St Barnabas Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Gibsonia, Pennsylvania.
- Location
- 5827 Meridian Road, Gibsonia, Pennsylvania 15044
- CMS Provider Number
- 395605
- Inspections on file
- 19
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at St Barnabas Nursing Home during CMS and state inspections, most recent first.
The facility failed to report an allegation of abuse through the required electronic reporting system after a resident, admitted with a humeral fracture, pain, and HTN, called 911 and was documented as attempting to photograph other residents without their consent. According to the DON, a roommate’s family had told the resident to watch out for their loved one, which the resident interpreted by taking photos of the roommate, who remained fully clothed. Facility policy requires all abuse allegations, including potentially demeaning or humiliating photography, to be reported via ERS, but review of ERS reports showed no entry for this event, and the DON stated the facility did not realize it was reportable.
A resident with severe cognitive impairment, stroke, and Parkinson’s disease, and documented behavioral symptoms including disrobing and sexualized behaviors, did not receive adequate behavioral health management. The care plan called for anticipating needs, monitoring and documenting behaviors, identifying underlying causes, and using non-medical interventions, and the resident’s preferences included reading materials, music, pets, favorite activities, and going outside. Despite this, the resident repeatedly disrobed and manipulated his genitals in common areas, upsetting another resident, and was often seated at the nurses’ station next to non-clinical staff without any diversional activities. Staff reported frequent disrobing and genital manipulation, difficulty redirecting the resident, and an inability to leave the resident alone in the room due to fall risk, and the DON acknowledged the failure to provide appropriate behavioral health management.
The facility failed to notify the Office of the Long-Term Care Ombudsman Division about the hospital transfers of four residents, as required by regulations. The residents, with various medical conditions, were transferred on different dates, but there was no documented evidence of the required notifications. This deficiency was confirmed by a staff interview.
A facility failed to address significant weight loss for a resident with anemia and Alzheimer's, lacking documentation of RD assessments and nutritional recommendations. Additionally, two residents admitted with conditions like femur fracture and aortic stenosis did not receive initial nutrition assessments. The RD was not employed during a critical period, and a resident's care was influenced by family refusal, which was undocumented.
The facility failed to provide mandatory QAPI training to five staff members, including four NAs and one RN, as required by their policy. The deficiency was identified through a review of training records and confirmed by the Staff Development Coordinator.
The facility failed to administer prescribed medication to a resident due to pharmacy delays and did not notify the physician. Another resident experienced significant weight loss, which was not promptly communicated to the physician, delaying necessary interventions. The facility also delayed changing the resident's tube feeding formula, waiting to exhaust the existing supply before implementing the physician's order.
A resident with an enteral feeding tube experienced significant weight loss, and the facility failed to provide appropriate treatment and services. The resident's weight loss was not addressed in a timely manner, with delays in notifying the physician and changing the tube feeding formula. The Registered Dietitian was not employed during a critical period, and the resident's husband's refusal to increase feeding was not documented.
The facility failed to provide appropriate respiratory care for two residents. One resident received oxygen at a higher rate than prescribed, while another lacked a care plan and physician order for nebulizer equipment maintenance. Staff interviews revealed the absence of policies for respiratory care, confirming the deficiency.
A resident with atrial fibrillation, hypertension, and macular degeneration did not receive their prescribed Synthroid medication on four occasions due to unavailability. The facility's policy requires medications to be administered by the same nurse who prepared them, but this was not adhered to, as confirmed by the DON.
The facility failed to employ a qualified Registered Dietitian for the entire month of October 2024. Interviews revealed that the dietitian was employed until August 2024 and resumed PRN work in November 2024, leaving a gap in compliance with staffing requirements.
A facility failed to obtain a necessary diagnosis for hospice services for a resident. The resident, admitted with conditions like high blood pressure and respiratory failure, was ordered to hospice care without a specific diagnosis justifying the need. The care plan noted a terminal prognosis but lacked a related diagnosis. The DON confirmed this oversight during an interview.
The facility failed to maintain a comprehensive infection control program, particularly in managing Legionella risk in water systems and implementing transmission-based precautions for a resident with shingles. The water management plan lacked specific protocols and documentation, while the resident's care plan did not reflect necessary precautions for shingles and wounds.
The facility failed to provide mandatory abuse and neglect prevention training for a Nurse Aide, Employee E8, who did not receive the required in-service education between April 2023 and April 2024. This oversight was confirmed by the Staff Development Coordinator, highlighting a breach in the facility's policy on resident protection training.
The facility failed to provide the required minimum of twelve hours of in-service training for two nurse aides, Employees E7 and E8, as per regulatory requirements. Employee E7 received only 8.5 hours, and Employee E8 received 5.25 hours of training within the specified period. This deficiency was confirmed by the Staff Development Coordinator.
The facility failed to ensure the presence of all required multidisciplinary members at the Infection Control Committee Meetings throughout 2024, missing laboratory personnel, physical plant personnel, and pharmacy staff in various quarters, as confirmed by the Infection Preventionist.
The facility did not ensure that seven staff members completed the required annual Restorative Nursing Techniques education. A review of training records showed that Nurse Aides and RNs did not have documented training for the specified periods, as confirmed by the Nursing Home Administrator.
The facility did not notify the Department about renovations in Two North Unit, room 213, where maintenance workers were replacing flooring. The room was empty, and the resident was relocated during the construction. The Nursing Home Administrator confirmed the lack of notification.
The facility used its LTC kitchen to prepare meals for ALF residents without obtaining the necessary waivers from the State Licensing Agency. This was confirmed through staff interviews, including the Dietary Supervisor and Nursing Home Administrator, who acknowledged the failure to maintain kitchen services designated for LTC residents.
The facility failed to obtain the Department of Health's approval before removing beds from resident bedrooms. Rooms on One North were converted into offices, and many other rooms were turned into private rooms with fewer beds than licensed. The Nursing Home Administrator confirmed these changes were made without the required approval.
The facility failed to maintain the automatic sprinkler system, leading to deficiencies in three smoke compartments. Observations revealed missing and broken ceiling tiles in the HR Copy Room and Dietary Storage, and a missing escutcheon plate on a sprinkler head in the Chemical Storage room North stairwell. These issues were confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain smoke barrier doors, as observed in the South Wing hallway, where an excessive gap between the doors compromised their ability to resist smoke passage. This issue affected two of the 15 smoke compartments, as confirmed by the Facility Administrator and Maintenance Director.
The facility did not maintain the required fire resistance rating for vertical opening enclosures, affecting one smoke compartment. Observations revealed multiple wires passing through a large open hole in Room U 115, confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain electrical receptacles according to NFPA 101 standards, with a broken receptacle found in the HR Hallway. This deficiency was confirmed by the Facility Administrator and Maintenance Director, indicating non-compliance with grounding and GFCI requirements.
An inspection revealed that an electrical junction box next to the Exit doors in the North Stairwell was missing a cover plate. This deficiency was confirmed by the Facility Administrator and Maintenance Director.
Failure to Report Allegation of Abuse Involving Resident Photography
Penalty
Summary
The facility failed to report an allegation of abuse through the required Electronic Event Reporting system (ERS) for one of three residents. Facility policy titled "Prohibition and Prevention of Resident Abuse, Neglect, Exploitation, Mistreatment, or Misappropriation of Resident Property" dated 12/9/25 states that all allegations of abuse must be reported initially through ERS, and defines emotional or psychological abuse to include taking or using photos or recordings in any manner that would demean or humiliate a resident. Resident R3 was admitted with diagnoses including a right humeral fracture, pain, and high blood pressure. Behavior Night Shift Documentation for 3/8/26 showed that Resident R3 called 911 and was attempting to take photos of other residents without their consent. During an interview, Resident R3 stated that everything was fine until the resident called the police, after which the facility "turned everything around" on the resident and removed the roommate, Resident R4, from the room. In a separate interview, the Director of Nursing (DON) reported that Resident R4's family had told Resident R3 to watch out for their loved one, and that Resident R3 took this too seriously and began photographing Resident R4, who was always fully clothed in the photos. Review of the facility's ERS reports showed no entry for this allegation of abuse, and in an interview the DON acknowledged that the facility did not realize the incident was reportable and therefore failed to report the allegation of abuse as required by policy and state regulations.
Failure to Provide Appropriate Behavioral Health Management for a Resident With Sexualized Behaviors
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with severe cognitive impairment and known behavioral issues. The resident had diagnoses including stroke, cognitive impairment of unknown etiology, and Parkinson’s disease, with a BIMS score of 2 indicating severe cognitive impairment. The MDS documented other behavioral symptoms not directed toward others occurring on one to three days, and the care plan identified a potential for behavioral problems due to cognitive impairment, including sexually inappropriate behavior toward staff. The care plan interventions included anticipating and meeting needs, monitoring behavior episodes to determine underlying causes, documenting behaviors and potential causes, and praising progress. The resident’s activity preferences indicated that reading materials, music, being around animals, doing favorite activities, and going outside for fresh air were important to them. Behavior documentation showed that the resident made numerous attempts to disrobe in the hallway and was later documented as exposing and manipulating his penis. Another resident reported being upset after observing this resident masturbating in a common area, and facility documentation acknowledged that the resident had advanced dementia and had been observed at the nurses’ station with displaced clothing due to confusion. During observation, the resident was seated at the nurses’ station in a reclining medical wheelchair next to a non-medical unit secretary, with no stimulation or diversional activities provided. Staff interviews confirmed that the resident frequently disrobed and manipulated his penis, that redirection efforts were not always successful, and that the resident could not be left alone in his room due to fall risk. The DON confirmed that the facility failed to ensure the resident received appropriate behavioral health management to maintain the highest practicable well-being.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to comply with the regulatory requirement to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for four residents. This deficiency was identified through clinical record reviews and staff interviews. The residents involved were transferred to the hospital on various dates, but there was no documented evidence that the required written transfer notification was sent to the Ombudsman. Resident R1, admitted on January 10, 2023, with diagnoses including hemiplegia, diabetes mellitus, and hypertension, was transferred to the hospital on August 27, 2024. Similarly, Resident R18, admitted on August 22, 2024, with high blood pressure, anemia, and urine retention, was transferred on October 8, 2024. Resident R27, admitted on September 16, 2024, with congestive heart failure, respiratory failure, and diabetes mellitus, was transferred on September 1, 2024. Lastly, Resident R32, admitted on January 7, 2025, with high blood pressure, hyponatremia, and respiratory failure, was transferred on January 16, 2025. During an interview, Secretary Employee E3 confirmed the facility's failure to provide the necessary transfer notices for these residents. This oversight indicates a lack of adherence to the regulatory requirements for notifying the Ombudsman about resident transfers, as mandated by the relevant sections of the Code of Federal Regulations and Pennsylvania Code.
Plan Of Correction
Assuming for the sake of this discussion, the validity of the deficiencies noted in the Department of Health's Statement of Deficiencies Report to St. Barnabas Nursing Home, Inc. for the Survey ending January 30, 2025, which St. Barnabas does not admit, we offer the following Plan of Correction. Nothing contained in the Plan of Correction shall/should be deemed an admission, either expressed or implied, on the part of St. Barnabas Nursing Home, Inc. as to the validity of the deficiencies noted in the report. The monthly letter on transfers/discharges has been corrected to be mailed to the correct location of the State Office of Long-Term Care Ombudsman. The letter will continue to be completed monthly and as needed and submitted per email, at the request of the State Office of Long-Term Care Ombudsman as opposed to submitting to the Allegheny County Office of Long-Term Care Ombudsman. The transfers/discharges letter for December 2024 and January 2025 have already been submitted to the State Office of Long-Term Care Ombudsman via email. Education provided to administrative staff by the Administrator. A Quality Assurance Program will be implemented to ensure the letter is sent to the correct location and will be monitored on a monthly basis for the next 3 months and reported to the QAPI Committee.
Failure to Address Weight Loss and Conduct Nutritional Assessments
Penalty
Summary
The facility failed to address significant weight loss in a timely manner for a resident, identified as Resident R36. The resident, who had diagnoses including anemia, Alzheimer's Disease, and hyperlipidemia, experienced a significant weight loss of 9.12% in one month and 15% over three months. Despite these changes, there was no documentation of an assessment by the Registered Dietitian (RD) during the critical months of September, October, November, and December 2024. Additionally, there was a change in the tube feeding order that decreased the amount of formula administered, but no documentation supported this change or any nutritional recommendations. The report also highlights the facility's failure to complete initial nutrition assessments for two other residents, identified as Resident R29 and Resident R49. Resident R29, admitted with conditions such as a fracture of the right femur and atrial fibrillation, did not have documented assessments by the RD in the months following admission. Similarly, Resident R49, with diagnoses including asthma and aortic stenosis, also lacked documented nutritional assessments in the months after admission. Interviews with RD Employee El revealed that the RD was not employed at the facility during a critical period and was only notified of Resident R36's weight loss in November. The RD recommended increasing the tube feeding rate, but the resident's husband, who dictated most of her care, refused this change. This refusal was not documented in the resident's clinical record, indicating a lack of proper documentation and communication regarding the resident's care and nutritional needs.
Plan Of Correction
Resident 36 MD aware of the weight loss. Dietician restarted on 11-6-2024. Dietician reviewing all weights and notifying physician timely. All residents reviewed for weight loss and MD updated as indicated. Resident 29 and Resident 49 nutritional assessments completed. All residents verified for having a current nutritional assessment. Dietician will monitor all current residents and any new admissions to ensure they have an assessment. Dietician educating nursing on need for nutritional assessments and addressing weight loss timely. QAPI will be initiated on timely notification of physician on weight loss and nutritional assessments completed on new admissions, weekly for one month, bi-weekly for one month and monthly thereafter. All results for QAPI will be reported to the QA committee.
Deficiency in QAPI Training for Staff
Penalty
Summary
The facility failed to meet the requirement for Quality Assurance and Performance Improvement (QAPI) training as outlined in §483.95(d). This deficiency was identified through a review of facility documents, employee education records, and staff interviews. Specifically, five out of seven staff members, including four Nurse Aides (Employees E7, E8, E9, and E11) and one Registered Nurse (Employee E12), did not receive the mandatory QAPI training within the specified time frames. The facility's policy, dated 5/23/24, mandates that all new staff receive training during orientation and annually thereafter. However, the training records revealed that these employees did not have documented QAPI education during their respective annual periods. The Staff Development Coordinator confirmed the lack of training for these staff members during an interview.
Plan Of Correction
All employees with upcoming evaluations will have necessary required in-service education and training, including QAPI, for a total of 12 hours by their evaluation date. Employee training will be monitored, and each employee's status of education completion will be pulled at least each quarter to ensure completion in a timely manner prior to the evaluation date, by the staff development coordinator and Director of Nursing. Education to all nursing staff will be given by Staff Development or designee. QAPI on staff education training compliance will be done weekly for one month, bi-weekly for one month, and monthly thereafter. All results will be reported to the QA Committee.
Failure to Follow Physician Orders and Timely Notify of Weight Loss
Penalty
Summary
The facility failed to follow physician orders and provide appropriate treatment and care for two residents, leading to deficiencies in quality of care. For one resident, the facility did not administer the prescribed medication, Empagliflozin, on multiple occasions due to delays in delivery from the pharmacy. The Director of Nursing confirmed that the medication was not administered on the specified dates and that the physician was not notified of these missed doses. Another resident experienced significant weight loss, which was not promptly communicated to the physician. The resident's weight dropped from 119.5 lbs to 108.6 lbs in one month, and further to 101.5 lbs over three months, indicating a 15% loss. Despite this, the physician was not informed until a month later, delaying necessary interventions. The resident's tube feeding formula was not adjusted in a timely manner, as the facility waited to exhaust the existing supply before implementing the physician's verbal order for a change. Interviews with facility staff confirmed these lapses in care. An LPN Assessment Coordinator acknowledged the delay in notifying the physician about the weight loss and the subsequent delay in changing the tube feeding formula. These actions and inactions demonstrate a failure to adhere to professional standards of practice and timely implementation of physician orders, as required by the facility's policies and regulations.
Plan Of Correction
Resident 23 medications arrived from pharmacy and administered per orders. All residents' medication cards were evaluated to ensure medications are available. Nursing staff will be educated by the Director of Nursing or designee on ensuring that medications are available and the need to reorder is completed timely, as well as physician notified when medication are not given. Night shift will check medication carts for need to reorder medication before quantity is low. Charge nurse will check daily if meds are not available or not received, with unit nurse, to ensure they are ordered and MD aware. Audits will be completed that nurses reorder medications timely and MD notification for medication not received. The Director of Nursing or a designee will audit for medications that quantity is sufficient weekly for a month. Bi-weekly for a month and monthly thereafter. All results will be reviewed at QAPI. Resident 36 MD aware of weight loss. Dietician restarted on 11-6-2024. Dietician reviewing all weights and notifying physician timely. All residents reviewed for weight loss and MD updated as indicated. Changes in orders implemented on recommendation. Dietician educating nursing on notifying MD on weight loss and changing orders for tube feeding on recommendation. QAPI for Weight loss MD notification and change in orders will be done by the dietician or designee, weekly for one month, bi-weekly for one month and monthly thereafter. All results will be reviewed with the QAPI committee.
Failure to Provide Adequate Enteral Feeding Management
Penalty
Summary
The facility failed to ensure that a resident with an enteral feeding tube received appropriate treatment and services. The resident, who had diagnoses of anemia, Alzheimer's Disease, and hyperlipidemia, experienced significant weight loss over several months. Despite the weight loss, there was no documentation of assessment by the Registered Dietitian in September, October, November, and December 2024, nor were there any nutritional recommendations documented in the clinical record. The resident's weight loss was significant, with a 9.12% loss in one month and a 15% loss over three months. The facility's records showed a decrease in the tube feeding formula rate without supporting documentation for the change. The Registered Dietitian was not employed at the facility during a critical period and was only notified of the weight loss in November. The resident's husband, who dictated most of her care, refused to increase the tube feeding rate, but this refusal was not documented in the clinical record. The physician was not informed of the resident's weight loss until November 1st, despite the weight loss being evident in October. A verbal order to change the tube feeding formula was given, but the change was delayed until December 12th due to the need to use up the existing supply. The facility's failure to act promptly and document appropriately contributed to the deficiency in providing adequate care for the resident with an enteral feeding tube.
Plan Of Correction
Resident R36 is on the ordered tube feeding. There are no other tube feed residents presently in the building. Education being completed to nursing by the dietician or designee on orders for tube feedings being updated when recommended and ordered as well as weight loss monitored and nutritional assessment completed with weight loss. Education will include changing the feeding immediately when ordered and available. A QAPI will be completed to ensure weight loss and nutritional assessments completed by the dietician or designee. Weekly for one month, bi-weekly for one month and weekly thereafter. All results will be reported at to the QA committee.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in their treatment. Resident R32, who was admitted with diagnoses including respiratory failure, was observed receiving oxygen at 3 liters per minute (LPM) via nasal cannula, despite a physician's order specifying 1-2 LPM. This discrepancy was confirmed by a registered nurse, indicating a failure to adhere to the prescribed oxygen therapy. Resident R36, with diagnoses including Alzheimer's Disease and hyperlipidemia, was prescribed Ipratropium-Albuterol for congestion. However, the facility did not have a physician order to change the nebulizer tubing and aerosolized face mask, nor was there a care plan addressing the maintenance of respiratory equipment or procedures for adverse reactions. Interviews with staff, including the Director of Nursing, revealed that the facility lacked policies and procedures for respiratory care and aerosolized medication therapy, further confirming the deficiency in providing appropriate respiratory care for Resident R36.
Plan Of Correction
Resident 32 oxygen order updated for the liter flow of oxygen that was needed. All resident records evaluated to ensure that the physician order matched the delivery of liter flow. Staff re-educated that oxygen delivery will have an order and be in the care plan. Staff will also verify oxygen order to the oxygen concentrator each shift by the Director of Nursing or designee. Audits to be completed by the director of nursing or designee to ensure that the oxygen flow that the resident is receiving matches the physician orders. Audits completed weekly for one month, bi-weekly for one month, and monthly thereafter. All results will be reviewed with the QAPI committee. Resident 36 nebulizer tubing had been changed 1/24/25, per our normal procedure of changing on Thursday, night shift. Order written to change tubing/aerosolizer weekly. All residents' nebulizer tubing checked and verified MD order for changing the tubing weekly and noted in care plan. Staff education by the Director of nursing or designee completed on policy to add orders for the nebulizer tubing to be changed weekly for anyone ordered a nebulizer and anyone admitted with an order for nebulizer treatment. Change of tubing also to be noted in the care plan. QAPI will be done to ensure an order for nebulizer tubing changes is written for patients with a nebulizer. The director of Nursing or designee will audit residents with nebulizer treatments to ensure there is an order in place for changing the tubing weekly. Audits will be completed weekly for one month, bi-weekly for one month, and monthly thereafter. All results will be reviewed by the QA committee.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that significant medications were administered as ordered by the physician for a resident. The facility's policy on medication administration, dated May 23, 2024, requires that medications and biologicals be administered by the same licensed nurse who prepared the dose and that they be given as soon as possible after preparation. However, a review of the clinical record for a resident admitted on November 22, 2024, with diagnoses including atrial fibrillation, hypertension, and macular degeneration, revealed that the resident did not receive their prescribed medication, Synthroid, on four separate occasions. The resident's physician orders dated November 23, 2024, indicated that the resident was to receive Synthroid orally once a day. The Medication Administration Record (MAR) showed that on December 29, 2024, December 30, 2024, January 21, 2025, and January 27, 2025, the medication was documented as unavailable and not given. During an interview on January 30, 2025, the Director of Nursing confirmed the facility's failure to administer the medication as ordered.
Plan Of Correction
Resident 50 medications arrived from pharmacy and administered per orders. All residents' medication cards were evaluated to ensure medications are available. Nursing staff will be educated by the Director of Nursing or designee on ensuring that medications are available and the need to reorder is completed timely, as well as physician notified when medication are not given. Night shift will check medication carts for need to reorder medication before quantity is low. Charge nurse will check daily if meds are not available or not received, with unit nurse, to ensure they are ordered and MD aware. Audits will be completed that nurses reorder medications timely and MD notification for medication not received. The Director of Nursing or a designee will audit for medications that quantity is sufficient weekly for a month, bi-weekly for a month, and monthly thereafter. All results will be reviewed at QAPI.
Failure to Employ Qualified Registered Dietitian
Penalty
Summary
The facility failed to employ a qualified Registered Dietitian for one of the twelve months, specifically in October 2024. This deficiency was identified through staff interviews, which revealed that the Registered Dietitian, Employee El, was employed from June 29, 2021, to August 20, 2024, and did not resume work on a PRN basis until November 6, 2024. During this gap, the facility did not have a qualified Registered Dietitian on staff as required by the regulations. An interview with the Nursing Home Administrator on January 29, 2025, confirmed that the facility had a Registered Dietitian from September 5, 2024, to October 4, 2024, but not for the entire month of October 2024. This lapse in employing a qualified dietitian is a violation of the regulatory requirements, which mandate that the facility must have sufficient dietary staff to meet the needs of the residents, taking into account their assessments, care plans, and the facility's resident population.
Plan Of Correction
Dietician was rehired and worked as a consultant from 11-6-2024 through present. On 2-17-2025 the dietician will again hold a part time position. If a qualified dietician is no longer employed, a contracted dietician will be hired either independently or through an agency until a new dietician is employed. All food service supervisors and current dietician have been educated on the requirements by the Administrator. The Administrator or designee will complete a monthly QAPI to ensure there is an appropriate dietician employed at the facility and results will be reported to the QAPI committee.
Failure to Obtain Hospice Diagnosis
Penalty
Summary
The facility failed to obtain a diagnosis for hospice services for one of its residents, identified as Resident R32. The resident was admitted to the facility on January 7, 2025, and had a Minimum Data Set (MDS) assessment dated January 14, 2025, which indicated diagnoses of high blood pressure, hyponatremia, and respiratory failure. Despite these documented conditions, the facility did not secure a specific diagnosis related to the need for hospice services. A physician order dated January 22, 2025, instructed the admission of Resident R32 to hospice care. However, this order did not include a diagnosis that justified the need for hospice services. Similarly, the resident's care plan, also dated January 22, 2025, noted that the resident had a terminal prognosis and was receiving hospice care, but it failed to specify a diagnosis related to the hospice services requirement. During an interview on January 20, 2025, the Director of Nursing confirmed the facility's failure to obtain the necessary diagnosis for hospice services as required. This deficiency was identified based on a review of the facility's policy, resident clinical records, and staff interviews, highlighting a lapse in compliance with the regulatory requirements for hospice care coordination.
Plan Of Correction
Resident R32 diagnosis added for hospice care. All residents with hospice have been checked to ensure there is an admission diagnosis ordered with the start of hospice care. For all admissions to hospice, a diagnosis will be obtained from hospice and noted with the hospice order to admit to hospice, that clarifies why someone was admitted to hospice. The Director of nursing or designee will educate all the nursing staff that a diagnosis is needed in order for someone to be admitted to hospice and to verify the diagnosis is with the order for hospice services. The Director of Nursing or designee will initiate a QAPI to check that every new hospice admission has a diagnosis for admission to hospice. QAPI will be completed every week for 1 month, bi-weekly for one month and monthly thereafter. All results will be reviewed with the QA committee.
Deficiency in Infection Control and Water Management
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program, specifically in managing the risk of Legionella bacteria in its water systems. The facility's policy on 'Legionella Prevention' was found lacking as it did not include measures to prevent microbial growth throughout the facility. The facility did not implement control measures for Legionella for eleven out of twelve months, from February 2024 through January 2025. The facility's water management plan was incomplete, missing specific testing protocols, acceptable ranges for control measures, and a description of the water system using a flow diagram. Additionally, there was no log for monitoring chlorine concentration levels in the water, which are crucial for controlling Legionella growth. The report also identified a failure to implement transmission-based precautions for a resident diagnosed with shingles. The resident, who had been admitted to the facility with conditions including anemia, Alzheimer's Disease, hyperlipidemia, and multiple pressure ulcers, was not placed in the necessary contact precautions for shingles. The facility's records lacked documentation of Enhanced Barrier Precautions (EBP) for the resident's wounds and indwelling medical devices, which are critical for preventing the spread of infections. Interviews with facility staff revealed a lack of clarity and communication regarding the implementation of isolation precautions. The Infection Preventionist confirmed that there was no documentation in the resident's care plan to reflect the necessary precautions for shingles, nor were EBPs implemented for the resident's wounds and medical devices. This oversight indicates a significant gap in the facility's infection control practices, as required by regulatory standards.
Plan Of Correction
Water lines were tested on January 29, 2025. Chlorine was at appropriate levels. Facility maintenance will enact a monthly water test on water lines to ensure correct levels of chlorine are present. The water management manual was updated to include water testing. All maintenance staff will be educated on the process and testing by the Director of Maintenance or designee. The Director of Maintenance or designee will perform monthly testing to ensure proper levels of chlorine are present in the water supply lines. A QAPI will be started and verified by the Director of Maintenance or designee; all results will be reported to the QA committee. Resident R36's plan of care was updated to reflect the enhanced barrier precautions that were in place for the resident, and a physician order was obtained for Enhanced Barrier Precautions. All resident care plans and physician orders were checked to ensure that enhanced barrier precautions were present where necessary. Education was provided by the Director of Nursing on updating the care plan and physician orders when enhanced barrier precautions are put into place. The Director of Nursing or designee will complete an audit to ensure care plans and orders are updated with enhanced barrier precautions, weekly for one month, bi-weekly for one month, and monthly thereafter. All results will be reported to the QA committee.
Failure to Provide Abuse and Neglect Training
Penalty
Summary
The facility failed to provide mandatory training on resident protection from abuse and neglect for one of its staff members, specifically Nurse Aide Employee E8. According to the facility's policy, all new staff are required to undergo training during the orientation process, which includes a checklist on both theory and skills material. This training is supposed to be repeated annually. However, a review of the facility's documents and training records revealed that Employee E8, who was hired on April 27, 2017, did not receive the required abuse and neglect prevention in-service education between April 27, 2023, and April 27, 2024. During an interview, the Staff Development Coordinator, Employee E14, confirmed the oversight, acknowledging that the facility did not provide the necessary training for one of the seven staff members reviewed. This deficiency is a violation of the facility's policy on the prohibition and prevention of resident abuse, neglect, exploitation, mistreatment, or misappropriation of resident property, which mandates that all employees receive abuse training during general orientation and annually thereafter.
Plan Of Correction
All employees with upcoming evaluations will have necessary required in-service education and training, including abuse and neglect, for a total of 12 hours by their evaluation date. Employee training will be monitored, and each employee's status of education completion will be pulled at least each quarter to ensure completion in a timely manner prior to the evaluation date, by the staff development coordinator and Director of Nursing. Education to all nursing staff will be given by Staff Development or designee. QAPI on staff education training compliance will be done weekly for one month, bi-weekly for one month, and monthly thereafter. All results will be reported to the QA Committee.
Deficiency in Required In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that all nurse aide staff received the required minimum of twelve hours of in-service education training each year. This deficiency was identified for two out of five nurse aides, specifically Employees E7 and E8. Employee E7, who was hired on March 12, 2020, only received 8.5 hours of in-service training between March 12, 2023, and March 12, 2024. Similarly, Employee E8, hired on April 27, 2017, received only 5.25 hours of in-service training between April 28, 2023, and April 27, 2024. The facility's policy, "Facility Assessment: Staff Training and Competencies," dated May 23, 2024, requires that all new staff are trained during the orientation process and annually thereafter. However, the review of facility documents and training records revealed that the required training hours were not met for the mentioned employees. This was confirmed during an interview with the Staff Development Coordinator, Employee E14, who acknowledged the failure to meet the training requirements for the nurse aides.
Plan Of Correction
All CNA's with upcoming evaluations will have necessary required in-service education and training, for total of 12 hours by their evaluation date. CNA training will be monitored by staff development and Director of Nursing for education completion. Education status will be pulled, at least each quarter, to ensure completion in a timely manner, prior to evaluation date. Education to all CNA's will be given by Staff Development or designee. QAPI on staff education training compliance will be done weekly for one month, bi-weekly for one month and monthly thereafter. All results will be reported to the QA Committee.
Infection Control Committee Attendance Deficiency
Penalty
Summary
The facility failed to meet the minimum standards for infection control as required by the Medical Care Availability and Reduction of Error (MCARE) Act. Specifically, the facility did not ensure that all required multidisciplinary members were present at the Infection Control Committee Meetings for all four quarters of 2024. The required members include laboratory personnel, physical plant personnel, and pharmacy staff, among others. The absence of these key personnel was noted in the attendance records for each quarter, indicating a consistent failure to comply with the regulation. In Quarter 1, laboratory personnel were not present at the meeting. In Quarter 2, the absence extended to laboratory personnel, physical plant personnel, and pharmacy staff. Quarters 3 and 4 again saw the absence of laboratory personnel. This deficiency was confirmed during an interview with the Infection Preventionist, who acknowledged the facility's failure to ensure the presence of all required multidisciplinary members at the meetings.
Plan Of Correction
All 9 of the required Multidisciplinary team members will be present at the quarterly Infection Control/QAPI meeting. All members will be notified of when each quarterly Infection Control/QAPI meeting will be held and all signatures of those attending will be obtained. Members who attend via phone or video will be documented/signed as such for their attendance. Education will be provided to all Multidisciplinary team members by the RNAC or designee on their requirement to attend the Infection Control/QAPI meeting each quarter and to ensure they are signing the attendance log. Attendance/ signatures will be monitored at each quarterly Infection Control/QAPI meeting by the RNAC or designee.
Failure to Provide Annual Restorative Nursing Training
Penalty
Summary
The facility failed to ensure that seven employees completed the required annual Restorative Nursing Techniques education. This deficiency was identified through a review of facility policy, documents, and staff interviews. The facility's policy, dated 5/23/24, mandates that all new staff receive training during orientation and complete a checklist on both theory and skills material, which is to be repeated annually. However, training records revealed that Nurse Aides and Registered Nurses, specifically Employees E7 through E13, did not have documented training in Restorative Nursing Techniques for the specified annual periods. During an interview, the Nursing Home Administrator confirmed the lack of training for these staff members.
Plan Of Correction
All employees with upcoming evaluations will have necessary required in-service education and training, including restorative, for a total of 12 hours by their evaluation date. Employee training will be monitored, and each employee's status of education completion will be pulled at least each quarter to ensure completion in a timely manner prior to the evaluation date, by the staff development coordinator and Director of Nursing. Education to all nursing staff will be given by Staff Development or designee. QAPI on staff education training compliance will be done weekly for one month, bi-weekly for one month, and monthly thereafter. All results will be reported to the QA Committee.
Failure to Notify Department of Renovations
Penalty
Summary
The facility failed to notify the Department of renovations made to one of its nursing units, specifically Two North Unit, room 213. During an observation and interview, it was found that the room was empty, with no furniture or bed, and maintenance workers were actively working on replacing the flooring. The maintenance worker confirmed that the renovations began that day, and the resident who previously occupied the room had been relocated to another room during the construction. The Nursing Home Administrator later confirmed that the facility did not notify the Department of these renovations prior to their commencement.
Plan Of Correction
Room 213 carpet was pulling up and posed a safety/tripping hazard. Resident was moved to another room temporarily on January 27, 2025, to prevent injury. New vinyl flooring was installed on January 31, 2025. The resident returned to room 213 on January 31, 2025. Department of Health was emailed on January 29, 2025, and Life Safety was emailed on January 30, 2025, concerning changing the flooring due to safety. Reviewed information with Life Safety via phone call on February 11, 2025. Life Safety suggested using their web request and submit information on the flooring. Information submitted on February 14, 2025. All future flooring changes or other similar necessities of change will be reported to the Department of Health Supervisor and will be routed through the Life Safety portal for approval/notification. Education will be provided to the Director of Maintenance. A QAPI will be initiated to ensure any change is reported to the appropriate authorities of the Department of Health and Life Safety. QA will be completed by the Director of Maintenance or designee on a monthly basis and reported to the QA committee.
Unauthorized Use of LTC Kitchen for ALF Meals
Penalty
Summary
The facility failed to maintain kitchen services designated for its residents by using the Long Term Care (LTC) kitchen to prepare meals for residents of the Assisted Living Facilities (ALF) located on the Third Floor and Courtyard Floor. This was determined based on observations and staff interviews. During an interview, the Dietary Supervisor confirmed that the LTC kitchen was being used for ALF meal preparation. Additionally, the Nursing Home Administrator acknowledged that the facility did not obtain the necessary waivers or exceptions from the State Licensing Agency to allow the LTC kitchen to serve ALF residents, as required by regulations.
Plan Of Correction
In 2009, an exemption request was granted for the Personal care home, The Arbors to reside in the same building as St. Barnabas Nursing Home. Request submitted to the department of Health on February 14, 2025 for the Kitchen to prepare foods for the Personal Care Home and St. Barnabas Nursing Home as a second Waiver/exemption is required. Administrative Staff and Maintenance supervisor educated on requested waiver/exemption noted in PA 3060. QAPI will be completed to ensure the waiver/exemption is received from the Department of Health. Results will be reported in the QAPI meeting.
Failure to Obtain Approval for Bed Removal
Penalty
Summary
The facility failed to obtain the Department of Health's approval before removing beds from resident bedrooms, as observed during a survey on various nursing units. On One North, rooms licensed for multiple beds were found to have no beds present, as they had been converted into offices. Similarly, on One South, Two North, and Two South, rooms licensed for two to four beds were observed to have fewer beds than licensed, with many rooms converted into private rooms with only one bed. During an interview, the Nursing Home Administrator confirmed that the facility had converted rooms on One North into offices and most other rooms into private rooms without the intention of reverting them to their original licensed capacity. The administrator acknowledged that the facility did not seek or obtain the necessary approval from the Department of Health before making these changes, leading to the deficiency noted in the report.
Plan Of Correction
There are rooms that are not immediately able to be set up as a patient room. A request to delicense beds will be submitted to the Department of Health. Education to the administrative staff, nursing and maintenance managers concerning what is needed for a functioning room and if we do not have a functioning room a bed may need delicensed. A QAPI will be completed monthly to ensure that the delicensing of beds was approved and all licensed beds are immediately available for a resident. Results will be reported to the QA committee.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system, resulting in deficiencies in three of the 15 smoke compartments. During an observation on January 23, 2025, several issues were identified: a ceiling tile in the HR Copy Room was missing a portion larger than 1/8 inch, a ceiling tile in the Dietary Storage was broken and missing a corner piece, and a sprinkler head in the Chemical Storage room North stairwell was missing an escutcheon plate. These deficiencies were confirmed through an interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
A. 1. Facility maintenance will repair gaps in ceiling tile in HR copy room and dietary storage greater than 1/8" with, but not limited to tighter fitting ceiling tile and/or caulking. On or before March 14, 2025. 2. Director of maintenance or designee will perform quarterly audits of facility to ensure no penetrations or gaps in ceiling. 3. Results of audit will be reviewed in QA. B. 1. Facility maintenance will install escutcheon on chemical room sprinkler head and ensure all facility sprinkler heads have the proper escutcheon plates in place on or before March 14, 2025. 2. Director of maintenance or designee will perform quarterly audits of facility to ensure escutcheon plates are in place around sprinkler heads. 3. Results of audit will be reviewed in QA.
Smoke Barrier Door Deficiency
Penalty
Summary
The facility failed to maintain smoke barrier doors in compliance with NFPA 101 standards, specifically affecting two of the 15 smoke compartments. During an observation on January 23, 2025, at 10:40 a.m., it was noted that the smoke barrier doors in the South Wing hallway had an excessive gap between their meeting edges. This gap was significant enough to prevent the doors from effectively resisting the passage of smoke. An interview conducted with the Facility Administrator and Maintenance Director later that day at 1:30 p.m. confirmed the presence of the excessive gap in the smoke barrier doors, which compromised their ability to resist smoke passage.
Plan Of Correction
1. Facility maintenance contacted the vendor that installed the 1st floor south fire doors. The vendor made repairs to the doors on January 31st, 2025, eliminating the excessive gap between the meeting edges of the doors. 2. The maintenance director or designee will perform a one-time inspection of the facility to ensure fire doors do not have excessive gaps between the meeting edges of the doors on or before March 14, 2025. 3. Results of the audit will be reviewed in QA.
Vertical Opening Enclosure Deficiency
Penalty
Summary
The facility failed to maintain the required fire resistance rating for vertical opening enclosures, specifically affecting one of the 15 smoke compartments. During an observation, it was noted that multiple data, cable, and electrical wires were passing through a large open hole in the back corner of Room U 115. This deficiency was confirmed through an interview with the Facility Administrator and Maintenance Director, who acknowledged the issue with the vertical opening enclosure.
Plan Of Correction
Assuming for the sake of this discussion, the validity of the deficiencies noted in the Department of Health's Statement of Deficiencies Report to St. Barnabas Nursing Home, Inc for the survey ending January 23, 2025, which St. Barnabas does not admit, we offer the following Plan of Correction. Nothing contained in the Plan of Correction shall/should be deemed an admission either expressed or implied, on the part of St. Barnabas Nursing Home, Inc. as to the validity of the deficiencies noted in the report. 1. Facility maintenance will purchase and install the proper electrical tray and fire blocking material around cables, data lines, and electrical wires in U115 on or before March 14, 2025. 2. Director of maintenance or designee will perform a one-time audit of the building ensuring all data, cable, and electrical wires passing through vertical openings are properly sealed. 3. Results of the audit will be reviewed in QA.
Electrical Receptacle Deficiency in HR Hallway
Penalty
Summary
The facility failed to maintain electrical receptacles in compliance with NFPA 101 standards, specifically in one of the 15 smoke compartments. During an observation on January 23, 2025, at 10:35 a.m., a broken electrical receptacle was identified in the HR Hallway near the entrance doors. This deficiency was confirmed through an interview with the Facility Administrator and Maintenance Director later that day at 1:30 p.m. The report highlights that the receptacle did not meet the requirement for having a highly dependable grounding pole and, if used in a patient care room, being equipped with a ground-fault circuit interrupter (GFCI).
Plan Of Correction
1. Facility maintenance will replace broken electrical receptacle in hallway of HR on or before March 14, 2025. 2. Director of maintenance or designee will perform a onetime inspection of electrical receptacles throughout facility to ensure all electrical receptacles are properly maintained. 3. Results of audit will be reviewed in QA.
Uncovered Electrical Junction Box in North Stairwell
Penalty
Summary
The facility failed to maintain electrical junction boxes in compliance with safety standards, as evidenced by an observation on January 23, 2025. During the inspection, it was noted that an electrical junction box next to the Exit doors in the North Stairwell lacked a cover plate. This deficiency was confirmed through an interview with the Facility Administrator and Maintenance Director later that day.
Plan Of Correction
A. 1. Facility maintenance will ensure a cover plate is installed on the electrical junction box in the North stairwell by exit doors on or before March 14, 2025. 2. Director of maintenance or designee will perform a one-time inspection of the facility to ensure all electrical junction boxes have the proper cover plate. 3. Results of the audit will be reviewed in QA.
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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