Quality Life Services - Markleysburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Markleysburg, Pennsylvania.
- Location
- 252 Main Street, Markleysburg, Pennsylvania 15459
- CMS Provider Number
- 395870
- Inspections on file
- 25
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Quality Life Services - Markleysburg during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and high assistance needs for bed mobility sustained a femur fracture during repositioning when only one staff member assisted, despite documentation showing frequent need for two-person assistance. The facility lacked clear policies and consistent documentation regarding ADLs, transfers, and bed mobility, leading to inconsistent staff understanding and communication about required assistance levels.
Surveyors found that insulin vials and pens on a medication cart were not properly labeled with open or expiration dates, some expired vials were not disposed of, and medications were left accessible in an unattended area. An LPN and the ADON confirmed that medications were not stored or labeled according to facility policy, and insulin pens were not stored to prevent cross-contamination.
A resident with decreased mobility and a right ankle fracture immobilized with a T scope brace did not receive timely or consistent skin assessments, resulting in the development of Stage I and Stage III pressure ulcers related to the brace. The care plan was not updated to address the resident's increased risk, and staff did not implement necessary preventive interventions, leading to actual harm.
A resident with significant physical and cognitive impairments, who required staff assistance and adaptive equipment for eating, was served hot soup without a lid and left unsupervised. The resident spilled the soup, resulting in a second-degree burn to the thigh that required treatment. Staff and DON confirmed that care plan interventions for hot liquid safety and supervision were not followed at the time of the incident.
A resident with a history of stroke, lung disease, and falls inappropriately touched another resident and was prescribed medication for hypersexual behaviors. However, staff failed to monitor or document the resident's sexual behaviors, and there was no tracking of his whereabouts to prevent further incidents, as confirmed by the DON.
Surveyors identified that 16 rooms did not meet the required 80 square feet per resident, with measured space per bed ranging from 64.92 to 78.40 square feet. The NHA confirmed the deficiency during interview.
Five nurse aides did not receive the required 12 hours of annual in-service education within their respective 12-month periods, as confirmed by review of training records and the DON. Each aide received only four to nine hours of education, resulting in noncompliance with staff development regulations.
A resident with a suprapubic catheter, diagnosed with multiple sclerosis and neuromuscular bladder dysfunction, reported that a CNA failed to empty the catheter bag as ordered, resulting in excessive urine accumulation. Although the facility's policy required reporting all allegations of neglect, this incident was not reported to the appropriate authorities as required.
Two residents experienced incidents—one involving inappropriate contact and another involving elopement—where clinical records were not accurately or completely documented according to facility policy. The DON confirmed failures in documentation following these events.
Several residents with diabetes did not receive their prescribed insulin doses as ordered, despite blood sugar checks being performed by an RN. The missed administration of insulin was identified by supervisory staff, and the responsible RN acknowledged the oversight, which was confirmed by nursing leadership as a failure to protect residents from neglect.
Four residents with diabetes did not receive insulin as ordered, either due to missed blood sugar checks or failure to administer insulin coverage before meals. Facility leadership and nursing staff confirmed that insulin administration was not consistently managed according to policy, resulting in significant medication errors.
A resident experienced a significant delay in bowel movements, and the facility failed to follow its bowel management protocol. Despite the resident's dangerously high blood pressure and emergent symptoms, the nursing staff did not take immediate action, leading to the resident calling 911 for hospital transport. The resident was later admitted to the ICU with serious conditions.
The facility failed to notify physicians of abnormal blood glucose levels and did not assess residents for hyperglycemia and hypoglycemia, affecting four residents with diabetes. Despite facility policies requiring physician notification for clinical changes, residents with abnormal CBG levels were not assessed or reported. Interviews with LPNs revealed inconsistencies in understanding notification thresholds, and the DON confirmed the failure to notify physicians.
A resident with dementia and unsteadiness on feet experienced two falls due to improper footwear. The facility failed to update the care plan with non-skid footwear interventions until after the second fall, despite the resident's poor safety awareness. The Nursing Home Administrator and DON confirmed the oversight.
The facility failed to provide mandatory annual training on the prevention of abuse, neglect, and misappropriation for four staff members, including two NAs and two RNs. Despite the facility's policy requiring such training, records showed these employees did not receive the necessary education within the specified timeframe. This deficiency was confirmed by the Nursing Home Administrator.
A resident with mood disorder and depression exhibited increased behavioral symptoms after a medication dose reduction. The facility failed to conduct an evaluation for these symptoms and possible suicidality, and the psychiatrist decreased medications without an assessment. Staff confirmed the lack of appropriate treatment and services for the resident's mental health needs.
The facility did not provide mandatory effective communication training for four staff members, including two NAs, an LPN, and an RN, as required by their policies. This deficiency was confirmed by the Nursing Home Administrator.
The facility failed to provide mandatory annual training on residents' rights for a Nurse Aide and an RN. Despite the facility's assessment requiring such training, these staff members did not have documented training within the specified timeframe. This deficiency was confirmed by the Nursing Home Administrator.
The facility did not provide mandatory QAPI training to six staff members, including NAs and RNs, as required by their policy. The absence of documented training was confirmed by the Nursing Home Administrator, indicating a deficiency in meeting training requirements.
The facility failed to provide mandatory Compliance and Ethics training for six staff members, including NAs and RNs, as required by their policies. The deficiency was confirmed by the Nursing Home Administrator and violates Pennsylvania Code regulations related to staff development and management.
Failure to Prevent Injury During Bed Mobility Due to Lack of Clear Policies and Communication
Penalty
Summary
The facility failed to prevent injury to a resident during the provision of care, specifically while assisting with bed mobility. The resident in question had significant cognitive impairment, as indicated by a BIMS score of 03, and required substantial to maximum assistance for bed mobility, as documented in the Minimum Data Set (MDS) and daily care records. Physician orders specified the use of bilateral assist rails for bed mobility and a mechanical lift with two staff for transfers. The care plan also directed staff to use caution during transfers and repositioning to prevent injury. However, the facility was unable to provide policies regarding Activities of Daily Living (ADLs), resident transfers, or bed mobility, and the Kardex did not indicate the resident's bed mobility status. On the date of the incident, a nurse aide was assisting the resident with rolling in bed using standard technique when the resident began to push against the handrail, causing a shift in body weight and resistance. The aide applied additional pressure to complete the turn, at which point an audible snap was heard from the resident's leg area, and the resident began to scream in pain. Subsequent x-rays confirmed an acute spiral oblique subtrochanteric fracture of the proximal left femur. Documentation showed that the resident routinely required assistance of two staff for bed mobility on most days in the months leading up to the incident. Interviews with staff revealed inconsistencies in how bed mobility assistance needs were determined and communicated. Some staff relied on point of care charting, while others would ask nurses or therapy staff. The occupational therapist stated that substantial/maximal assistance did not always mean two staff were needed, and that staff were left to decide the level of assistance required. The facility's failure to provide clear policies and consistent documentation regarding bed mobility and assistance needs contributed to the incident in which the resident sustained a significant injury during care.
Improper Labeling and Storage of Insulin Medications
Penalty
Summary
Facility staff failed to properly label and store insulin medications in accordance with facility policy and accepted professional standards. During an observation of the Blue medication cart, several insulin vials and pens were found to be either undated upon opening, lacking expiration dates, or not disposed of after expiration. Specifically, one Aspart insulin vial was found with both open and expiration dates, two Aspart vials were missing expiration dates, one Lantus vial was opened but not dated, and three Lantus flex pens were opened, undated, and not stored in individual bags, increasing the risk of cross-contamination. Additionally, the medication cart was left unattended in a resident lounge with medications accessible to residents, guests, and visitors. Staff interviews confirmed these findings, with both an LPN and the Assistant Director of Nursing acknowledging that the medications were not stored or labeled according to policy. Facility policies require that insulin vials be marked with the resident's name, the date opened, and an expiration date, and that all medications be stored in a locked, organized, and sanitary manner. The observed deficiencies included failure to date insulin vials upon opening, failure to dispose of expired vials, and improper storage of medications, all of which were confirmed by facility staff during the survey.
Failure to Prevent and Manage Pressure Ulcers Associated with Medical Device
Penalty
Summary
The facility failed to develop and implement care and services consistent with professional standards of practice to prevent the development of pressure ulcers in a resident with a right ankle fracture who was immobilized with a T scope brace. The resident, who had multiple diagnoses including respiratory failure, traumatic brain injury, and decreased mobility requiring assistance of two staff for bed mobility, was ordered to wear the brace at all times except for hygiene. Despite this, there was no documentation of skin checks to the right leg for 16 days after the brace was applied, and weekly skin assessments were inconsistently documented, with several missed opportunities noted in the Treatment Administrative Record. As a result of these lapses, the resident developed a Stage I pressure ulcer on the right inner and outer knee, and a Stage III pressure ulcer on the right lateral ankle, both associated with the use of the medical device. The care plan was not updated to reflect the resident's increased risk for pressure ulcers or the need for individualized interventions and skin assessments. Staff interviews confirmed that required interventions to prevent pressure ulcers were not implemented, leading to actual harm for the resident.
Failure to Provide Supervision and Hot Liquid Safety Results in Resident Burn
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for one resident, resulting in harm. The resident, who had multiple diagnoses including respiratory failure, traumatic brain injury, communication deficit, repeated falls, and required physical assistance with eating, was served hot soup measured at 170 degrees Fahrenheit. The resident's care plan and physician orders specified that hot liquids should be served with lids and that the resident required supervision and assistance during meals. However, these interventions were not followed, and the resident was left unsupervised with uncovered hot soup, which he subsequently spilled onto his right upper, inner thigh, causing a second-degree burn. Staff interviews and documentation confirmed that the dietary and care plans indicated the need for lids on hot liquids and staff assistance, but these were not implemented at the time of the incident. The DON acknowledged that the resident should have had a lid on the soup and required assistance during meals, which was not provided. As a result, the resident suffered a burn injury that required treatment, demonstrating a failure to follow established safety protocols and care plan interventions.
Failure to Monitor and Document Sexual Behaviors
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of behaviors for a resident who had a history of stroke, lung disease, and falls. The resident was involved in an incident where he inappropriately touched another resident without consent. Documentation showed that the resident admitted to the behavior and was questioned about increased sexual drives, to which he was unsure, and he refused a transfer to a Behavioral Health Unit. The facility physician was notified and prescribed medication to address hypersexual behaviors. Despite the prescription of Medroxyprogesterone to decrease sexual drive, the resident's Medication Administration Record and Treatment Administration Record did not include any monitoring of sexual behaviors. There was no documentation of behavior monitoring by nursing, social services, or nursing assistants, and the resident's whereabouts were not tracked to prevent further incidents. The resident's room was located near rooms occupied by female residents, increasing the risk of recurrence. The Director of Nursing confirmed the lack of proper monitoring and documentation for this resident.
Resident Bedroom Size Below Regulatory Minimum
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet of space per resident in multiple occupancy rooms, as mandated by regulation. During an observation of the facility's floor plan, it was found that 16 out of 25 resident rooms did not meet this requirement, with individual resident space ranging from 64.92 to 78.40 square feet per bed in affected rooms. This deficiency was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the room sizes were less than the required 80 square feet per resident. The findings were based on direct measurement and review of the facility's room dimensions.
Failure to Provide Required Annual In-Service Education for Nurse Aides
Penalty
Summary
The facility failed to provide the required 12 hours of annual in-service education within 12 months of the hire date anniversary for five nurse aides. Review of staff education records and facility-provided documents showed that each of these nurse aides received between four and nine hours of in-service education during the relevant 12-month periods, falling short of the regulatory requirement. The Director of Nursing confirmed during an interview that the required education was not completed for these staff members. This deficiency was cited under 28 Pa. Code: 201.14(a) and 28 Pa. Code: 201.20(c) for responsibility of the licensee and staff development, respectively.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect involving one resident. The resident, who had multiple sclerosis and neuromuscular dysfunction of the bladder, was re-admitted to the facility and had a suprapubic catheter in place. According to a physician's order, the catheter was to be emptied every two hours with documentation. On one occasion, the resident reported through a grievance form that a CNA did not empty the catheter bag as required, resulting in the bag containing 1300cc of urine instead of the usual 500cc. The resident expressed concern about potential illness due to this incident. The facility's policy required all allegations of abuse or neglect to be reported to the appropriate authorities, including the PA Department of Health/Long Term Care Division. However, a review of reports submitted to the state field office showed that this specific allegation was not reported. The Assistant Director of Nursing confirmed during an interview that the facility did not report the resident's allegation of neglect as required by policy and state regulations.
Incomplete and Inaccurate Clinical Record Documentation Following Resident Incidents
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for two residents. For one resident with epilepsy, obesity, and dysphagia, an incident occurred in which another resident inappropriately touched her. While immediate actions were taken to separate the residents and assess for injuries, documentation in the clinical record was incomplete, lacking detailed information as required by facility policy. The care plan was updated days later, but the initial documentation did not fully capture the assessment, interventions, and communications as outlined in facility procedures. For another resident with encephalopathy, depression, and alcohol dependence, an incident was reported where the resident was found outside the facility after allegedly climbing out of a window. Although the resident had a history of wandering risk, assessments were inconsistent, with some indicating risk and others not. The care plan included interventions for monitoring and documenting wandering behavior, but documentation was not accurate or complete regarding the incident. The DON confirmed that the facility failed to ensure accurate and complete documentation for both residents following these incidents.
Failure to Administer Insulin as Ordered Resulting in Resident Neglect
Penalty
Summary
The facility failed to protect residents from neglect by not administering insulin as ordered to four of eight residents with diabetes. Facility policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. Clinical record reviews showed that residents with diagnoses including hypertension, cerebrovascular disease, and Type 2 diabetes had physician orders for scheduled insulin administration. On the specified date, a registered nurse obtained blood sugar readings for several residents but did not administer the required insulin coverage before meals as ordered. In one case, a blood sugar reading was not obtained, resulting in no insulin being given. Documentation and staff interviews confirmed that the missed insulin doses were identified by the RN Supervisor, and the responsible RN acknowledged not covering the residents' blood sugars after obtaining accuchecks, stating that priorities were not in line and residents were put at risk. The Director of Nursing and Assistant Director of Nursing confirmed the failure to administer insulin as ordered, which constituted neglect under facility policy and state regulations.
Failure to Administer Insulin as Ordered Results in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically related to the administration of insulin for four out of eight residents reviewed. Facility policy required medications to be administered according to physician orders, manufacturer specifications, and professional standards. However, documentation showed that insulin was not administered as ordered for multiple residents with type 2 diabetes and other comorbidities such as hypertension and cerebrovascular disease. In several cases, blood sugar checks were either not performed as ordered or, when performed, were not followed by the required insulin coverage prior to meals. For example, one resident did not receive sliding scale insulin coverage before breakfast despite a blood sugar check, and another did not have a blood sugar reading obtained, resulting in no insulin being given. A review of staff documentation and interviews confirmed that the responsible RN did not administer insulin coverage after obtaining blood sugar readings for four residents. The Nursing Home Administrator, DON, and Assistant DON acknowledged that insulin administration was not consistently managed under the facility's medication administration policy, leading to these significant medication errors. The findings were supported by clinical record reviews, staff statements, and direct confirmation from facility leadership.
Failure to Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to appropriately respond to a resident's change in condition, specifically regarding bowel management and cardiovascular monitoring. The facility's policy for bowel management was not followed for a resident who experienced a significant delay in bowel movements. Despite the resident not having a bowel movement for several days, the administration of Senna and Bisacodyl, as per the facility's protocol, was not documented. This oversight led to the resident experiencing lower abdominal pain and a firm, tender abdomen with decreased bowel sounds, prompting the resident to call 911 for hospital transport. Additionally, the resident's blood pressure was recorded at dangerously high levels, significantly above their normal range, yet the nursing staff did not take immediate action. The resident was eventually admitted to the Intensive Care Unit with serious conditions, including osteomyelitis, hydronephrosis, and hydroureter, and required intravenous antibiotics. The Nursing Home Administrator confirmed that the nursing staff should not have attempted to delay the resident's request for hospital evaluation, acknowledging the failure to respond appropriately to the resident's emergent symptoms.
Failure to Notify Physicians of Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to notify physicians of abnormal capillary blood glucose (CBG) levels and did not assess residents for hyperglycemia and hypoglycemia, affecting four residents. The facility's policies required staff to notify physicians of clinical changes, including abnormal lab values, and to document these notifications. However, the facility did not adhere to these policies, resulting in a lack of physician notification for residents with abnormal CBG levels. Resident R6, diagnosed with diabetes, dementia, and depression, had multiple instances of elevated CBG levels, including readings of 416, 450, and 439, without physician notification or assessment for hyperglycemia. Similarly, Resident R31, with diabetes, anxiety, and high blood pressure, experienced hypoglycemic episodes with CBG levels of 51, 51, and 52, yet was not assessed for hypoglycemia, and the physician was not notified. Resident R39, with diabetes, depression, and shortness of breath, also had low CBG readings of 58, 53, and 57, without appropriate assessment or physician notification. Resident R45, diagnosed with diabetes and high blood pressure, consistently had a CBG level of 341 over several dates, but the facility failed to assess for hyperglycemia or notify the physician. Interviews with LPNs revealed inconsistencies in their understanding of when to notify physicians, with varying thresholds for abnormal CBG levels. The Director of Nursing confirmed the facility's failure to notify physicians of changes in residents' conditions related to blood glucose levels.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement interventions to prevent falls for a resident identified as R25, who had a history of dementia and unsteadiness on feet. The resident experienced two falls within a short period. The first fall occurred in the dining room, where the resident was found on the floor with a small skin tear on the left elbow. It was noted that the resident's shoes were not non-skid and slid easily on the floor, but this was not initially documented as a predisposing factor in the incident report. The care plan at that time did not include an intervention for non-skid footwear. The second fall happened when the resident attempted to walk independently and slid, reopening the previous skin tear on the right elbow. Again, the resident was wearing shoes that slid easily on the floor. This time, the incident report acknowledged improper footwear as a predisposing factor. Despite the resident's dementia and poor safety awareness, the care plan was not updated to include non-skid footwear until after the second fall. The Nursing Home Administrator and Director of Nursing confirmed the failure to implement necessary interventions to prevent falls.
Failure to Provide Mandatory Abuse Prevention Training
Penalty
Summary
The facility failed to provide mandatory annual training on the prevention of abuse, neglect, and misappropriation for four out of ten staff members, specifically Employees E2, E3, E5, and E7. The facility's assessment, which was reviewed on multiple occasions, indicated that staff training should include topics such as abuse, neglect, misappropriation, the Elder Justice Act, residents' rights, person-centered care, dementia training, and infection control and prevention. However, a review of the facility's documents and training records revealed that these employees did not have documented training on effective communication, which is a critical component of preventing abuse and neglect. The specific employees identified in the deficiency include Nurse Aide (NA) Employee E2, who was hired on 4/21/99, NA Employee E3, hired on 5/9/11, Registered Nurse (RN) Employee E5, hired on 5/8/17, and RN Employee E7, hired on 4/22/13. Each of these employees failed to receive the required in-service education on the prevention of abuse, neglect, and misappropriation within the specified timeframe for their respective hire dates. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the facility's failure to provide the necessary training for these staff members.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident, identified as Resident R39, to maintain the highest practicable mental and psychosocial well-being. Resident R39 was admitted with diagnoses of persistent mood disorder and depression, with a BIMS score indicating moderate cognitive impairment. The resident's care plan included monitoring for signs of depression and adverse effects of antidepressant medication. However, after a gradual dose reduction of Depakote, the resident exhibited increased behavioral symptoms, including striking out at a nurse aide and expressing a desire to die. Despite these concerning behaviors, the facility did not conduct an in-person or telehealth evaluation of the resident's increased behavioral symptoms and possible suicidality. The psychiatrist further decreased the resident's medications without evaluating the resident for these behaviors. Interviews with facility staff, including the Director of Nursing and the Nursing Home Administrator, confirmed the failure to provide appropriate treatment and services to address the resident's mental health needs, as required by the facility's policies and state regulations.
Failure to Provide Effective Communication Training
Penalty
Summary
The facility failed to provide mandatory training on effective communication for four out of ten staff members, as required by their own policies. The facility assessment indicated that staff training and education should include topics such as abuse, neglect, misappropriation, the Elder Justice Act, residents' rights, person-centered care, dementia training, and infection control and prevention, with effective communication being a mandatory annual training topic. However, upon review of the facility's documents and training records, it was found that Nurse Aide Employee E2, Nurse Aide Employee E4, Licensed Practical Nurse Employee E6, and Registered Nurse Employee E7 did not have documented training on effective communication within the specified time frames. This deficiency was confirmed by the Nursing Home Administrator during an interview.
Failure to Provide Residents' Rights Training
Penalty
Summary
The facility failed to provide mandatory annual training on residents' rights for two staff members, specifically a Nurse Aide and a Registered Nurse. The facility's assessment, which outlines required training topics such as abuse, neglect, and residents' rights, was reviewed and confirmed that these two employees did not have documented training on residents' rights within the specified timeframe. The Nurse Aide, hired in 1999, and the Registered Nurse, hired in 2013, both lacked this training between April 2023 and April 2024. This deficiency was confirmed during an interview with the Nursing Home Administrator.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on Quality Assurance and Performance Improvement (QAPI) for six out of ten staff members, as required by their policy. The review of facility documents and training records revealed that Nurse Aides (NAs) and Registered Nurses (RNs) with hire dates ranging from 1999 to 2022 did not receive documented QAPI in-service education within the specified annual period. This lack of training was confirmed during an interview with the Nursing Home Administrator. The facility's assessment indicated that staff training and education should include mandatory annual topics such as abuse, neglect, misappropriation, the Elder Justice Act, residents' rights, person-centered care, dementia training, and infection control and prevention. However, the absence of QAPI training for the identified staff members highlights a deficiency in adhering to these training requirements. The report cites specific Pennsylvania Code regulations related to the responsibility of the licensee, management, and staff development, underscoring the facility's failure to meet these standards.
Failure to Provide Compliance and Ethics Training
Penalty
Summary
The facility failed to provide mandatory training on Compliance and Ethics for six out of ten staff members, as required by their own policies. The facility's assessment, which was reviewed on multiple occasions, mandates annual training on various topics, including Compliance and Ethics. However, upon reviewing the education documents and training records, it was found that Nurse Aides E2, E3, and E4, Registered Nurses E5 and E7, and Licensed Practical Nurse E6 did not have documented training on Compliance and Ethics within the specified time frames corresponding to their hire dates. During an interview, the Nursing Home Administrator confirmed the lack of compliance with the training requirements for these staff members. This deficiency is in violation of several Pennsylvania Code regulations, specifically those related to the responsibility of the licensee, management, and staff development. The absence of documented training indicates a failure in the facility's staff development and management processes, as outlined in the cited regulations.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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