Saint Joseph Villa
Inspection history, citations, penalties and survey trends for this long-term care facility in Flourtown, Pennsylvania.
- Location
- 110 West Wissahickon Ave, Flourtown, Pennsylvania 19031
- CMS Provider Number
- 395278
- Inspections on file
- 16
- Latest survey
- March 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Saint Joseph Villa during CMS and state inspections, most recent first.
A resident sustained a burn on the right shoulder due to improper monitoring during a hot pack treatment. The resident, with a history of diabetes and other conditions, requested heat therapy for shoulder pain. The PTA applied the treatment without authorization or proper documentation, and failed to monitor the resident's skin condition. The treatment was not part of the resident's care plan, and the lack of adherence to protocols led to the injury.
The facility failed to implement comprehensive care plans for two residents. One resident, post-hip surgery, was transferred by a single staff member despite needing two-person assistance. Another resident, with mobility issues, had no care plan for an ankle-foot orthotic causing discomfort. These actions indicate a lack of adherence to established care plans.
The facility failed to obtain a physician's order for an AFO for a resident experiencing discomfort and did not clarify a physician's order regarding another resident's alcohol consumption. The resident with the AFO had no documented order, and the resident allowed wine had no specified amount or frequency, with no documentation of wine administration.
The facility did not ensure proper disposal of garbage and recyclables in the receiving and dumpster area. Observations revealed the trash compactor with its door ajar, exposing trash bags, and recycling dumpsters with open doors. Additionally, wooden pallets with splintered wood, trash cans, and laundry bins filled with rainwater and trash were found scattered around. These findings were confirmed by the Dining Operations Manager.
The facility failed to maintain acceptable food storage and service practices, as observed during kitchen tours. Items in the walk-in freezer, dairy refrigerator, and dry storage room were found opened and unlabeled. Additionally, produce pasta and raw salmon were improperly stored, and ready-to-serve shrimp was not covered or dated. These observations indicate non-compliance with the facility's food and supply storage policy.
A resident with anoxic brain damage and other conditions slid off the bed and sustained injuries due to unlocked bed wheels during incontinence care. The nurse aide assumed the brakes were locked, but they were not, leading to the incident.
Failure to Monitor Resident During Heat Therapy Results in Burn Injury
Penalty
Summary
The facility failed to ensure proper monitoring and assessment of a resident during a hot pack treatment, resulting in actual harm. The incident involved a resident who sustained a burn on the right shoulder after receiving heat therapy. The facility's policy required that residents be checked every 5-10 minutes during such treatments, and that the area be inspected for any unusual signs after the treatment. However, these procedures were not adequately followed, leading to the resident's injury. The resident, who had a medical history including anemia, hyperlipidemia, hypertension, and diabetes, requested heat therapy for shoulder pain during a physical therapy session. The Physical Therapy Assistant (PTA) applied the hot pack without proper authorization or documentation, and failed to monitor the resident's skin condition during and after the treatment. The resident later reported irritation and a burn-like area was discovered on the shoulder, which was confirmed by a licensed nurse and a wound nurse. The incident was further compounded by the fact that the hot pack treatment was not part of the resident's authorized plan of care, and the PTA did not consult with a physical therapist before administering the treatment. Additionally, there was no documentation of the treatment duration or the condition of the resident's skin, which was a requirement of the therapy department. This lack of adherence to established protocols and failure to monitor the resident's condition led to the resident sustaining a burn injury.
Plan Of Correction
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual. a. The resident (R 302) wound was resolved and discharged to home instructed to apply vaseline to keep skin moist and tight. The Contracted employee of Select Rehabilitation Co (E9) was educated on 11/14/24 for not following the plan of care for treatment, as a result his employment was Terminated at St Joseph Villa. Date: Deficient Practice was resolved on 11/4/24. 2. Indicate how the facility will act to protect residents in similar situations. a. All residents were reviewed for Hot Pack treatments to ensure any contraindications, precautions, adequate supervision and monitoring for signs of skin irritation and burning, there were no other residents receiving hot packs. The use of Hot Packs were discontinued for all residents and the use of the Hydrocollator Mobile Heating Unit was discontinued on 11/14/24. Date: Deficient practice was resolved on 11/14/24. 3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur. a. The clinical staff coordinator and director of therapy provided formal education to the nurses and therapy staff for Hot Pack treatments to ensure any contraindications, precautions, adequate supervision and monitoring for signs of skin irritation and burning on 11/14/24. Date: Deficient Practice was resolved on 11/14/24. 4. Indicate how the corrective action will be monitored to ensure that the deficient practice will not recur: a. An audit tool is in place for all residents with orders for Hot pack treatments and reviewed by the Nurse Coordinator for any contraindications and precautions prior to treatment and to ensure adequate supervision and signs of skin irritation. The audit will be reviewed weekly x 4 and then monthly, results were reviewed and discussed at Quarterly QAPI meeting. Date: Deficient Practice was resolved 11/14/24. 5. Dates of when the corrective action will be completed: a. The facility completed this plan of correction 11/14/2024.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement the comprehensive care plan for two residents, leading to deficiencies in their care. Resident R306, who was admitted following a left hip surgery, had a care plan that required assistance from two staff members for transfers due to limited mobility and deconditioning. However, an observation revealed that the resident was transferred by only one staff member, Nurse Aide Employee E8, which was confirmed in an interview with the aide. This action was contrary to the care plan's specified interventions, indicating a failure to adhere to the established care plan. Resident R67, admitted with gait and mobility abnormalities, was observed wearing a brace on the right lower leg and complaining of discomfort. The resident's clinical record included a physical therapy note about irritation from the ankle-foot orthotic (AFO), but there was no care plan addressing the use of the AFO. An interview with the Director of Nursing confirmed the absence of a care plan for the AFO, highlighting a lack of comprehensive planning for the resident's needs. These findings demonstrate the facility's failure to develop and implement appropriate interventions as outlined in the comprehensive care plans for these residents.
Plan Of Correction
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual. The resident (R306) that was affected Care Plan was updated to transfer assistance with one staff member after re-evaluation with Rehab Therapist. Employees (E8) was educated and received counseling regarding reviewing the Care plan prior to delivering care. The resident (R 67) was evaluated by the Rehab Therapist and Care Plan updated to include Right Lower Leg AFO. 2. Indicate how the facility will act to protect residents in similar situations. All current residents requiring Transfer Assistance and AFO devices Care Plans have been reviewed and updated. A formal education for Comprehensive Care Planning of Transfer Assistance and AFO devices was initiated by the facility Nurse Educator for all Nursing Staff. 3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur. To ensure that this problem does not occur in the future, the facilities will conduct a formal education for Comprehensive Care Planning of Transfer Assistance and AFO devices was initiated by the facility Nurse Educator for all Nursing Staff. 4. Indicate how it plans to monitor its performance to make sure that solutions are sustained. The Director of Nursing will perform weekly Care Plan audits x4 and then monthly for 3 months to ensure that resident Transfer Assistance Status and Residents requiring AFO devices are appropriate. Results will be submitted and reviewed at Quarterly QAPI meeting for continued compliance. 5. Provide dates when corrective action will be completed. The facility will complete this Plan of Correction_April 4, 2025.
Failure to Obtain Physician Orders for AFO and Clarify Alcohol Consumption
Penalty
Summary
The facility failed to obtain a physician's order for the use of an ankle-foot orthotic (AFO) for a resident, identified as R67, who was observed wearing a brace on the right lower leg and complaining of discomfort. The resident mentioned that the brace had been fixed with glue but preferred an older brace that fit better. A review of the resident's clinical record showed no physician order for the AFO, and the Director of Nursing confirmed the absence of such an order. This oversight indicates a failure to adhere to professional standards of practice and ensure proper treatment and care based on a comprehensive assessment. Additionally, the facility did not clarify a physician's order regarding the alcohol consumption of another resident, identified as R4. The physician's order allowed the resident to have wine but did not specify the amount or frequency. The resident reported being served wine at least once a week, but there was no documentation in the Medical Administration Record or Treatment Administration Record to track the administration of wine. An interview with a unit manager confirmed the lack of clarity in the physician's order and the need to consult the physician for further instructions.
Plan Of Correction
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual. The resident (R67) a physician order was obtained for the use of the AFO (ankle foot orthidic) that was being used on his right foot. The resident's (R4) & (302) a physician order was clarified for the residents consumption of alcohol. The pharmacy was also contacted to determine if any of the residents (R4 & R302)) current medications would interact with alcohol. 2. Indicate how the facility will act to protect residents in similar situations. All current residents requiring an AFO device medical records were reviewed to ensure that a Physician Order was obtained prior to use. All current residents that have an order for alcohol consumption, the Physician Order was clarified to indicate the specific amount of alcohol that could be served and how often the resident could have the alcohol. The facility requested that the Pharmacy Company review all the Medications of those residents that consume alcohol to ensure that the medications would interact with alcohol. 3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur. To ensure that this problem does not occur in the future, the facility will conduct formal education for Physician Orders & Alcoholic Beverages which was initiated by the facility Nurse Educator for all Nursing Staff. 4. Indicate how it plans to monitor its performance to make sure that solutions are sustained. The Director of Nursing or designee will perform weekly audits x4 then monthly for 3 months to ensure Physician Orders for AFO's are obtained prior to use. The facility will monitor residents Alcoholic Beverage consumption to ensure that a Physician Order is obtained for the amount of alcohol and dose is in accordance with the physician order, as well as, pharmacy recommendation for medication interaction. The results will be submitted and reviewed at the Quarterly QAPI meeting for continued compliance. 5. Provide dates when corrective action will be completed. The facility will complete this Plan of Correction 4/04/2025.
Improper Disposal of Garbage and Recyclables
Penalty
Summary
The facility failed to ensure proper disposal of garbage and recyclables in the receiving and dumpster area. During a tour of the Food Service Department, it was observed that the trash compactor had its metal door ajar, leaving bags of trash exposed. Additionally, the cardboard recycling dumpster had two sliding doors open, and the can recycling dumpster had both top doors and the side sliding door open. Near the receiving door, four wooden pallets were found on the ground with broken pieces of splintered wood scattered around. Furthermore, three large grey trash cans were lying on the ground, and two large blue laundry bins were half-filled with rainwater and trash, including a broken hot holding pan warmer. These observations were confirmed in an interview with the Dining Operations Manager.
Plan Of Correction
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual. a. There were no residents affected by this deficient practice. The metal trash compactor metal door that was ajar was closed, the cardboard recycling dumpster sliding doors were closed, and the can recycling dumpster top doors and side sliding doors were closed. The wood pallets on the ground were removed, the large grey trash can laying on the ground was removed, and the blue laundry bins that were filled with rainwater and trash were removed. 2. How will you identify other residents that have the potential to be affected by the deficient practice and what corrective action will be taken: a. The Maintenance Director, Environmental Director, and Dining Manager provided immediate education to the relevant staff on the proper waste disposal of trash and recyclables. 3. What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur. a. The Maintenance Director or designee will conduct formal education and training of the facilities Dispose Garbage and Refuse Policy. 4. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur. a. The Maintenance Director or designee will conduct weekly x4 audits for 3 months to ensure that the proper disposal of garbage and refuse. 5. Indicate how it plans to monitor its performance to make sure that solutions are sustained. The Maintenance Director or designee will conduct weekly audits x4 then monthly for three months. All findings from these audits will be reviewed during the facility's Quarterly QAPI meetings to determine if further corrective actions or further monitoring is required. 6. Provide dates when corrective action will be completed: The facility will complete this Plan of Correction on 4/4/2025.
Failure to Maintain Acceptable Food Storage and Service Practices
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, as observed during an initial tour of the kitchen. The walk-in freezer contained items such as frozen pies, chocolate cakes, and chicken nuggets that were opened but not labeled. The dairy refrigerator had opened cheeses and slicing meats that were only dated with one date, making it unclear if it was the opened date or expiration date. Additionally, the walk-in refrigerator had leftover pasta that was not labeled, and the dry storage room contained various items such as dry peas, rice bags, spices, and large containers of sugar, rice, flour, and thickener that were all open and not labeled with any dates. These observations were made in the presence of the facility's Dietary Manager, Employee E6, on April 23, 2024, at 9:36 a.m. Further observations on April 26, 2024, at 9:41 a.m. with Dining Manager, Employee E10, revealed that refrigerator #2 had uncovered and unlabeled produce pasta. Raw salmon packaged in a clear bag was stored on the middle shelf with veggie produce beneath it. A cart full of ready-to-serve food included a sheet of shrimp that was not covered or dated. The dry storage room continued to have items such as peppermint pieces, pasta, seafood breading mix, granola, chips, thickener, sugar, flour, and rice in large bins that were not labeled with any dates. These findings indicate a failure to adhere to the facility's policy on food and supply storage, which requires all food items to be covered, labeled, and dated to prevent contamination and ensure food safety.
Failure to Lock Bed Wheels Resulting in Resident Injury
Penalty
Summary
The facility failed to maintain an environment free from hazards related to an unlocked bed wheel brake for one resident. Resident R83, who was admitted with diagnoses including anoxic brain damage, abnormal posture, and unspecified mental disorder, required one-person physical assistance for bed mobility. During incontinence care, the resident slid down between the bed and the wall, resulting in a laceration to the left forehead. The incident occurred because the bed wheels were not locked, causing the bed to move while the nurse aide was turning the resident. The facility's investigation confirmed that the bed wheels were unlocked during the incident. The nurse aide involved assumed the brakes were locked but later discovered they were not. The Director of Nursing also confirmed that the unlocked bed wheels were the reason for the resident's fall. The resident was transferred to the hospital and returned with a laceration on the forehead and an abrasion on the left shoulder. No acute intracranial hemorrhage or mass effect was found in the CT scan conducted at the hospital.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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