the family reported that after a hospital stay, the resident was discharged with a 30-day order for Keppra, an anti-epileptic medication. The facility did not continue the Keppra order after the initial 30 days, and this lapse was not identified by staff but was instead brought to their attention by the resident's family. Review of the clinical records confirmed that Keppra was not ordered or administered for several months, and the facility's investigation into this medication error lacked a summary of findings, witness statements, relevant discharge summaries, and documentation explaining how the error occurred or why it persisted undetected. For another resident with dementia, anxiety disorder, and hypothyroidism, a medication error occurred when the resident was administered medications intended for another resident, including Trazodone, Senna, Zyprexa, and Tramadol. The incident was documented in a progress note and an incident report, but the documentation lacked critical details such as a witness statement from the LPN responsible, an interview with the affected resident, identification of whose medications were given, assessment of whether other residents were affected, and a root cause analysis or corrective action plan. Interviews with the DON and ADON confirmed that the facility did not conduct thorough or complete investigations into these incidents. The facility's failure to follow its own policy for investigating allegations of neglect and medication errors resulted in incomplete documentation and a lack of understanding of the circumstances and causes of the incidents.
Failure to Communicate Resident Information and Bed-Hold Policy During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for two residents. Specifically, for both residents, there was no documented evidence that information such as care plan goals, advanced directive details, specific instructions for ongoing care, resident representative information, and all other information necessary to meet the residents' needs was provided to the hospital at the time of transfer. This lack of communication was confirmed through clinical record review and staff interviews. Additionally, the facility did not provide written notification of the bed-hold policy to the residents or their representatives at the time of hospital transfer, as required by facility policy. Both residents were transferred to the hospital and later returned, but their records did not contain documentation that the bed-hold policy was communicated. Staff interviews further confirmed that this notification was not provided.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For one resident, the MDS indicated that insulin injections were administered for seven days during the look-back period; however, a review of the clinical record did not show any physician order for insulin injections. This discrepancy suggests that the MDS assessment did not accurately represent the resident's actual care and treatment as documented in the clinical record. For another resident, the quarterly MDS assessment failed to indicate that the resident was receiving hospice care, despite a physician order for hospice services due to a terminal diagnosis of neurocognitive disorder with Lewy bodies. The MDS section for hospice care was coded as 'no,' which did not match the resident's documented status and physician orders. These findings were confirmed by the Registered Nurse Assessment Coordinator during an interview.
Failure to Provide Scheduled Activities for Memory-Impaired Residents
Penalty
Summary
The facility failed to provide sufficient activities to meet the interests and support the physical, mental, and psychosocial well-being of residents on the Third Floor Memory Impaired unit on two out of five days observed. Observations revealed that scheduled activities, such as 'Silly songs,' 'movement group,' and 'crafts,' did not occur as posted on the activity calendar. On multiple occasions, residents were present in the common area with no activities taking place, despite the calendar indicating otherwise. Staff interviews confirmed that activities were either delayed, changed, or not provided due to staffing shortages in the activities department. The facility's Life Enrichment Program policy requires an ongoing, resident-centered program based on comprehensive assessments and care plans, with activities scheduled seven days a week, including evenings and weekends. However, both the Activity Director and a nurse aide acknowledged that there were not enough activity staff to provide the scheduled activities, resulting in residents not receiving the planned engagement. The deficiency was identified through observations, review of activity calendars, and staff interviews, and was communicated to the Nursing Home Administrator.
Failure to Individualize Care Plans and Monitor Nutrition Status
Penalty
Summary
The facility failed to individualize care plans and properly monitor the nutritional status of two residents. For one resident with diagnoses including anemia, dementia, and dysphagia, the care plan did not include goals or interventions related to dysphagia, despite documented symptoms such as loss of liquids/solids from the mouth, holding food in the mouth, coughing or choking during meals, and significant weight loss over several months. Additionally, the facility did not obtain or document the resident's weight in several months as required by policy, which mandates routine weight monitoring upon admission, weekly for the first four weeks, and monthly thereafter or as indicated by risk. Another resident, admitted with traumatic brain injury, hemiplegia, and anxiety, had a physician order for specific amounts of free water to be administered daily. However, the resident's care plan was not updated or individualized to reflect these specific nutritional and hydration needs, as the interventions listed did not match the physician's order. These deficiencies were confirmed through review of clinical records, facility policies, and staff interviews.
Failure to Ensure Consistent Dialysis Communication and Comprehensive Care Planning
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for a resident with End-Stage Renal Disease (ESRD) who required regular hemodialysis treatments. Review of the clinical record showed that communication forms between the facility and the dialysis provider were missing or incomplete for several dates within a specified period. Additionally, a physician order for dialysis did not include essential information such as the dialysis center's name, address, phone number, or the resident's scheduled chair time. These omissions were contrary to the facility's own policy, which required communication before and after each dialysis treatment. Further review revealed that the resident's care plan, while noting that the resident received dialysis, did not include specific details such as the scheduled dialysis days or the dialysis facility information. The lack of a comprehensive, person-centered care plan and incomplete communication documentation were confirmed during an interview with the Director of Nursing. The resident involved had diagnoses of high blood pressure, ESRD, and muscle weakness at the time of the deficiency.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving two residents. In the first case, a resident with a history of epilepsy and anxiety disorder experienced a grand mal seizure and was hospitalized. The family reported that the resident had not received Keppra, an anti-epileptic medication, for several months following a 30-day order after a previous hospital visit. Review of the medication administration records confirmed that Keppra was not administered from mid-May until the resident's hospitalization in August, and facility leadership acknowledged they were unaware of the lapse until notified by the family. There was no documentation of a physician's order to discontinue the medication or any explanation for the omission. In the second case, another resident with dementia, anxiety disorder, and hypothyroidism was administered medications intended for a different resident, including Trazodone, Senna, Zyprexa, and Tramadol. The error was documented in the clinical progress notes, and it was confirmed that the resident did not receive her routine medications at bedtime on the day of the incident. The LPN involved was educated on proper medication administration checks following the event. The resident did not exhibit any acute distress or adverse effects as a result of the error. Interviews with the Director of Nursing and Assistant Director of Nursing confirmed both incidents and acknowledged that the facility failed to prevent significant medication errors for both residents. The facility's own policies require verification of medication orders, resident identification, and administration procedures, which were not followed in these cases. The deficiencies were cited under multiple state regulations regarding licensee responsibility, management, resident care policies, and nursing services.
Failure to Coordinate Hospice Services in Resident Care Plans
Penalty
Summary
The facility failed to ensure proper coordination of hospice services with facility services for two residents who had been admitted to hospice care. Review of the facility's hospice care policy indicated that the resident's written plan of care should include both the most recent hospice plan of care and a description of the services provided by the facility, including contact information for the hospice agency and instructions on accessing the hospice's 24-hour on-call system. However, for both residents, the comprehensive care plans did not include this required information. One resident had diagnoses of anemia, dementia, and dysphagia, and had a physician order for hospice admission. Another resident had diagnoses of high blood pressure, dementia, and anxiety, and was also admitted to hospice care with a terminal diagnosis of neurocognitive disorder with Lewy bodies. In both cases, the care plans lacked documentation of hospice agency contact information and access instructions for the hospice's 24-hour on-call system. This deficiency was confirmed by a social worker during an interview.
Failure to Document COVID-19 Vaccine Offer and Status
Penalty
Summary
The facility failed to provide accurate and timely documentation regarding the offering of the COVID-19 vaccination to two residents. According to the facility's Resident Vaccination Policy, consents, refusals, or medical ineligibility for vaccinations are required to be documented in the electronic health record. For one resident with diagnoses including high blood pressure, depression, and anxiety, the clinical record did not contain documentation that the COVID-19 vaccine was offered, administered, or declined, despite the Minimum Data Set (MDS) indicating the vaccination was not up to date. Another resident, diagnosed with dementia, high blood pressure, and hyperlipidemia, had not received a COVID-19 vaccination since a previous documented dose, and there was no record in the clinical file that the vaccine had been offered or declined since that time. The Infection Preventionist confirmed that the required documentation was missing for these two residents, which is not in compliance with facility policy and regulatory requirements.
Misappropriation of Resident Controlled Medications by LPN
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property, specifically controlled medications, as evidenced by discrepancies in medication administration and documentation for 16 residents. Facility records, including narcotic count sheets and medication administration records (MARs), revealed that an LPN removed and signed out controlled substances such as alprazolam, oxycodone, tramadol, and lorazepam in quantities that did not match what was documented as administered to residents. In several cases, medications were signed out but not recorded as given, or the number of doses removed exceeded those documented as administered, indicating probable diversion of medications. Witness statements and facility documentation indicated that the LPN in question was observed removing medications inappropriately and appeared impaired while on duty. The discrepancies were identified during a narcotic count and review of the MARs, which showed multiple instances where medications were either not given as ordered, not documented correctly, or removed without proper documentation. The issue was reported to facility leadership, and law enforcement was involved after the LPN was found to be impaired and refused a urine test. The affected residents had orders for various controlled medications for pain and anxiety, with specific dosing instructions. The clinical records and narcotic count sheets for these residents showed multiple inconsistencies, such as medications being signed out but not administered, doses given at incorrect intervals, and conflicting documentation between the narcotic sheets and MARs. These actions resulted in the wrongful use of residents' medications without their consent, constituting misappropriation of resident property.
Failure to Provide Current Abuse Training to LPN
Penalty
Summary
The facility failed to provide current abuse, neglect, and misappropriation training to one of three employees reviewed, specifically an LPN. Documentation showed that the most recent training for this employee was completed in 2022, and no evidence of training within the current year was found. This deficiency was confirmed by the Nursing Home Administrator during an interview.
Failure to Report Suspected Misappropriation of Resident Medication
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident medication to the State Survey Agency as required by regulation. Documentation and staff interviews revealed that an LPN was observed by another LPN removing two Xanax tablets from a resident's medication card, despite the medication being ordered as PRN and only one tablet being indicated. The witness also noted discrepancies in the narcotic log, with several medications being administered twice in a short time frame. The incident was immediately reported to the ADON and Staff Educator, and further review of the medication administration records and narcotic logs indicated probable diversion of medications. Following the internal investigation, the NHA and DON were notified, and the police were called to the facility. The LPN in question was found to be impaired and refused a urine test, after which they were escorted from the facility by police. Despite these findings and actions, the NHA confirmed that the incident was not reported to the State Survey Agency, citing direction from the corporate office. This omission constitutes a failure to comply with mandatory reporting requirements for suspected misappropriation.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to document, resolve, and provide responses to residents and/or their responsible parties regarding concerns for ten out of thirteen grievances submitted in March 2025. According to the facility's Resident Grievances and Concerns Policy, grievances are to be reviewed and completed within a reasonable time frame, not to exceed thirty days. However, a review of the March 2025 grievance log showed that as of May 15, 2025, ten grievances lacked documentation of parties being informed of findings or completed dispositions. This was confirmed by the Nursing Home Administrator during an interview, indicating noncompliance with the facility's own policy and state regulations regarding grievance handling and resident rights.
Unsupervised Hot Beverage Carts Create Accident Hazard
Penalty
Summary
The facility failed to maintain a resident environment free from potential accident hazards in two of six hallways (2A and 2B). Facility policy prohibits personal beverage heating devices and requires that hot beverages not be left unattended for resident self-service, especially for residents with decreased safety awareness or physical limitations. Despite this, observations revealed that coffee carts containing hot beverages were left unsupervised in the hallways outside resident rooms on multiple occasions. Staff interviews confirmed that residents, including those with Alzheimer's and dementia, were able to access the carts and serve themselves throughout the day without supervision. The facility's CMS-802 form indicated that 24 residents with Alzheimer's or dementia resided on the affected hallways, conditions that can impair memory, judgment, and safety awareness. Multiple nurse aides and a registered nurse acknowledged that the coffee carts were left unattended and that residents frequently accessed them independently. The Director of Nursing confirmed the failure to provide a resident environment free of potential accidental hazards in these areas.
Failure to Implement Effective QAPI for LPN Staffing
Penalty
Summary
The facility failed to maintain and implement an effective Quality Assurance and Performance Improvement (QAPI) program specifically for staffing Licensed Practical Nurses (LPNs). The deficiency was identified through a review of facility documentation and staff interviews, which revealed that the facility did not adhere to the required staffing ratios for LPNs. The Plan of Correction indicated that the facility administration was responsible for ensuring a minimum of one LPN per 25 residents during the day shift and one LPN per 30 residents during the evening shift. However, the staffing sheets from September 21 to September 23, 2024, showed that the facility did not meet these staffing requirements on several occasions. On September 21, 2024, during the day shift, the facility had a census of 127 residents but only 3 LPNs, whereas 5.08 were needed. Similarly, on the evening shift of the same day, with a census of 128 residents, the facility had 4 LPNs instead of the required 4.27. The following day, the day shift required 5.12 LPNs for a census of 128, but only 4 were present. The evening shift also fell short with 4 LPNs instead of the needed 4.27. On September 23, 2024, the day shift required 5.12 LPNs for a census of 128, but only 5 were available. These discrepancies were confirmed during an interview with the Assistant Director of Nursing, who acknowledged the facility's failure to implement an effective QAPI plan for LPN staffing.
Failure to Protect Resident from Verbal Abuse and Medication Administration Lapse
Penalty
Summary
The facility failed to protect a resident, identified as CR2, from verbal abuse and mental anguish. The incident involved a Nurse Aide (NA) Employee E10, who was reported to have been verbally abusive towards Resident CR2. The resident, who has a history of atrial fibrillation, heart failure, and high blood pressure, and is dependent on assistance for toileting, was criticized by NA Employee E10 for experiencing incontinence. The NA made derogatory remarks about the resident's condition and her relationship with her daughter, causing the resident to feel ashamed and tearful. The NA admitted to not being kind or pleasant during an interview about the incident, leading to her termination for verbal abuse. Additionally, the facility failed to provide necessary medication administration services to 29 residents on the Memory Impaired Unit. Medications from a previous evening shift were found unattended at the bedside in multiple rooms, indicating they were not administered. A Registered Nurse (RN) Employee E12, who was responsible for 45 residents, reported being unable to ensure each resident took their medications due to the workload. This omission of medication administration was confirmed by the Nursing Home Administrator, highlighting a significant lapse in the facility's duty to provide essential care services.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to fully investigate alleged allegations of abuse and neglect for 30 residents. The facility's policy, dated 6/1/24, mandates the investigation of all allegations and suspicions of abuse, neglect, and other related incidents. However, the facility did not adhere to this policy. For instance, Resident R20, who has dementia, diabetes, and hypertension, sustained a leg injury from a Hoyer lift, but no investigation was conducted. Additionally, medications were found at the bedside in multiple rooms on the Memory Impaired Unit, indicating they were not administered to residents. The facility did not document which medications were found, how long they were unattended, or whether they were re-administered. The Director of Nursing confirmed that a thorough investigation was not completed, as only staff directly involved were interviewed, and not all potential witnesses or other staff members who had contact with the residents were questioned. This lack of comprehensive investigation was consistent across all 30 residents involved in the alleged abuse and neglect incidents. The facility's failure to investigate these allegations violated several Pennsylvania Code regulations, including those related to the responsibility of the licensee, management, resident rights, resident care policies, and nursing services.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for five out of six residents who were transferred from the facility. The facility's policy, dated 6/1/24, required the completion of appropriate forms to convey specific information during resident transfers. However, upon review of the clinical records for Residents R7, R9, R21, R56, and R58, there was no documented evidence that the facility had communicated essential information such as care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information to the receiving health care provider. Each of the residents involved had significant medical conditions, including diabetes, major depressive disorder, myelodysplastic syndrome, acute respiratory failure, hypertension, severe protein-calorie malnutrition, cerebral infarction, cerebral palsy, aphasia, epilepsy, and end-stage renal disease. Despite these complex medical needs, the facility did not provide the necessary information to ensure continuity of care during their transfers to the hospital. This deficiency was confirmed during an interview with the Director of Nursing.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to the Office of the Long-Term Care Ombudsman Division regarding the transfer of five residents to the hospital. According to the facility's policy, a staff designee is responsible for ensuring that the original discharge-transfer letter is given to the resident or guardian, with copies sent to the Ombudsman Office and scanned into the electronic chart. However, the facility did not adhere to this policy for residents who were transferred to the hospital, as there was no documented evidence of written transportation notifications being sent to the Ombudsman Office. The residents involved had various medical conditions, including diabetes, major depressive disorder, myelodysplastic syndrome, acute respiratory failure, hypertension, severe protein-calorie malnutrition, cerebral infarction, cerebral palsy, aphasia, epilepsy, and end-stage renal disease. Despite these conditions, the facility did not provide the required notifications for their hospitalizations. The Director of Nursing confirmed the oversight during an interview, acknowledging the failure to notify the Ombudsman for the transfers of these residents.
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to notify residents or their representatives about the bed-hold policy during hospital transfers for five out of six cases reviewed. The bed-hold policy is an agreement for the facility to hold a resident's bed for an agreed-upon rate during hospitalization. The facility's policy, dated 6/1/24, requires that a bed-hold notice be provided along with the discharge-transfer letter, and these notices should be documented in the electronic records. However, the clinical records for Residents R7, R9, R21, R56, and R58 lacked documented evidence that such notifications were given at the time of their respective hospital transfers. The residents involved had various medical conditions, including diabetes, major depressive disorder, myelodysplastic syndrome, acute respiratory failure, hypertension, severe protein-calorie malnutrition, cerebral infarction, cerebral palsy, aphasia, epilepsy, and end-stage renal disease. Despite these conditions and the transfers to hospitals, the facility did not provide the required written information about the bed-hold policy. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the failure to notify the residents or their representatives as per the facility's policy.
Care Plan Deficiencies for Multiple Residents
Penalty
Summary
The facility failed to update care plans for four residents, leading to deficiencies in accurately reflecting their current status and care needs. Resident R63's care plan did not include the use of a wander guard bracelet, despite physician orders indicating its necessity for safety. Resident R66's care plan was not updated to reflect the current diet order and use of a protein modular supplement, as confirmed by the Registered Dietitian. Additionally, the care plan for Resident R66 did not address impaired skin integrity for a chronic callus on the right plantar foot and an abrasion on the left second toe. Resident R98's care plan failed to include a fluid restriction order, which was part of the physician's directives. Similarly, Resident R111's care plan did not incorporate a cardiac care plan or management of medications, despite the resident's complex medical history, including dementia, anxiety, depression, and various cardiac conditions. The Director of Nursing confirmed these deficiencies, which were in violation of specific Pennsylvania Code regulations related to resident care policies, care plans, and nursing services.
Lack of Supervision and Elopement Risk Management in Memory Impaired Unit
Penalty
Summary
The facility failed to provide necessary supervision and monitoring of potential resident accidents for all 29 residents on the Memory Impaired Unit. This was evidenced by medications from the previous evening shift being found at the bedside in multiple rooms, not administered to the residents. Observations indicated that residents were freely wandering about the unit, with some lying in other residents' beds and taking items from tables and trays. The BIMS scores for these residents ranged from 0-9, indicating severe to moderate cognitive impairment. Staff interviews confirmed the lack of supervision, with residents wandering aimlessly and taking each other's belongings. Additionally, the facility failed to assess and implement interventions to prevent the potential for elopement for a resident admitted with cognitive decline. Although a wander guard was placed on the resident, there was no assessment for elopement risk on admission, no physician order for the wander guard, and no plan of care indicating goals or interventions to prevent elopement. The DON confirmed these deficiencies during an interview.
Failure to Include Medical Director in QAA Meetings
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for three out of four quarterly meetings. Specifically, the meetings held in October 2023, February 2024, and April 2024 did not include the attendance of the facility's Medical Director, as evidenced by the review of Quality Assurance and Performance Improvement (QAPI) sign-in sheets and attendance records. This deficiency was confirmed during an interview with the Nursing Home Administrator on September 13, 2024, who acknowledged the absence of the Medical Director from these meetings, which is a requirement under the Code of Federal Regulations S483.75(g). The regulation mandates that the QAA committee must include the Director of Nursing Services, the Medical Director or their designee, at least three other staff members including one in a leadership role, and the Infection Preventionist.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement effective infection prevention and control measures, as evidenced by several deficiencies observed during a survey. One significant issue involved a Licensed Practical Nurse (LPN) who did not follow proper procedures during a dressing change for a resident with a sacral wound. The LPN entered the resident's room without donning isolation equipment, touched objects without gloves, and failed to change gloves after cleaning the wound, which could lead to cross-contamination. Additionally, the LPN did not clean the bedside table before placing supplies on it, further increasing the risk of infection. The facility also failed to track Enhanced Barrier Precautions (EBP) for four residents, as they were not listed on the facility's isolation-precaution tracking list despite having personal protective equipment (PPE) and signage for EBP. This oversight was confirmed by the Infection Preventionist, indicating a lack of proper surveillance and documentation of infection control measures. Furthermore, the facility did not follow proper PPE usage protocols on one of the units, as staff were observed reusing isolation gowns, which should have been disposed of after each use. Additionally, the facility did not maintain an effective infection control program, as there was no surveillance for tracking infections for residents and staff over a ten-month period. The Infection Preventionist admitted to not plotting out infections monthly to monitor their spread. Moreover, comprehensive care plans related to infection precautions were not developed for five residents, leaving them without appropriate care plans to address their isolation precautions. These deficiencies highlight significant lapses in the facility's infection prevention and control practices.
Failure to Timely Convey Resident Funds After Death
Penalty
Summary
The facility failed to convey resident funds in accordance with State law and did not close accounts upon death in a timely manner for one of the closed resident records reviewed. The facility's Admission Assessment policy, last reviewed on June 1, 2024, indicated that available funds in a resident's account should be distributed within 60 days of the resident's death. However, this policy was not followed for a resident who had a balance of $8,480 at the time of her death. The resident, who had been admitted with diagnoses including congestive heart failure, gastro-esophageal reflux disease, and constipation, was noted to have passed away on May 12, 2024. Despite this, her account remained open beyond the 60-day period stipulated by the facility's policy. During an interview, the Business Office Manager, who had been in the position for about three months, acknowledged that the account closure process required corporate approval, which contributed to the delay. This failure was confirmed by the Business Office Manager, indicating non-compliance with the state regulation 28 Pa. Code 211.5(d) regarding clinical records.
Failure to Notify Physician of Medication Error
Penalty
Summary
The facility failed to notify a medical provider of a change in condition for Resident R111, as required by their policy. The policy, dated 6/1/24, mandates that the physician/provider and resident/family/responsible party be notified in the event of an accident or incident involving the resident. Resident R111, who has diagnoses of dementia, stroke, and high blood pressure, was involved in an incident on 8/22/24, where medications scheduled for 7:00 a.m. were found at the resident's bedside, indicating they were not taken. The medications included Lopressor, Plavix, Lexapro, Norvasc, and an unidentified pink pill. The event report noted that neither the attending physician nor the resident's representative was notified of this medication error. The deficiency was confirmed during an interview with the Director of Nursing on 9/13/24, who acknowledged the failure to notify a medical provider of the change in condition for Resident R111. The review of Resident R111's progress notes also failed to show any entry regarding the notification of the physician about the medication error. This oversight is a violation of the resident's rights and the facility's resident care policies, as outlined in the relevant Pennsylvania Code sections.
Failure to Ensure Understanding of NOMNC for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident's rights to make informed decisions and choices about their health, safety, and welfare were upheld. Specifically, the facility did not adequately explain the Notice of Medicare Non-Coverage (NOMNC) form to a resident, identified as Resident R14, who had a moderate cognitive impairment. The resident was admitted to the facility with a BIMS score of 10, indicating moderate cognitive impairment, and had diagnoses of colon cancer and heart failure. Despite this, the NOMNC form was signed by the resident without ensuring that the resident or their representative fully understood the implications of the document. The resident expressed a desire for more therapy and wanted to appeal the decision, instructing the facility to contact their son to handle the appeal. However, the facility only left a message for the son with details about the NOMNC and the appeal process, without confirming that the information was understood or acted upon. This oversight was confirmed by the Nursing Home Administrator during an interview, acknowledging the failure to explain the NOMNC in a manner comprehensible to the resident and their representative.
Inaccurate Resident Assessments Identified
Penalty
Summary
The facility failed to ensure accurate resident assessments for two of twelve residents, as identified through a review of the Resident Assessment Instrument (RAI), clinical records, and staff interviews. For Resident R52, the Minimum Data Set (MDS) assessment did not reflect the use of continuous oxygen therapy, despite physician orders and care plans indicating oxygen at five liters per minute was administered continuously. The resident's administration record for July 2024 confirmed the use of oxygen every shift throughout the month, yet this was not documented in Section O of the MDS, which pertains to special treatments, procedures, and programs. For Resident R111, the MDS assessment failed to accurately code the resident's diagnoses. Although the resident was admitted with multiple diagnoses, including dementia, anxiety, depression, and several other conditions, the MDS only reflected a diagnosis of non-traumatic brain dysfunction. This omission was confirmed during an interview with a registered nurse and the nursing home administrator, who acknowledged the inaccuracies in the MDS assessments for both residents. These deficiencies were found to be in violation of 28 Pa. Code: 211.12(d)(1)(2)(3)(5) regarding nursing services.
Failure to Notify Physician and Provide Wound Care
Penalty
Summary
The facility failed to notify a physician of abnormal glucose readings for a resident with diabetes, hemiplegia, and protein-calorie malnutrition. The resident's care plan required monitoring for signs of hypoglycemia and hyperglycemia, with specific instructions to notify the physician if glucose levels were below 70 or above 400. Despite this, the resident experienced multiple abnormal glucose readings, including low and high off-scale readings, and a reading of 55, without any documented notification to the physician. The Director of Nursing confirmed the failure to notify the physician as per the order. Additionally, the facility did not provide appropriate treatment for a non-pressure wound on another resident, who had a cerebral infarction, aphasia, and dysphagia. The resident's clinical notes indicated a chronic callus and an improving abrasion on the left second toe, with specific wound care orders to cleanse and apply betadine. However, the current physician orders and treatment records did not reflect these wound care instructions, and no treatment was documented for the abrasion over a ten-day period. The Resident Nursing Assessment Coordinator confirmed the lack of appropriate treatment for the wound.
Failure to Document and Plan for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the resident's status and did not develop a comprehensive care plan for a resident with a pressure ulcer. The Resident Assessment Instrument (RAI) User's Manual requires documentation of skin conditions, including pressure ulcers, in the MDS assessments. However, the MDS for a resident with high blood pressure, anxiety, and Alzheimer's disease did not include the current pressure ulcer, despite the resident being followed by Hospice and Wound management. Additionally, the resident's care plan did not address the existing pressure ulcer or outline a treatment plan, even though physician orders specified daily wound care procedures. Interviews with the Registered Nurse Assessment Coordinator and the Director of Nursing confirmed the oversight, acknowledging the absence of a care plan and the failure to capture the pressure ulcer in the MDS. This deficiency was identified for one of four residents reviewed.
Inadequate Catheter Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate treatment and services for two residents with indwelling urinary catheters. Resident R49, who has diagnoses of obstructive uropathy, diabetes, and heart failure, was observed in a wheelchair with the catheter drainage bag attached to the bottom of the chair without a protective dignity pouch, contrary to the physician's order and care plan. This was confirmed by an LPN during an observation. Similarly, Resident R107, diagnosed with obstructive uropathy, Alzheimer's Disease, and sepsis, was found in bed with the catheter drainage bag on the floor and uncovered, which was against the physician's order and care plan. This was confirmed by a nurse aide. The Director of Nursing acknowledged the facility's failure to ensure appropriate catheter care for these residents.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide specialized respiratory care in accordance with professional standards for three residents. Resident R52, diagnosed with Alzheimer's Disease, heart failure, and respiratory failure, had a physician's order for continuous oxygen at five liters per minute. However, observations revealed that the oxygen cannula was not attached to the concentrator, was on the floor, and the filter tube was disconnected. Additionally, the cannula was outdated, as confirmed by an LPN. Resident R60, with diagnoses including high blood pressure and non-Alzheimer's dementia, had a physician's order for oxygen at two liters per minute via nasal cannula. The cannula was found on top of the concentrator, not stored in a plastic bag, and lacked a date. Similarly, Resident R101, diagnosed with high blood pressure, Alzheimer's dementia, and respiratory failure, had a physician's order for albuterol nebulization twice daily. The nebulizer tubing and mask were observed on top of the machine, not bagged, and undated. These deficiencies were confirmed by a nurse aide and the Nursing Home Administrator.
Insufficient Staffing in Memory Impaired Unit
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents in the Memory Impaired Unit, affecting 29 residents. Observations, clinical record reviews, and interviews with residents and staff revealed that the facility did not maintain adequate staffing levels, as required by their policy. The Dayforce Scheduling Policy, which mandates proficiency in scheduling to ensure adequate staffing, was not effectively implemented. Additionally, the Registered Nurse Supervisor's job description emphasized the importance of administering medications per physician orders, which was not adhered to, as medications were found unadministered at residents' bedsides. Interviews with staff highlighted the challenges faced due to insufficient staffing. A Registered Nurse reported being the only nurse on the floor for 45 patients, making it difficult to administer medications and provide quality care. Nurse aides also reported being understaffed, which led to delays in providing essential care such as showers and meals. The Director of Nursing confirmed the facility's failure to provide adequate nursing services, impacting the physical, mental, and psychosocial well-being of the residents. This deficiency was in violation of several Pennsylvania Code regulations related to resident care and nursing services.
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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