Rehab & Nursing Ctr Greater Pittsburgh
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensburg, Pennsylvania.
- Location
- 890 Weatherwood Lane, Greensburg, Pennsylvania 15601
- CMS Provider Number
- 395851
- Inspections on file
- 38
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Rehab & Nursing Ctr Greater Pittsburgh during CMS and state inspections, most recent first.
A resident with dementia, psychotic disorder with delusions, and a known history of wandering and wanting to leave, had been identified as an elopement risk and was documented as testing door handles and keypads and running toward open lobby doors. One evening, the resident was last observed in a wheelchair at the nurse’s station before EMS arrived and was granted entry through a remotely opened coded mag lock door. The resident, positioned close enough to the door, prevented it from closing, then moved through the corridor to an unalarmed exterior door, exited undetected, and was later found outside in a wheelchair by EMS attempting to approach the ambulance. Facility leadership acknowledged that adequate supervision to prevent elopement was not provided.
Surveyors observed that food products in the main kitchen's walk-in cooler and freezer were not stored according to facility policy, including an undated opened jar of grape jelly and boxes of food stacked to the ceiling and under fans. The Dietary Manager confirmed these improper storage practices and the failure to maintain sanitary conditions.
Three residents with diabetes experienced low blood glucose levels, but staff did not assess for hypoglycemia, monitor the effectiveness of treatment, or notify the physician as required by facility policy and physician orders. Care plans lacked appropriate interventions, and the DON confirmed these failures in documentation and protocol adherence.
Four residents with various medical conditions requiring oxygen therapy were found using oxygen equipment that was not labeled with the required date, contrary to facility policy and physician orders. Observations and staff interviews confirmed that proper labeling and maintenance procedures for oxygen tubing were not followed.
Grievance boxes in three facility locations were mounted above ADA-recommended heights and were sometimes blocked by furniture, making them inaccessible to residents, especially those using wheelchairs. Residents reported being unable to file grievances anonymously and often had to ask staff for assistance, which compromised their privacy. The NHA confirmed the lack of accessibility for these grievance boxes.
A resident who was cognitively intact and required moderate assistance for mobility was subjected to neglect and verbal abuse when a nurse aide failed to respond promptly to a call bell, made dismissive remarks, and exhibited a pattern of negative behavior including swearing and refusing assistance. The DON did not recognize these incidents as potential neglect or abuse and did not investigate further.
A resident with multiple medical conditions reported delayed response to a call bell and dismissive behavior from a nurse aide. Staff statements described the aide as having a negative attitude, swearing, and being unhelpful to residents. The DON did not recognize these incidents as potential abuse or neglect, failed to conduct a thorough investigation, and did not report findings to the State Survey Agency as required.
The facility did not post up-to-date nurse staffing information, as required, with the displayed information being outdated and not reflecting the current census or staffing hours. Both the receptionist and the NHA confirmed the posting was not current.
Surveyors found that the facility did not post required contact information for APS, the Medicaid Fraud Control Unit, or a statement about filing complaints with the State Survey Agency. The Nursing Home Administrator confirmed the absence of this information during an interview.
A resident with multiple medical conditions and a high risk for falls was not provided with adequate assistance or bedrails during incontinence care. A nurse aide turned the resident away and left her unsupervised while retrieving supplies, resulting in the resident falling from bed and sustaining a head injury and cervical fracture. Staff and leadership confirmed that proper supervision and interventions were not provided, constituting neglect.
A resident with multiple medical conditions and a high risk for falls was left unattended during incontinence care when a nurse aide turned away to retrieve supplies, resulting in the resident rolling out of bed. Bedrails, which were part of the care plan, were not in place at the time, leading to the resident sustaining a subarachnoid hemorrhage, scalp laceration, and C4 fracture. Staff and leadership confirmed that proper supervision and interventions were not provided.
The facility failed to offer four residents the opportunity to formulate advance directives, as required by policy. Despite having significant medical conditions, their records lacked documentation of being informed about their rights to accept or refuse treatment and to create an advance directive. This was confirmed by the Social Worker and DON.
The facility failed to secure medications in the B cart on the 300 hall, leaving it unattended and accessible to passersby. This was against the facility's policy, which requires medications to be stored in locked compartments with access limited to authorized personnel. The issue was confirmed by the DON.
A resident suffered a superficial frostbite burn due to improper supervision of cold pack use. The resident, with a history of sciatica and other conditions, reported that the ice pack was left on direct skin for too long, causing redness and blistering. The facility's policy required toweling and regular checks, but these were not effectively implemented, leading to harm.
Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for a resident who had documented dementia, a psychotic disorder with delusions, and a known history of wandering and expressing a desire to leave the facility. An Elopement Risk Evaluation completed months earlier identified the resident as being at risk for elopement, and the care plan reflected this risk due to wandering and verbalizations about wanting to leave. A progress note documented that the resident had been testing door handles and keypads and would run toward the lobby door when it was open, indicating ongoing elopement-seeking behavior. On the night of the elopement event, the resident was last seen by an LPN sitting in a wheelchair at the nurse’s station. When EMS arrived and rang the buzzer for entry, staff remotely opened the coded mag lock door after visually confirming who was entering. Based on the facility’s reenactment, the resident was close enough to the door to keep it from closing and then propelled through the door and down a 25-foot corridor to an outside door that was not alarmed. The resident pushed this outside door open and went outside undetected by staff. EMS later found the resident outside in a wheelchair attempting to go toward the ambulance, and nursing staff then brought the resident back inside. The Nursing Home Administrator and Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent this elopement.
Improper Food Storage in Main Kitchen
Penalty
Summary
The facility failed to properly store food products in the main kitchen's walk-in cooler and freezer, as observed during a survey. Specifically, an opened jar of grape jelly was found undated in the walk-in cooler, and multiple boxes of food items were stored up to the ceiling on top shelves and under fans in the freezer. These practices did not comply with the facility's policy, which requires all refrigerated and frozen foods to be covered, labeled, dated, and stored to allow adequate air circulation. The Dietary Manager confirmed these storage issues and acknowledged that the facility did not maintain sanitary conditions in the main kitchen.
Failure to Assess, Document, and Notify Physician of Hypoglycemia
Penalty
Summary
The facility failed to assess, document, and notify physicians of decreased capillary blood glucose (CBG) levels for three residents with diabetes. Facility policy required specific actions for hypoglycemia, including immediate notification of the provider, administration of glucose, monitoring, and documentation. However, clinical records and electronic medication administration records (eMAR) showed that when residents experienced low blood glucose readings, these protocols were not followed. For one resident with diagnoses including congestive heart failure and diabetes, multiple CBG readings below 70 mg/dL were recorded, but there was no evidence of assessment for hypoglycemia, monitoring for effectiveness of treatment, or physician notification as required by both physician orders and facility policy. The resident's care plan also lacked interventions for diabetes management, including hypo- or hyperglycemia. Another resident with diabetes had a CBG reading of 58 mg/dL, but again, there was no assessment, monitoring, or physician notification documented, despite care plan interventions instructing staff to report symptoms of hypo- and hyperglycemia. A third resident with diabetes had several CBG readings below 70 mg/dL, but the clinical record and eMAR did not show that the resident was assessed for hypoglycemia, that blood glucose was monitored for effectiveness of treatment, or that the physician was notified of abnormal results. The Director of Nursing confirmed that the facility failed to notify the doctor of a change in condition, failed to document assessments or interventions related to blood glucose, and failed to follow physician orders for these residents.
Failure to Maintain and Label Oxygen Equipment for Residents Receiving Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and maintain oxygen equipment for four out of five sampled residents. According to facility policy, oxygen cannulas and tubing should be changed every seven days or as needed, and both oxygen and nebulizer equipment should be labeled with the date and stored properly between uses. During observations and interviews, it was found that residents with diagnoses such as pneumonia, coronary artery disease, heart failure, anemia, hypertension, respiratory failure, chronic obstructive pulmonary disease, bipolar disorder, and diabetes mellitus were receiving oxygen therapy, but the tubing in use was not labeled with an identifiable date as required by policy and physician orders. Specifically, residents were observed either in bed or sitting in a chair while using oxygen, and in each case, the oxygen tubing lacked proper labeling. Staff interviews confirmed that the required labeling and maintenance procedures were not followed for these residents. The Nursing Home Administrator acknowledged that the facility did not meet the standards for respiratory care and equipment maintenance for these residents, as outlined in both facility policy and physician orders.
Inaccessible Grievance Boxes Limit Resident Access
Penalty
Summary
The facility failed to provide accessible grievance boxes to residents in three locations: the 300-lounge, main dining room, and front lobby. According to the facility's own grievance policy, grievances may be submitted orally or in writing and may be filed anonymously. However, observations and interviews revealed that the grievance boxes were mounted at heights of 53, 52, and 51 inches, respectively, which exceeds the ADA-recommended maximum height of 48 inches for operable parts to ensure accessibility for individuals using wheelchairs. Additionally, access to the boxes in the 300-lounge and front lobby was obstructed by tables. During a resident group interview, residents reported that they could not anonymously file grievances because the boxes were too high to reach, not designed for people in wheelchairs, and required assistance from staff, which compromised anonymity. The Nursing Home Administrator confirmed these findings during an interview, acknowledging that the facility did not make the grievance boxes accessible in the identified locations.
Failure to Protect Resident from Neglect and Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from neglect and verbal abuse. The resident, who was cognitively intact and required moderate assistance for mobility, reported that her call bell was not answered in a timely manner when she requested help to use the bathroom. As a result, she had to take herself to the bathroom, and when the nurse aide eventually responded, the aide made a dismissive comment and left the room in a huff. Facility grievance documentation and staff statements indicated that the nurse aide in question had a pattern of negative behavior, including slamming doors, bullying residents, swearing, and refusing to assist with resident needs such as answering call bells and helping with meal trays. Despite these reports and statements from multiple staff members, the Director of Nursing did not identify the incidents as potential neglect or abuse and did not conduct a further investigation. The facility's failure to recognize and address these behaviors resulted in a lack of protection for the resident from neglect and verbal abuse, in violation of facility policy and state regulations.
Failure to Investigate and Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to promptly conduct a thorough investigation into allegations of potential abuse and neglect involving a resident. According to the report, a resident with diagnoses including kidney disease, Crohn's disease, and diabetes, who was cognitively intact and required moderate assistance with mobility, reported that her call bell was not answered in a timely manner when she needed help to go to the bathroom. The nurse aide responded dismissively, and additional staff statements described the same aide as having a negative attitude, swearing, and being unhelpful to residents, including leaving call bells unanswered and making inappropriate comments to residents. Despite these grievances and staff statements indicating possible abuse and neglect, the Director of Nursing confirmed that she did not identify these as potential abuse or neglect incidents and did not conduct a thorough investigation or implement corrective actions. Furthermore, the facility did not submit the results of a completed investigation to the State Survey Agency within the required five working days, as mandated by facility policy and federal requirements.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that current and accurate nurse staffing information was posted at the beginning of each shift. During an observation, it was found that the nurse staffing information displayed in the main lobby was outdated, showing a date from over two weeks prior and not reflecting the current resident census or the actual staffing hours for licensed and unlicensed nursing staff responsible for resident care. Interviews with the receptionist and the Nursing Home Administrator confirmed that the posted staffing information was not up to date and did not meet the required standards for accuracy and timeliness.
Failure to Post Required State Agency and Advocacy Contact Information
Penalty
Summary
Surveyors observed that the facility failed to post the required contact information for Adult Protective Services (APS), the Medicaid Fraud Control Unit, and a statement informing residents that they may file a complaint with the State Survey Agency. During observations on the nursing units, it was noted that the necessary elements, including agency names, addresses (mailing and email), and telephone numbers, were not accessible or visible to residents or their representatives. In an interview, the Nursing Home Administrator confirmed that this information was not posted as required by regulations. The deficiency was identified based on these observations and staff confirmation.
Failure to Prevent Resident Fall Due to Inadequate Supervision and Assistance
Penalty
Summary
The facility failed to protect a resident from neglect by not providing adequate assistance and interventions to prevent a fall with injury. The resident, who had multiple diagnoses including anemia, gastrointestinal bleed, diabetes, stroke, sacroilitis, anxiety, difficulty walking, abnormal posture, and Stage 5 kidney disease, was assessed as having intact cognition and required moderate assistance for bed mobility. The resident's care plan identified her as being at risk for falls due to impaired balance and poor coordination, and specified that staff should provide necessary assistance during transfers and ambulation, as well as use bedrails as needed. On the day of the incident, the resident had recently returned from the hospital after a blood transfusion and required incontinence care. During care, a nurse aide turned the resident away from herself and then turned away to retrieve supplies, leaving the resident unsupervised. At this time, the resident rolled out of bed, resulting in a head laceration, subarachnoid hemorrhage, and a C4 cervical fracture. Bedrails were not present on the bed at the time, despite the resident's care plan indicating their use. Staff interviews confirmed that proper technique would have involved either using bedrails or turning the resident toward the caregiver, or obtaining a second staff member for assistance. The Director of Nursing and the Nursing Home Administrator confirmed that the nurse aide's actions constituted neglect, as the resident was not adequately supervised or assisted during care, directly leading to the fall and resulting injuries. Facility policies reviewed emphasized the importance of safe resident handling, use of bedrails when indicated, and the need to prevent neglect by providing necessary goods and services to avoid physical harm.
Failure to Provide Adequate Supervision and Assistance During Incontinence Care Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate assistance and interventions to prevent a fall with injury for a resident who had multiple medical conditions, including anemia, diabetes, stroke, sacroiliitis, difficulty walking, abnormal posture, and advanced kidney disease. The resident was identified as being at risk for falls and required partial to moderate assistance for bed mobility, with care plans specifying the use of bedrails and staff assistance during transfers and ambulation. Despite these documented needs, during incontinence care, a nurse aide turned the resident away from her and left the resident unattended on the bed while reaching for supplies, resulting in the resident rolling out of bed. At the time of the incident, bedrails were not in place, contrary to the resident's care plan and facility policy. As a result of this lapse in supervision and failure to follow established protocols, the resident sustained significant injuries, including a subarachnoid hemorrhage, a scalp laceration requiring six sutures, and a C4 vertebrae fracture. Staff interviews confirmed that proper procedures, such as using bedrails or turning the resident toward the caregiver, were not followed. Facility leadership acknowledged that adequate assistance and interventions were not provided to prevent the fall and resulting harm.
Failure to Provide Opportunity for Advance Directives
Penalty
Summary
The facility failed to provide the opportunity for four residents to formulate an advance directive, as required by their policy and regulatory standards. The facility's policy on Advance Directives, last reviewed on January 18, 2024, mandates that all adult residents be informed and provided with written information regarding their right to accept or refuse medical or surgical treatment and to formulate an advance directive. However, upon review of the clinical records for Residents R24, R29, R57, and R71, there was no documentation indicating that these residents were given the opportunity to formulate an advance directive. Resident R24 was admitted with diagnoses including type II diabetes, dysphagia, muscle weakness, and a left below-knee amputation. Resident R29 had type II diabetes, dysphagia, high blood pressure, and difficulty walking. Resident R57 was diagnosed with high blood pressure, a history of falling, and stage III chronic kidney disease. Resident R71 had multiple sclerosis, dysphagia, and stage III chronic kidney disease. Despite these significant medical conditions, the clinical records for these residents did not contain any advance directives or documentation of being offered the opportunity to create one. This deficiency was confirmed during an interview with the Social Worker and the Director of Nursing.
Medication Cart Left Unsecured on 300 Hall
Penalty
Summary
The facility failed to properly secure medications in one of the two medication carts on the 300 hall nursing unit, specifically the B cart. According to the facility's policy on Medication Labeling and Storage, medications should be stored in locked compartments with access restricted to authorized personnel. However, during an observation, the B medication cart was found unsecured and unattended, making it accessible to any passerby. This was confirmed by the Director of Nursing during an interview, indicating a breach in the facility's protocol for securing medications.
Failure to Supervise Cold Pack Use Results in Resident Harm
Penalty
Summary
The facility failed to implement effective safety measures by not supervising the use of a cold pack, resulting in actual harm to a resident. The resident, who was cognitively intact and had a history of sciatica, hyperlipidemia, polyneuropathy, and hypertension, suffered a superficial frostbite burn on the right knee. The facility's policy required appropriate toweling between the ice pack and the skin, with treatment times of 10-20 minutes and checks every 10 minutes. However, the resident reported that the ice pack was left on direct skin for too long, leading to redness and blistering. The incident occurred after the resident refused physical therapy due to pain and requested pain medication and an ice pack. A PT employee provided the ice pack, allegedly with proper toweling, but the resident later admitted to removing the cloth and placing the ice pack directly on the skin. The care plan did not include the use of cold packs as an intervention, and there was a lack of clear communication and supervision between the PT employee and the nursing staff. Interviews with staff revealed inconsistencies in the handling of the ice pack, and the facility acknowledged the failure to provide adequate education and supervision, resulting in harm to the resident.
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.
Trusted by long-term care providers and associations.
