Scranton Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Scranton, Pennsylvania.
- Location
- 2933 Mccarthy Street, Scranton, Pennsylvania 18505
- CMS Provider Number
- 396095
- Inspections on file
- 21
- Latest survey
- August 26, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Scranton Health Care Center during CMS and state inspections, most recent first.
A resident with impaired mobility and a physician's order for Prevalon boots repeatedly refused to wear the boots, as documented in clinical records and confirmed by observation and interview. Despite these documented refusals and the resident's clear preference, the care plan was not updated to reflect the resident's choice, contrary to facility policy requiring person-centered care planning.
A resident with dementia and arthritis was assessed in the MDS as having no range of motion impairment and using a manual wheelchair, but observations and staff interviews revealed limited right wrist movement and use of a Broda chair. Therapy staff and clinical records confirmed these limitations, yet the MDS did not accurately reflect the resident's condition or equipment use.
A resident with a history of fracture and muscle weakness received PRN Oxycodone multiple times without staff attempting or documenting non-pharmacological pain interventions beforehand, contrary to facility policy and regulatory requirements. Record reviews and staff interviews confirmed the lack of individualized pain management and documentation.
The facility failed to prevent the misappropriation of narcotic medications for two residents. An LPN signed out doses of Oxycodone and Hydrocodone-Acetaminophen without proper documentation or physician orders. The facility did not timely report or investigate these discrepancies, violating policies on abuse and misappropriation.
The facility failed to develop and implement individualized toileting programs for three residents, leading to deficiencies in bowel and bladder management. One resident, with severe cognitive impairment, was not placed on a toileting management program, resulting in moisture-associated skin damage. Another resident with Parkinson's disease did not have a completed 72-hour toileting diary, preventing the development of a continence management program. A third resident with chronic kidney disease and diabetes lacked a specific toileting plan, and no additional assessments were conducted. The facility's failure to assess bowel and bladder function was confirmed by the NHA.
A facility failed to reassess a resident's pain management plan despite repeated daily use of opioid medications. The resident, admitted with cerebral infarction and shoulder pain, frequently received Oxycodone without further pain evaluations or non-pharmacological interventions. The DON confirmed the lack of assessment, leading to ineffective individualized pain management.
The facility failed to maintain accurate clinical records for two residents, leading to deficiencies in care documentation. One resident's records lacked evidence of preventative measures for skin damage, and another resident's toileting diary was incomplete, hindering continence management. The Director of Nursing confirmed discrepancies in the electronic health record system and care plans.
A resident with dementia, who was cognitively intact, expressed a desire to be discharged home. However, the facility failed to document an individualized discharge plan in her care plan, as confirmed by the DON. The social service notes only mentioned her wish to be discharged, with no further updates.
A resident with severe cognitive impairment and multiple health issues developed a Stage 3 pressure ulcer due to the facility's failure to implement consistent preventative measures. The facility lacked documentation of interventions like turning and repositioning, and the resident's care plan did not include individualized strategies to prevent skin impairments. Preventative measures were not transferred to a new EHR system, contributing to the deficiency.
The facility did not develop individualized care plans for two residents with dementia, failing to address their behavioral symptoms with person-centered, non-pharmacological approaches. The care plans lacked documentation of activities tailored to the residents' routines and preferences.
The facility failed to reconcile controlled drug records for two residents. An LPN signed out doses of Oxycodone for a resident when not on duty, and these were not recorded on the MAR. Another resident received Hydrocodone-Acetaminophen after it was discontinued, with doses documented on the narcotic record but not on the MAR. The DON and Nursing Home Administrator confirmed these discrepancies.
A resident was administered Cefdinir for a UTI without documented clinical necessity, as the antibiotic was not effective against the bacteria present. Despite this, the resident received four doses before the medication was changed to Levaquin. The facility failed to ensure proper documentation and administration of antibiotics.
The facility failed to provide written notices of hospital transfers to two residents and their representatives, as well as to the Ombudsman. One resident with osteoarthritis and muscle weakness, and another with diabetes, were transferred without documented evidence of notification. The DON confirmed the lack of documentation for these transfers.
The facility failed to provide written notice of its bed-hold policy to two residents and their representatives upon hospital transfer. There was no documentation in the clinical records indicating that the residents or their responsible parties were informed of the facility's bed-hold and reserve bed payment policy. The NHA and DON could not provide evidence of notification, resulting in a deficiency under resident rights regulations.
Failure to Incorporate Resident Preferences into Care Plan
Penalty
Summary
The facility failed to honor and incorporate a resident's expressed preferences and choices into the care planning process. A resident with alcoholic cirrhosis of the liver and ascites, who was cognitively intact, was admitted to the facility and had a physician's order for Prevalon boots to be worn while in or out of bed, with removal allowed for hygiene and skin checks. The resident's care plan included goals to prevent deterioration in activities of daily living (ADL) functional status, and nursing documentation indicated the boots were initiated for preventive care. However, clinical records, nursing progress notes, and the Treatment Administration Record (TAR) documented multiple instances where the resident refused to wear the boots and was re-educated on their purpose. Despite repeated refusals and clear documentation of the resident's choice not to wear the Prevalon boots, the resident's expressed preference was not incorporated into the comprehensive care plan. Observations confirmed the resident was not wearing the boots during multiple checks, and the resident verbally confirmed their preference not to use them. An interview with the Nursing Home Administrator confirmed that the resident's choice was not addressed in the care plan, which is inconsistent with the facility's policy to develop person-centered care plans focused on resident choices and abilities.
Inaccurate MDS Assessment and Documentation for Resident Functional Status
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for one resident, as required by federal regulations. The resident, who had diagnoses including dementia and rheumatoid arthritis, was documented in the quarterly MDS as having no impairment in range of motion for upper and lower extremities. However, direct observations and staff interviews revealed that the resident's lower extremities were sometimes flexed while seated, and the right hand was often in a closed position, requiring staff assistance to open. Further assessments by therapy staff confirmed limited range of motion in the resident's right wrist due to osteoarthritis, which was also supported by a clinical record and X-ray. Despite these findings, the MDS did not accurately reflect the resident's actual physical limitations. Additionally, the MDS indicated that the resident utilized a manual wheelchair and was dependent on chair mobility. Observations and staff interviews, however, showed that the resident primarily used a Broda chair, which is not classified as a manual wheelchair according to the RAI manual. Documentation in the clinical record and therapy notes confirmed the use of the Broda chair. The facility was unable to provide documentation to support the MDS coding, and the Regional Reimbursement Specialist could not confirm the accuracy of the MDS. These discrepancies demonstrate that the facility did not ensure the MDS assessment accurately reflected the resident's status, as required.
Failure to Implement Non-Pharmacological Pain Management Prior to PRN Narcotic Administration
Penalty
Summary
The facility failed to develop and implement individualized pain management programs consistent with professional standards of practice for a resident with a history of a left fibula fracture and muscle weakness. Despite facility policy requiring non-pharmacological interventions to be attempted prior to administering as-needed (PRN) narcotic pain medication, staff repeatedly administered Oxycodone without first attempting or documenting any non-pharmacological pain relief methods. This was evidenced by a review of the resident's Medication Administration Records (MAR) over several months, which showed multiple instances where Oxycodone was given without prior non-pharmacological interventions. Interviews and record reviews confirmed that the facility could not provide documentation supporting the use of non-pharmacological interventions before administering PRN pain medication, as required by their policy. The deficiency was identified for one resident out of fourteen reviewed, and the failure was in direct violation of both facility policy and state regulations regarding pain management and resident care.
Failure to Prevent Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to implement measures to deter the misappropriation of resident property, specifically narcotic medications, for two residents. Resident 9, who was cognitively intact and had a prescription for Oxycodone for severe pain, had multiple doses of the medication signed out by an LPN who was not on duty at the time. The medication administration record (MAR) did not reflect these doses as given, indicating a discrepancy in the medication management process. Similarly, Resident 90, who was also cognitively intact and on hospice services, had a prescription for Hydrocodone-Acetaminophen that was discontinued. Despite this, doses of the medication were signed out and documented as administered after the discontinuation date. The facility's investigation revealed that the same LPN was involved in signing out these medications without proper documentation or physician orders. The facility's administration confirmed that the allegations of misappropriation were not reported or investigated in a timely manner. Witness statements indicated suspicious behavior by the LPN, who was found to have administered medications without proper authorization. The facility's policies on abuse, neglect, and misappropriation were not followed, leading to a failure in protecting residents' rights and ensuring proper medication management.
Failure to Implement Individualized Toileting Programs
Penalty
Summary
The facility failed to develop and implement individualized measures for the toileting needs of three residents, leading to deficiencies in bowel and bladder management. Resident 34, who had severe cognitive impairment and was dependent on staff for activities of daily living, was not placed on a toileting management program despite being identified as a candidate for bowel and bladder retraining. The resident's care plan did not address incontinence management needs, and there was no documented evidence of a 72-hour bowel and bladder tracker being completed. This oversight contributed to the development of moisture-associated skin damage (MASD) on the resident's left buttock. Resident 19, diagnosed with Parkinson's disease and dementia, was also affected by the facility's failure to complete a 72-hour toileting diary consistently. This inconsistency prevented the development of an individualized continence management program, which could have helped restore normal bladder function and prevent incontinence-related complications such as skin breakdown. The resident's clinical record lacked evidence of a completed bowel and bladder tracker upon admission, which was necessary for an accurate assessment of toileting needs. Resident 20, who had chronic kidney disease and diabetes, was identified as frequently incontinent of the bladder. However, the facility did not complete a 72-hour bowel and bladder assessment to determine the feasibility of a retraining program or the need for an individualized incontinence management program. The resident's care plan lacked specific toileting instructions, and there was no evidence of additional assessments or evaluations regarding the resident's bladder status. The facility's failure to thoroughly assess bowel and bladder function for these residents was confirmed by the Nursing Home Administrator.
Failure to Reassess Pain Management Plan for Resident
Penalty
Summary
The facility failed to reassess a resident's pain management plan despite the repeated daily use of opioid pain medications prescribed on an as-needed basis. The resident, who was admitted with a diagnosis of cerebral infarction and right shoulder pain, was cognitively intact and independent in activities of daily living. The resident had a physician's order for Oxycodone 5 mg to be taken every 4 hours as needed for moderate to severe pain. However, the facility did not conduct further assessments or evaluations of the resident's pain despite the frequent administration of the medication over several months. The facility's policy required a comprehensive pain evaluation at admission, quarterly reviews, significant changes in condition, or new pain onset. Despite this, there was no documented evidence of additional pain evaluations or the development of non-pharmacological interventions to manage the resident's pain. The Director of Nursing confirmed the lack of further assessment for the resident's continued daily use of the opioid medication. This oversight resulted in a failure to develop and implement an effective individualized pain management plan consistent with professional standards and the resident's goals and preferences.
Deficiencies in Clinical Record Maintenance and Documentation
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for two residents, as required by professional standards. For Resident 34, the clinical record did not provide evidence of preventative measures to deter or prevent the re-opening of moisture-associated skin damage (MASD) and the development of pressure ulcers. The resident's plan of care did not accurately reflect the care and services provided to maintain skin integrity, and some preventative measures were not carried over to the new electronic health record (EHR) system. Resident 34's clinical record showed discrepancies in wound observation entries, with missing documentation of preventative measures such as turning, repositioning, and the application of barrier cream. The Director of Nursing (DON) confirmed that the resident's plan of care did not accurately reflect the actual care provided, and the facility failed to ensure that the clinical record accurately documented the resident's care needs. For Resident 19, the facility did not consistently complete a 72-hour toileting diary to determine a bowel and bladder pattern for developing an individualized continence management program. The clinical record lacked a completed bowel and bladder tracker upon admission, which was necessary for assessing toileting needs and incontinence management. The DON acknowledged that the tracker was not consistently completed, hindering the development of a toileting plan to maintain or improve the resident's continence.
Failure to Develop Individualized Discharge Plan
Penalty
Summary
The facility failed to develop and implement an individualized discharge plan for a resident, identified as Resident 33, who was admitted with a diagnosis of dementia. Despite the resident's cognitive intactness, as indicated by a BIMS score of 14, and her expressed desire to be discharged home, there was no documented evidence of a discharge plan in her comprehensive care plan. The social service notes only mentioned the resident's wish to be discharged home, with no further documentation or updates regarding her discharge planning. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a documented discharge goal and plan for the resident.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to consistently implement measures to prevent pressure sore development for Resident 34, as identified in a survey. Resident 34, who was admitted with multiple diagnoses including Alzheimer's disease, dysphagia, and protein-calorie malnutrition, was found to have a re-opening of moisture-associated skin damage (MASD) on the left buttock. The facility did not provide documented evidence of preventative measures in place to prevent this re-opening, nor did they investigate the reopened area or develop appropriate interventions to prevent further skin breakdown. Further observations revealed a non-blanchable area on Resident 34's sacrum, which later developed into a Stage 3 pressure ulcer. Although some preventative measures were noted, such as an air overlay mattress and heel bows, the facility lacked documentation showing that turning and repositioning were performed prior to the ulcer's development. The resident's care plan also failed to specify individualized interventions to prevent skin impairments like MASD and pressure ulcers. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that some preventative measures were not carried over to the new electronic health record system implemented in mid-May 2024. The facility could not provide evidence that effective interventions were in place before the identification of the MASD and the sacral pressure ulcer. Additionally, the resident's comprehensive care plan was not fully developed with effective measures to prevent skin impairments and pressure ulcers.
Failure to Implement Individualized Dementia Care Plans
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for two residents diagnosed with dementia. Resident 34, admitted with conditions including traumatic subarachnoid hemorrhage, Alzheimer's disease, dysphagia, aphagia, and protein-calorie malnutrition, did not have a care plan that addressed their dementia-related behavioral symptoms. The care plan lacked documentation of individualized, non-pharmacological approaches to care, such as activities that align with the resident's routines, interests, and preferences to enhance their well-being. Similarly, Resident 33, who was admitted with a diagnosis of dementia, also did not have a documented individualized care plan. The care plan failed to include interventions based on an assessment of the resident's preferences, social history, and customary routines to manage or decrease dementia-related behavioral symptoms. An interview with the Nursing Home Administrator confirmed the absence of evidence for the development and implementation of such individualized care plans for these residents.
Failure to Reconcile Controlled Drug Records
Penalty
Summary
The facility failed to implement proper pharmacy procedures for reconciling controlled drugs and records, affecting two residents. For Resident 9, who was admitted with a cerebral infarction and shoulder pain, there were discrepancies in the administration of Oxycodone. The controlled substance record showed doses signed out by an LPN who was not on duty, and these doses were not recorded on the medication administration record (MAR). The Director of Nursing confirmed these inconsistencies during an interview. For Resident 90, who was admitted with hypertension, diabetes, and was on hospice services, there were issues with the administration of Hydrocodone-Acetaminophen. Despite a physician's order to discontinue the medication, doses were signed out and documented as given on the narcotic reconciliation record but not on the MAR. The Nursing Home Administrator confirmed that the narcotic pain medications were not administered according to facility policy and procedure.
Failure to Document Clinical Necessity for Antibiotic Administration
Penalty
Summary
The facility failed to ensure the presence of documented evidence of clinical necessity for the administration of an antibiotic drug to a resident. The resident, who was initially admitted with diagnoses including osteoarthritis, muscle weakness, and a recent infection of Clostridioides difficile, was prescribed Cefdinir for a urinary tract infection (UTI) based on an initial urinalysis. However, a subsequent culture and sensitivity test revealed that Cefdinir was not effective against the bacteria present in the resident's urine. Despite this finding, the resident received four doses of Cefdinir before the medication was discontinued and replaced with Levaquin, which was more appropriate for the infection. The Director of Nursing confirmed that the facility failed to ensure the resident received multiple doses of the antibiotic without documented evidence of its clinical necessity, as required by the relevant state codes.
Failure to Provide Transfer Notices to Residents and Ombudsman
Penalty
Summary
The facility failed to provide written notices of facility-initiated hospital transfers to two residents and their representatives, as well as to a representative of the Office of the State Long-Term Care Ombudsman. Regulatory requirements mandate that before a facility transfers or discharges a resident, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. However, the facility did not comply with these requirements for two residents. Resident 9, who was initially admitted with osteoarthritis and muscle weakness, was transferred to the hospital on July 20, 2024, but there was no documented evidence of a written notice provided to the resident or their responsible party. Similarly, Resident 23, admitted with diabetes, was transferred to the hospital on September 21, 2024, without documented evidence of a written notice to the resident or their responsible party. The Director of Nursing confirmed the lack of documentation for both residents' transfers and the absence of a copy of the transfer notice to the Ombudsman.
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to two residents and their representatives upon transfer to the hospital. Resident 9 was transferred to the hospital on July 20, 2024, and Resident 23 on September 21, 2024. In both cases, there was no documentation in the clinical records indicating that the residents or their responsible parties were informed of the facility's bed-hold and reserve bed payment policy at the time of transfer. During an interview on October 31, 2024, the Nursing Home Administrator and Director of Nursing were unable to provide evidence that the required notifications were made, resulting in a deficiency under 28 Pa. Code 201.29 (a)(c.3)(2) regarding resident rights.
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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