St John Specialty Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mars, Pennsylvania.
- Location
- 500 Wittenberg Way, Mars, Pennsylvania 16046
- CMS Provider Number
- 395164
- Inspections on file
- 31
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at St John Specialty Care Center during CMS and state inspections, most recent first.
A resident with cardiac comorbidities, cognitively intact and on anticoagulation, was being transported by wheelchair van when the wheelchair tipped during a left-hand turn, causing the resident to fall to the van floor and sustain multi-system trauma. Facility policy required use of a five-point Q-Straint securement system, including a chest lap harness, and driver competency in its use. The resident and facility documentation indicated that while the wheelchair was strapped to the floor, the passenger seatbelt/chest lap harness was not applied, and the incident was documented as a fall with injury during transport due to failure to apply the passenger seatbelt. Hospital evaluation identified multiple fractures involving the cervical and thoracic spine, ribs, clavicle, pelvis, and hip, and the resident was transferred to a trauma center.
A resident with cardiac comorbidities, cognitively intact and on anticoagulation, was being transported by wheelchair van to an appointment when the wheelchair tipped during a turn, causing the resident to fall and sustain multi-system trauma. Facility records and the resident’s statement indicated that although the wheelchair was secured to the van floor using a Q-Straint system, the driver did not apply the passenger chest lap harness, leaving the resident unsecured. The facility’s own incident documentation identified failure to apply the passenger seatbelt as the cause of the fall with injury, and leadership acknowledged that this failure to provide adequate supervision and assistance led to the accident and resulting injuries.
The facility failed to report an allegation of verbal abuse to state authorities as required by policy and regulation. A resident with dementia and other medical conditions, who was unable to complete a BIMS interview, was allegedly yelled and sworn at by a nurse aide during care. An LPN and another nurse aide reported hearing the aide repeatedly state that they could not stand the resident’s yelling, using profanity, and one staff member told the aide they could not speak to residents that way. Both staff reported the incident to the DON, and administration removed the aide from the unit. The DON acknowledged an internal investigation occurred but chose not to report the allegation to the Department of Health because she did not consider it threatening, and the administrator confirmed the failure to report.
A resident with Alzheimer's and other conditions was being transferred by two nurse aides who were unable to support the resident's weight and lowered the resident to the floor. The aides did not report the incident to nursing staff, and the resident was not assessed for injury until the next shift noticed swelling, bruising, and abnormal leg positioning. Evaluation revealed a hip fracture, and staff interviews confirmed the incident was not reported as required, resulting in neglect.
A resident with a traumatic brain injury and other conditions experienced a change in condition involving blood in urine and catheter dislodgement. Despite medical interventions and physician notifications, the facility failed to inform the resident's family representative of these significant changes, as confirmed by the DON.
The facility failed to maintain sanitary conditions in the kitchen and unit pantries, risking cross-contamination and food-borne illness. Observations revealed dust and grime in the main kitchen's dairy cooler and improper storage of ice packs in the Resident Food Pantry freezer. These issues were confirmed by staff, including the Dining Services Director and the Nursing Home Administrator.
The facility failed to provide appropriate catheter and bladder care for several residents. A resident's urinary drainage bag was found uncovered on the floor, and another's care plan lacked necessary catheter details. A resident's care plan did not address urinary issues despite physician orders, and another resident's catheter supplies were delayed. Additionally, improper catheter irrigation management was observed. The DON acknowledged these failures.
The facility failed to obtain physician orders and coordinate hospice services for three residents, leading to incomplete care plans lacking hospice provider details and contact information. This deficiency was confirmed by staff interviews.
The facility did not implement an effective infection control program, lacking surveillance for infections in September and October 2024. A nurse was observed improperly exiting a COVID isolation room with PPE still on. The DON confirmed the absence of required documentation.
A resident experienced a delay in meal service, receiving lunch 46 minutes after his roommate, causing distress and hunger. The facility's policy on maintaining resident dignity was not followed, as confirmed by staff and the Director of Nursing. The resident, diagnosed with anxiety, depression, and epilepsy, expressed discomfort with the situation.
The facility failed to address ongoing grievances from residents regarding food quality and call bell response over a three-month period. Residents reported issues such as undercooked pasta, inconsistent meal delivery, and staff turning off call bells without meeting needs. Despite these concerns being documented in Resident Council meetings, the facility did not investigate or resolve them, as confirmed by the Director of Activities.
A resident with dementia experienced verbal abuse in the dining room when a nurse aide yelled and used inappropriate language, witnessed by a speech therapist. The aide admitted to the behavior, which violated the facility's abuse prevention policy.
The facility failed to communicate necessary information to the receiving health care provider for two residents transferred to a hospital. One resident had diagnoses including aftercare following joint replacement, while the other had venous insufficiency and a colostomy. The clinical records lacked documentation of care plan goals, advanced directives, and other essential information, as confirmed by the ADON.
A facility failed to notify the Office of the LTC Ombudsman Division about a resident's transfer to a hospital. The resident, who had diagnoses including aftercare following joint replacement and hyperlipidemia, was transferred and returned without the required notification. This was confirmed by the DON.
A facility failed to notify a resident or their representative of the bed-hold policy during a hospital transfer. The resident, with diagnoses including aftercare following joint replacement and hyperlipidemia, was transferred without documented evidence of written notification about the policy. This oversight was confirmed by the Assistant Director of Nursing.
The facility failed to ensure accurate assessments for two residents. One resident's MDS inaccurately indicated the use of a limb restraint, which was not observed or confirmed by the resident. Another resident's discharge status was incorrectly recorded as being to a hospital, while progress notes showed discharge to Personal Care. These inaccuracies were confirmed by the RNAC.
A facility failed to update a resident's care plan to include the use of a prescribed blood thinner, Eliquis, despite the resident's diagnoses of anemia, coronary artery disease, and heart failure. The omission was confirmed by an RNAC, highlighting a lapse in accurately reflecting the resident's current care needs.
A resident with communication impairments was unable to access their Dynavox device, which is essential for their communication, due to the facility's failure to ensure it was within reach. Despite a care plan and physician order for the device's use, the clinical record lacked an order for the Dynavox, and staff confirmed the resident's reliance on it. The DON acknowledged the facility's failure to maintain the resident's communication ADLs.
A resident with a Tesio catheter, previously used for dialysis, did not have a physician order for its care and management. The resident's care plan lacked specific interventions for the catheter, and observations showed improper management, with visible catheter ports and a crumpled dressing with dried blood. The facility staff confirmed they did not handle the catheter, and the DON acknowledged the oversight.
A facility failed to provide a safe environment for a resident with severe cognitive impairment and physical limitations. Despite the resident's need for supervision, a personal microwave was present in the room without proper risk assessment or inclusion in the care plan. Staff interviews revealed uncertainty about the resident's ability to use the microwave safely.
A facility failed to provide colostomy care consistent with professional standards for a resident. The care plan and physician's orders lacked necessary details about the ostomy appliance, such as size and type, despite facility policy requiring such documentation. Interviews with an LPN and the DON confirmed the deficiency.
A resident with mental health issues, including depression and bipolar disorder, expressed suicidal thoughts and distress. The facility failed to notify psychiatric services as ordered by the physician and did not document a care plan for the resident's suicidal ideation, as confirmed by the DON and Administrator.
A facility failed to ensure a resident's drug regimen was free from unnecessary medication. The resident, diagnosed with Parkinson's Disease, depression, and intellectual disabilities, was prescribed Ativan and Lorazepam for sleep without a documented diagnosis of insomnia or a related care plan. The DON confirmed the oversight, violating Pennsylvania Code regulations.
The facility failed to limit PRN psychotropic medications to 14 days for two residents. One resident with Parkinson's Disease and depression had a Lorazepam order for sleep that exceeded the limit, with no care plan addressing its use. Another resident with anoxic brain damage had a Lorazepam order for seizures that also exceeded the limit, lacking care plan documentation for its use. The DON confirmed these deficiencies.
The facility failed to properly store medications and supplies, with expired items found in a medication room and on a medication cart. An LPN confirmed the expired Victoza pen on the 2nd Floor Middle Hall Medication Cart, while the DON confirmed numerous expired items in the Wellstep Medication Room, including medications for a resident.
A facility failed to provide a resident with the prescribed adaptive feeding device, a blue inner lip plate, as per the physician's order. The resident, who has encephalopathy, aphasia, and epilepsy, was observed receiving lunch in a Styrofoam container instead. This deficiency was confirmed by a nurse aide and the DON, highlighting non-compliance with the facility's policy on assistive devices.
The facility did not implement an antibiotic stewardship program for two months, failing to monitor antibiotic usage and resistance as required by their infection control policies. The DON confirmed the absence of surveillance and tracking records for these months.
The facility did not provide mandatory training on resident rights to a NA hired in 2016. Despite the policy requiring yearly education on resident rights, the NA's training record lacked this training. This deficiency was confirmed by the Nursing Home Administrator.
The facility did not provide mandatory QAPI training to a Nurse Aide, Employee E7, as required by their policy. Despite being hired in 2016, Employee E7's training records lacked evidence of QAPI training, which was confirmed by the Nursing Home Administrator. This oversight violated Pennsylvania Code regulations concerning licensee responsibility, management, and staff development.
A facility failed to update a resident's care plan to reflect their current status. The resident, with diagnoses of dementia, anxiety, and major depressive disorder, had a discrepancy in their care plan regarding bed mobility assistance. The care plan indicated a bed mobility assist of one, while the summary report indicated an assist of two. This inconsistency was confirmed by the Nursing Home Administrator, highlighting a failure to revise the care plan as required.
A resident with dementia and other conditions required bed mobility assistance. During care, a nurse aide turned the resident away and reached for supplies, leading to the resident rolling out of bed and sustaining injuries. The facility failed to prevent this accident.
The facility failed to report allegations of abuse involving four residents within the required timeframe. Residents reported rough handling and inappropriate behavior by aides, but these concerns were not identified as abuse, investigated, or reported to the State. The DON and Nursing Home Administrator confirmed the failure to adhere to reporting requirements.
The facility failed to investigate allegations of abuse for four residents, who reported rough and rude treatment by aides. The facility did not identify these concerns as abuse, did not conduct investigations, and failed to report the allegations to the State, violating federal regulations.
A facility failed to protect a resident from abuse when a bed sheet was tied to the bed rails, restricting movement. Three nurse aides were involved and later terminated. Additionally, the facility did not recognize or report abuse concerns for four other residents, who reported rough handling and inappropriate staff behavior. The DON and Nursing Home Administrator confirmed these failures.
A resident with dementia and other medical conditions was found restrained in bed with sheets tied to the handrails, contrary to facility policy. Staff reported the resident was active and agitated during the night, leading to the sheets being tucked under her. The incident resulted in the suspension and termination of three nurse aides.
The facility failed to investigate and report abuse allegations for four residents, despite having policies in place. Residents reported rough handling and inappropriate staff behavior, but their concerns were not identified as abuse, and no investigations or reports were made. The DON and Nursing Home Administrator confirmed the failure to follow procedures.
A resident with dementia and other conditions was not properly assessed for elopement risk, leading to an incident where they exited the facility through a malfunctioning door. Despite initial assessments indicating no risk, the resident required frequent monitoring. The door malfunctioned due to incorrect programming, and no prior monitoring was conducted. The facility failed to reassess the resident after the incident, and the Nursing Home Administrator confirmed the lack of required evaluations and supervision.
Failure to Properly Secure Wheelchair During Van Transport Resulting in Multi-System Trauma
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect during wheelchair van transportation, resulting in multi-system trauma and transfer to a trauma center. Facility policy on abuse and neglect required a safe and secure environment and protection from neglect, and the transportation policy required all drivers to be competent in Q-Straint wheelchair securement, van lift operation, driver responsibilities while escorting a resident, and safe vehicle operation. The Q-Straint system in use was described as a five-point system, with four points connecting to the wheelchair and a chest lap harness as the fifth point. The resident involved, identified as cognitively intact with a BIMS score of 15, had diagnoses including atrial fibrillation, heart failure, and hypertension, and was receiving Lovenox. On the day of the incident, the resident was being transported by wheelchair van to an appointment when, according to the resident’s statement, the van was taking a left-hand turn and the wheelchair tipped over, causing the resident to land on the right side and strike their head on the van door. The resident reported significant pain to the right shoulder and right hip, and was noted to have a small hematoma above the right ear and on the right ear; pain prevented full assessment of the right hip and shoulder while in bed. Hospital documentation indicated the resident stated they were not secure in the chair, although the chair itself was secured in the van, and that the wheelchair tipped and collapsed on the resident while going around a bend. The resident complained of right shoulder and hip pain and reported striking the side of the van and their head. Imaging revealed multiple injuries, including non-displaced fractures of C7 and T2 transverse processes, fractures of the first through fourth right ribs, a right clavicle fracture with possible joint extension, a non-displaced fracture of the posterior inferior right pubic ramus, an acute comminuted fracture of the anterior right hip acetabulum, and a questionable fracture of the right lateral sacrum. Facility documentation identified the incident as a fall with injury during wheelchair van transport due to failure to apply the passenger seatbelt, and both the resident and the maintenance manager reported that the chest lap harness (fifth point of the Q-Straint system) had not been applied, despite the driver having documented training on the Q-Straint securement system.
Failure to Secure Wheelchair Passenger Seatbelt During Van Transport Resulting in Multi-System Trauma
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents during wheelchair van transport, resulting in actual harm to a resident. Facility policies on Resident Accidents/Incidents and Reporting a Resident Incident During Transport required a safe and secure environment and cautious vehicle operation with resident safety as a priority. The resident involved had diagnoses including atrial fibrillation, heart failure, and hypertension, was cognitively intact with a BIMS score of 15, and was receiving Lovenox. While being transported to an appointment in the facility’s wheelchair van, the resident reported that the van was making a left-hand turn when the wheelchair tipped over, causing the resident to land on their right side and strike their head on the van door. The resident complained of significant right shoulder and hip pain and had hematomas above and on the right ear. Hospital documentation indicated the resident stated they were not secure in the wheelchair, although the wheelchair itself was secured to the van. Facility documentation of the incident identified that the fall with injury during wheelchair van transport occurred due to failure to apply the passenger seatbelt. The resident’s signed witness statement specified that the driver did not fasten the chest lap harness, and the resident reiterated in interview that while the wheelchair was strapped to the floor, the chest lap harness was never applied, allowing the chair to tip when the van went around a bend. The Maintenance Manager described the Q-Straint system as a five-point system, including a chest lap harness as the fifth point, and confirmed that all parts and belts were intact and functioning when examined the following day. The Nursing Home Administrator acknowledged that the facility failed to ensure adequate supervision and assistance to prevent accidents, which resulted in multi-system trauma and transfer to a trauma center hospital.
Failure to Report Allegation of Verbal Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving one resident to the Department of Health as required by its own policy and state regulations. The facility’s abuse policy dated 8/18/25 stated that all incidents of actual, alleged, or suspected abuse, neglect, theft, misappropriation of residents’ property, or injury of unknown origin would be promptly reported and thoroughly investigated. Resident R2 had diagnoses including dementia, heart failure, and high blood pressure, and a BIMS score of 99 indicating the resident was unable to complete the cognitive interview. On 12/30/25, two staff members reported to the Director of Nursing that they overheard a nurse aide (Employee E3) yelling and swearing at Resident R2 while assisting the resident off the toilet and getting the resident up for the day. Witness statements from an LPN (Employee E4) and a nurse aide (Employee E5) documented that NA E3 said to Resident R2, "I can't stand you f*cking yelling like that" and repeatedly stated, "I don't care, I can't f*cking stand you yelling like that," despite being told by NA E5 that they could not speak to the resident in that manner. Both E4 and E5 reported the incident to the Director of Nursing, and administration called to have NA E3 removed from the unit. During interviews, E4 and E5 confirmed the verbal statements made by NA E3 and that they reported the incident to the Director of Nursing. The Director of Nursing acknowledged that an investigation was conducted but stated the incident was not reported to the Department of Health because she did not feel it was threatening in nature. The Nursing Home Administrator confirmed that the facility failed to report this allegation of abuse involving Resident R2.
Failure to Report and Assess Resident Fall Resulting in Neglect
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not report a fall incident and did not assess the resident for injuries as required by facility policy. The resident, who had diagnoses including Alzheimer's disease, depression, and difficulty swallowing, had a physician order to ambulate with supervision. On the evening in question, two nurse aides were transferring the resident from a wheelchair to bed when they were unable to support his weight and lowered him to the floor. The aides did not notify a nurse of the incident, deciding among themselves not to report it because they did not consider it a fall. The following day, another staff member noticed significant swelling, bruising, and abnormal positioning of the resident's leg during morning care. The nurse was immediately alerted, and subsequent evaluation revealed a left hip fracture, leading to the resident's hospital admission. Documentation and staff interviews confirmed that the nurse aides involved in the transfer did not inform nursing staff of the incident, and the resident was not assessed for injury until the next shift discovered physical signs of trauma. Interviews with facility staff, including the DON and other nurse aides, confirmed that the event was not reported as required and that staff were aware of the policy to report any change of plane or fall. The failure to report and assess the resident after the incident resulted in a delay in identifying and treating a serious injury, constituting neglect under facility policy and regulatory requirements.
Failure to Notify Family of Resident's Condition Changes
Penalty
Summary
The facility failed to notify a family representative of a change in condition for a resident diagnosed with traumatic brain injury, urinary tract infection, and dysphagia. The resident had a foley catheter placed following hospitalization for chronic outlet obstruction. On November 15, 2024, a nursing progress note indicated that the resident was experiencing blood in the urine and brown discharge. The physician was notified, and orders were given for urinalysis testing, lab work, and straight catheterization if necessary. However, the Director of Nursing confirmed that the resident's representative was not informed of these new medical orders. Additionally, on December 23, 2024, the resident dislodged the foley catheter while being showered by a nurse aide, resulting in bleeding. The nurse assessed the situation, cleaned the area, and notified the nurse supervisor and physician. Despite these actions, the Director of Nursing confirmed that the resident's representative was not notified of the catheter dislodgement. This lack of communication with the resident's representative constitutes a deficiency in the facility's responsibility to keep family members informed of significant changes in the resident's condition.
Sanitation Deficiency in Kitchen and Pantries
Penalty
Summary
The facility failed to maintain kitchen equipment and unit pantries in a sanitary condition, which could lead to cross-contamination and food-borne illness. During an observation of the main kitchen's walk-in dairy cooler, it was found that the cold air condenser fan covers and the ceiling had a build-up of dust, grime, and debris. This observation was confirmed by the Dining Services Director. Additionally, the facility's policy on food storage, which mandates that food storage areas be kept clean, safe, and sanitary, was not adhered to. Further observations on the [NAME] Court Nursing Unit revealed that blue gel cold therapy ice packs were improperly stored in the Resident Food Pantry area freezer. This was confirmed by both an LPN and the Assistant Director of Nursing, who acknowledged that such storage practices could lead to cross-contamination. The Nursing Home Administrator also confirmed the facility's failure to maintain sanitary conditions in the kitchen and unit pantries, which could potentially result in food-borne illness.
Deficiencies in Catheter and Bladder Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for residents with indwelling urinary catheters and bladder needs. Resident R39 was observed with an uncovered urinary drainage bag lying on the floor, contrary to facility policy. The resident's physician orders and care plan lacked necessary details such as the diagnosis for catheter use and the size of the tubing and balloon. Similarly, Resident R236 was found with an uncovered urinary drainage bag hanging from the bed frame, and their care plan also lacked essential information regarding catheter use. Resident R44's care plan did not address urinary retention, urinary infection, or the need for bladder scans, despite physician orders indicating the necessity for these interventions. The Assistant Director of Nursing confirmed these omissions. Resident R63's treatment administration record did not include orders for an external female catheter, and the supplies for this were not made available to staff in a timely manner, leading to a delay in care. Resident R122's catheter irrigation procedure was not properly managed, as evidenced by the presence of a dated irrigation bottle with a syringe left inside. This was confirmed by LPN Employee E17. The Director of Nursing acknowledged the facility's failure to ensure appropriate treatment and services for these residents, as required by state regulations.
Failure to Coordinate Hospice Services for Residents
Penalty
Summary
The facility failed to obtain physician orders for hospice services and ensure the coordination of these services with facility services for three residents. Resident R55, who was admitted with vascular dementia, respiratory failure, and benign prostatic hyperplasia, had a physician order for hospice services dated 6/27/24. However, the order did not specify the hospice provider or include contact information. Additionally, Resident R55's care plan lacked details about the hospice diagnosis and provider information. This was confirmed by the Registered Nurse Assessment Coordinator during an interview. Similarly, Resident R84, admitted with Parkinson's Disease, depression, and intellectual disabilities, had a physician order to refer to hospice dated 12/6/23. The care plan indicated a terminal condition and suggested hospice referral, but it did not include the hospice agency's contact information or access to their 24-hour on-call system. This was confirmed by the Unit Manager. Resident R119, admitted with dementia and cachexia, also lacked a physician order for hospice services, and her care plan did not include necessary hospice details. The Nursing Home Administrator confirmed these deficiencies during an interview.
Inadequate Infection Control Program and PPE Misuse
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, specifically lacking a system of surveillance to identify possible communicable diseases or infections for two months, September and October 2024. The facility's policy, dated August 30, 2024, assigns the responsibility of infection control practices to the Infection Preventionist and the Committee. However, a review of infection control documentation revealed no surveillance records for these months. Additionally, an observation on October 8, 2024, noted a Registered Nurse exiting a COVID isolation room with gloves and gown still on, contrary to CDC guidelines for PPE removal. The Director of Nursing confirmed the absence of required documentation for the specified months during an interview on October 9, 2024.
Delayed Meal Service Compromises Resident Dignity
Penalty
Summary
The facility failed to provide a dignified dining experience for Resident R1 by not delivering meals in a timely manner. According to the facility's policy on maintaining respect and dignity, each resident should be cared for in a way that promotes quality of life and respect. However, during an observation, it was noted that Resident R1's lunch was delayed by 46 minutes compared to his roommate, causing him distress and hunger. This delay was confirmed by both the resident and the nurse aide, Employee E10, who acknowledged that the roommate received his meal first. Resident R1, who has diagnoses of anxiety, depression, and epilepsy, expressed that it bothers him when his roommate receives food before him. The Director of Nursing confirmed the failure to provide a timely meal, which is a violation of the resident's rights as outlined in the facility's policy and the 28 Pa Code: 201.29 (i) Resident rights. This incident highlights a deficiency in the facility's adherence to its own policies regarding resident dignity and timely meal service.
Failure to Address Resident Grievances on Food Quality and Call Bell Response
Penalty
Summary
The facility failed to address and resolve grievances and recommendations from residents and their families concerning issues of resident care and life in the facility over a period of three months. The facility's Grievance Policy, last reviewed on August 30, 2024, mandates a procedure for filing grievances and ensuring prompt resolution. However, during a Resident Group meeting on October 8, 2024, multiple residents expressed ongoing concerns about food quality and the handling of call bells, which had been reported to management for the past 3-4 months without resolution. Specific complaints included undercooked pasta, inconsistent meal tray delivery times, and staff turning off call bells without addressing residents' needs. The Resident Council meeting minutes from July, August, and September 2024 consistently documented these unresolved issues, including complaints about hard pasta, dry meat, and staff behavior during care. Despite these repeated concerns, the facility was unable to provide documentation of any investigation or resolution of the issues raised by the Resident Council. The Director of Activities confirmed during an interview on October 10, 2024, that the facility had not resolved the concerns, indicating a failure to consider and act on the views and grievances of residents and their families.
Verbal Abuse Incident Involving a Resident
Penalty
Summary
The facility failed to provide an environment free from verbal abuse for Resident R400, as evidenced by an incident involving a nurse aide. Resident R400, who has diagnoses of dementia, unspecified visual loss, and muscle weakness, was involved in an incident in the dining room. On the specified date, a speech therapist witnessed a nurse aide, Employee E15, verbally abusing Resident R400 by yelling and using inappropriate language. The nurse aide reportedly ripped a pillow from the resident's hands and shouted, 'Why don't you go the fuck to sleep?' This incident was documented and reported to the Director of Nursing. The facility's policy on abuse prevention, dated 8/30/24, mandates a safe and secure environment for all residents, protecting them from any form of abuse. Despite this policy, the incident occurred, and the nurse aide admitted to raising their voice to Resident R400, acknowledging that their actions were uncalled for and expressing shame. The Nursing Home Administrator confirmed the facility's failure to maintain an environment free from verbal abuse for the resident, as required by the relevant state codes.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for two residents who were transferred to a hospital and expected to return. Resident R16, who had diagnoses including aftercare following joint replacement, urinary tract infection, and hyperlipidemia, was transferred to the hospital on 8/6/24. Upon review of Resident R16's clinical record, there was no documented evidence that the facility communicated essential information such as care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information to the receiving health care provider. Similarly, Resident R37, with diagnoses including venous insufficiency, retention of urine, and colostomy, was transferred to the hospital on 6/9/24. The clinical record for Resident R37 also lacked documented evidence of communication of necessary information to the receiving health care provider. This deficiency was confirmed during an interview with the Assistant Director of Nursing, who acknowledged the facility's failure to provide the required information for both residents.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for one of four residents, identified as Resident R16. Resident R16 was admitted to the facility and had a Minimum Data Set (MDS) assessment indicating diagnoses of aftercare following joint replacement, urinary tract infection, and hyperlipidemia. The resident was transferred to a hospital and later returned to the facility. However, the clinical record lacked documented evidence that the facility provided a written transportation notification to the Ombudsman for the hospitalization. This deficiency was confirmed during an interview with the Director of Nursing.
Failure to Notify Resident of Bed-Hold Policy
Penalty
Summary
The facility failed to notify a resident or the resident's representative of the bed-hold policy during a hospital transfer, as required by regulations. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. Specifically, the clinical record of a resident, who was admitted to the facility with diagnoses including aftercare following joint replacement, urinary tract infection, and hyperlipidemia, did not contain documented evidence of written notification about the bed-hold policy at the time of their transfer to the hospital. The Assistant Director of Nursing confirmed this oversight during an interview.
Inaccurate Resident Assessments Identified
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, as identified through a review of the Resident Assessment Instrument (RAI), clinical records, and staff interviews. For Resident R1, the Minimum Data Set (MDS) indicated the use of a limb restraint in bed, which was not observed during an interview and observation. The resident confirmed that no limb restraints were utilized, indicating an inaccuracy in the assessment. For Resident R128, the MDS inaccurately recorded the discharge status as being to a Short-Term General Hospital, while progress notes indicated the resident was discharged to Personal Care. This discrepancy was confirmed during an interview with the Registered Nurse Assessment Coordinator (RNAC), highlighting the facility's failure to maintain accurate assessments for these residents.
Care Plan Update Failure for Blood Thinner Use
Penalty
Summary
The facility failed to update the care plan for Resident R29 to accurately reflect the current status and care needs. The facility's policy on the Comprehensive Plan of Care, dated 8/30/24, requires individualized steps or approaches for resident care to be identified and documented. However, upon review, it was found that Resident R29's care plan did not include the use of a blood thinner, Eliquis, which was prescribed on 10/8/24. This omission was confirmed during an interview with the Registered Nurse Assessment Coordinator (RNAC) Employee E4. Resident R29 had been diagnosed with anemia, coronary artery disease, and heart failure, and the care plan failed to address the monitoring and management of the blood thinner, which is crucial for the resident's care needs.
Failure to Maintain Communication ADLs for a Resident
Penalty
Summary
The facility failed to provide appropriate care and services to maintain activities of daily living (ADLs) for communication for a resident diagnosed with encephalopathy, aphasia, and epilepsy. The resident, who uses a Dynavox communication device at baseline function, was observed with the device out of reach, rendering them unable to communicate. The facility's policy on augmentative communication devices indicates that such devices should be provided to individuals who are limited in their ability to communicate verbally. However, during an observation, the resident's Dynavox was not accessible, and staff interviews confirmed the resident's reliance on the device for communication. The resident's care plan included the use of the Dynavox for communication, and a physician order specified that the device should be charged while the resident sleeps. Despite these directives, the clinical record review on a later date failed to include an order for the use of the Dynavox communication device. Interviews with staff, including a Licensed Practical Nurse and a Nurse Aide, confirmed the resident's preference and need for the Dynavox, yet the Director of Nursing acknowledged the facility's failure to maintain the resident's ADLs for communication.
Failure to Manage Invasive Catheter for Resident
Penalty
Summary
The facility failed to ensure that a resident, who was formerly on dialysis, had a physician order for the care and management of an invasive catheter. The resident, identified as having anoxic brain damage, renal insufficiency, and viral hepatitis, was admitted to the facility without a care plan that included specific interventions for the Tesio catheter, a long-term vascular access device for hemodialysis. The resident's current physician orders did not include instructions for the care and management of the catheter, and the care plan only mentioned the goal of remaining free from infection related to the dialysis catheter without detailing the necessary care procedures. Observations and interviews revealed that the Tesio catheter was not being managed appropriately. The catheter ports were visible under the resident's shirt, and the dressing at the insertion site was crumpled and had dark dried blood, with no readable date on the dressing. The resident reported not having dialysis for over a month, and the LPN confirmed that the facility staff did not handle the Tesio catheters. The Director of Nursing acknowledged the facility's failure to ensure proper physician orders and management for the resident's invasive catheter.
Failure to Ensure Safe Environment for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide a resident environment free of potential accidental hazards for Resident R30, who was admitted with diagnoses including hemiparesis, diabetes, and respiratory failure. The resident's Minimum Data Set (MDS) indicated a severe cognitive impairment with a BIMS score of 3, and the resident required supervision with oversight or cueing. Despite these needs, the facility did not assess or identify risks associated with a personal microwave in the resident's room, nor did it include these risks in the care plan. Observations confirmed the presence of a large microwave surrounded by personal items in the resident's room, and interviews with staff indicated uncertainty about the resident's ability to safely use the microwave. The Nursing Home Administrator confirmed the absence of a policy for personal microwave use and acknowledged the resident's severe cognitive impairment and the presence of the microwave in the room. The facility's failure to assess and manage the risks associated with the microwave, particularly given the resident's cognitive and physical limitations, resulted in a deficiency related to providing a safe environment free from potential accidental hazards.
Deficiency in Colostomy Care Documentation
Penalty
Summary
The facility failed to provide colostomy care and services consistent with professional standards of practice for a resident. The facility's policy on Colostomy/Ileostomy/Urostomy Care and Management required documentation of the plan of care in the patient's electronic medical record, including details such as the size, shape, and color of the stoma, as well as the size and type of ostomy appliance being used. However, the physician's orders for the resident did not include the size and type of ostomy appliance, and the resident's care plan also lacked this information. The resident, who was admitted with diagnoses of high blood pressure, anxiety, and diabetes, had a physician's order to assist in changing the colostomy and wafer. Despite this, the facility did not include the necessary specifications in the order and care plan. Interviews with an LPN and the Director of Nursing confirmed that the facility did not adhere to professional standards of practice in providing colostomy care for the resident.
Failure to Provide Appropriate Mental Health Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident, identified as Resident R22, who displayed mental or psychosocial adjustment difficulties. Resident R22 was admitted with diagnoses of depression, anxiety, and bipolar disorder. On a specific date, the resident exhibited severe distress by screaming loudly at the nurses' station and expressing suicidal thoughts, stating a desire to commit suicide. The physician was contacted and ordered a one-time dose of Xanax and instructed the unit manager to call psychiatric services to discuss the resident's behaviors. However, the clinical record did not indicate that psychiatric services were notified as per the physician's order. Additionally, the facility's documentation failed to include a care plan addressing the resident's suicidal ideation. During an interview, the Social Worker, Employee E13, stated that she was not aware of the resident's suicidal ideation on the specified date, and the Director of Nursing and Nursing Home Administrator confirmed the facility's failure to ensure appropriate treatment and services for the resident. The facility's policy on managing behaviors required team intervention and documentation when a behavioral concern emerged, which was not adhered to in this case.
Failure to Ensure Drug Regimen Free of Unnecessary Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medication. This deficiency was identified during a review of the facility's policy on psychotropic drugs, clinical records, and staff interviews. The policy indicated that psychotropic drugs should be evaluated and documented to determine their necessity, benefits, and impact on the resident's distress. However, the clinical record of a resident with Parkinson's Disease, depression, and intellectual disabilities did not show a diagnosis of insomnia or a care plan related to sleeping difficulties, despite the resident being prescribed Ativan and Lorazepam for routine sleeping care. The resident's Minimum Data Set confirmed the current diagnoses, but there was no documentation supporting the need for the prescribed medications for sleep. The Director of Nursing confirmed the oversight, acknowledging that the facility did not ensure the resident's drug regimen was free of unnecessary medication. This failure was in violation of specific Pennsylvania Code regulations related to management, pharmacy services, and nursing services.
Failure to Limit PRN Psychotropic Medications to 14 Days
Penalty
Summary
The facility failed to adhere to its policy regarding the limitation of PRN (as needed) psychotropic medications to a 14-day duration. This deficiency was identified for two residents, R84 and R122. Resident R84, who was admitted with diagnoses including Parkinson's Disease, depression, and intellectual disabilities, had a physician order for Lorazepam 0.5 mg at bedtime as needed for sleep, which extended beyond the 14-day limit. Additionally, Resident R84's care plan did not address the use of Lorazepam or include any monitoring or interventions related to its use or the resident's sleep needs. Similarly, Resident R122, admitted with anoxic brain damage, renal insufficiency, and viral hepatitis, had a physician order for Lorazepam 0.5 mg every four hours as needed for breakthrough seizures. This order also exceeded the 14-day duration requirement, and the resident's care plan lacked documentation of any problems or interventions related to Lorazepam use or seizure activity. The Director of Nursing confirmed the facility's failure to comply with the 14-day limitation for PRN psychotropic medications for these residents.
Improper Storage of Medications and Supplies
Penalty
Summary
The facility failed to properly store medications in one of its medication rooms and on one of its medication carts. During an observation, it was found that the 2nd Floor Middle Hall Medication Cart contained an expired Victoza pen, which is used to help control blood sugar, insulin levels, and digestion for a resident. This finding was confirmed by an LPN during an interview. Additionally, an observation of the Wellstep Medication Room revealed numerous expired medications and supplies, including needles, syringes, catheters, and various medications for a resident, such as Hydrochlorothiazide, Verapamil, Atorvastatin Calcium, and Memantine. These deficiencies were confirmed by the Director of Nursing during an interview. The facility's failure to adhere to its policy on the safe, secure, and proper storage of medications and biologicals was noted.
Failure to Provide Adaptive Feeding Device
Penalty
Summary
The facility failed to provide adaptive feeding devices for a resident, identified as Resident R1, who required such equipment. According to the facility's policy on assistive devices, any resident who would benefit from assistive equipment should have it available to maintain or improve their current function. Resident R1, who has diagnoses of encephalopathy, aphasia, and epilepsy, had an active physician order for a blue inner lip plate to be used with meals. However, during an observation, it was noted that Resident R1's lunch was served in a Styrofoam container instead of the prescribed adaptive device. This was confirmed by a nurse aide and the Director of Nursing, indicating a failure to adhere to the resident's care plan and physician orders.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for two months, specifically September and October 2024. This deficiency was identified through a review of the facility's infection control policies and procedures, which indicated that the program should include monitoring of antibiotic usage, susceptibility, resistance, and trend studies. However, the facility's infection control surveillance records for January to October 2024 lacked documentation of antibiotic monitoring for the specified months. During an interview, the Director of Nursing confirmed the absence of a system of surveillance to monitor antibiotic use and lab correlation for infections during these months and was unable to provide the necessary tracking records.
Failure to Provide Resident Rights Training
Penalty
Summary
The facility failed to provide mandatory training on resident rights to one of its staff members, specifically Nurse Aide (NA) Employee E7. According to the facility's policy on staff education, dated 8/30/24, all staff are required to complete yearly mandatory education, which includes training on resident rights. However, a review of NA Employee E7's training record revealed that this training was not completed. Employee E7 was hired on 1/7/16, and the deficiency was confirmed during an interview with the Nursing Home Administrator on 10/10/24.
Failure to Provide QAPI Training to Staff Member
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program for one of its staff members, specifically Nurse Aide (NA) Employee E7. According to the facility's policy on staff education dated August 30, 2024, all staff are required to complete yearly mandatory education, which includes QAPI training. However, a review of NA Employee E7's training records revealed that this training was not completed. Employee E7 was hired on January 7, 2016, and the omission was confirmed during an interview with the Nursing Home Administrator on October 10, 2024. This deficiency was identified as a violation of several Pennsylvania Code regulations related to the responsibility of the licensee, management, and staff development.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to update the care plan for Resident R1 to accurately reflect the current status of the resident. Resident R1 was admitted with diagnoses including dementia, anxiety, and major depressive disorder. The Minimum Data Set (MDS) assessment indicated these diagnoses remained current. However, there was a discrepancy between the Resident Care Plan Summary Report and the care plan regarding bed mobility assistance. The summary report dated July 1, 2024, indicated a bed mobility assist of two, while the care plan dated September 6, 2023, indicated a bed mobility assist of one. This inconsistency was confirmed during an interview with the Nursing Home Administrator on July 9, 2024, indicating a failure to revise the care plan as required by regulation 28 Pa. Code: 211.11(d) Resident Care Plan.
Failure to Prevent Resident Fall During Care
Penalty
Summary
The facility failed to ensure that a resident was free from a preventable accident during care. Resident R1, who was admitted with diagnoses including dementia, anxiety, and major depressive disorder, required assistance with bed mobility. On the date of the incident, Nurse Aide (NA Employee E1) was providing care to Resident R1. While NA Employee E1 was reaching for cream and powder in the resident's drawer, Resident R1 rolled out of bed, resulting in a head laceration and a left femoral fracture. The incident occurred because NA Employee E1 turned Resident R1 away from her instead of toward her, and was unable to prevent the fall. The Nursing Home Administrator confirmed the facility's failure to prevent this accident.
Failure to Report Allegations of Abuse in Required Timeframe
Penalty
Summary
The facility failed to report allegations of abuse in the required timeframe for four residents. According to the facility's policy on the prevention of resident abuse, all incidents of actual, alleged, or suspected abuse, neglect, theft, or misappropriation of resident property must be promptly reported and thoroughly investigated. However, the facility did not adhere to this policy, as evidenced by the failure to report allegations involving Residents R3, R4, R5, and R6. These residents reported instances of rough handling and inappropriate behavior by the aides, which were not identified as abuse by the facility, and no investigations were completed or reported to the State. Resident R3 reported that aides were rough and rude, treating her impersonally. Resident R4 described rough handling that resulted in pain and inappropriate conversations among aides. Resident R5 mentioned rough care but requested confidentiality, and Resident R6 reported unkind treatment and improper handling during a lift transfer. The Director of Nursing and the Nursing Home Administrator confirmed that these concerns were not reported as required, violating federal regulations and state codes.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to fully investigate allegations of abuse for four residents, identified as R3, R4, R5, and R6. The facility's policy on the prevention of resident abuse requires that all incidents of actual, alleged, or suspected abuse be promptly reported and thoroughly investigated. However, the facility did not adhere to this policy. Resident R3 reported that aides were rough and rude, treating her impersonally. Resident R4 expressed that aides were rough, hurt her leg, and engaged in inappropriate conversations in her presence. Resident R5 mentioned that her care was rough, and Resident R6 reported that staff were not nice and improperly handled her during a lift transfer. The Director of Nursing (DON) confirmed that the facility did not identify these concerns as abuse, did not complete investigations, and failed to report the allegations to the State. The Nursing Home Administrator and DON acknowledged the failure to investigate the allegations of abuse for the four residents. The facility's actions were in violation of Title 42 Code of Federal Regulations (CFR) S483.12, which mandates thorough investigation and reporting of alleged violations, as well as the prevention of further potential abuse during investigations.
Failure to Protect Residents from Abuse and Identify Abuse Concerns
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by the incident involving Resident R2. The resident, who had diagnoses including high blood pressure, hip fracture, and dementia, was found with a bed sheet tied to the bed rails, restricting her movement. This situation was discovered by a nurse aide during morning care, who then reported it to the nurse and the Manager on Duty. The incident involved three nurse aides who were identified as alleged perpetrators and were subsequently suspended and terminated. The aides were reported to have been loud and disruptive during their rounds, which disturbed several residents. Additionally, the facility did not recognize or report concerns of abuse for Residents R3, R4, R5, and R6. Resident R3 reported that aides were rough and rude, speaking to each other rather than to her, and made inappropriate comments. Resident R4 also reported rough handling and inappropriate conversations between aides, which caused her pain and discomfort. Resident R5 described her care as rough, and Resident R6 reported that staff were not nice and improperly strapped her feet during a lift transfer. These concerns were not identified as abuse by the facility. The Director of Nursing and the Nursing Home Administrator confirmed that the facility failed to ensure residents were free from abuse and did not identify the concerns of Residents R3, R4, R5, and R6 as abuse. This failure to recognize and address abuse concerns is a significant deficiency in the facility's care and management practices.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by an incident involving Resident R2. The facility's policy on physical and chemical restraints, dated 8/30/24, defines physical restraints as any device or material that restricts a resident's freedom of movement and should only be used as a last resort when there is an imminent risk of harm. Despite this policy, an incident occurred where a bed sheet was tied to the handrails of Resident R2's bed, effectively restraining the resident. Resident R2, who was admitted with diagnoses including high blood pressure, hip fracture, and dementia, was found by a nurse aide with a bed sheet tied to the bed, preventing movement. This was discovered during morning care when the aide attempted to remove the sheet to bathe the resident. The situation was immediately reported to the nurse and the Manager on Duty, who then informed the Director of Nursing. Witness statements from staff members indicated that the resident had been active and agitated during the night, with incidents of bowel movements and stool on her fingers. Staff members reported tucking the sheets under the resident to prevent her from reaching into her brief, but the sheets were later found tied to the bed. The incident led to the suspension and subsequent termination of three nurse aides identified as alleged perpetrators. The Nursing Home Administrator confirmed the facility's failure to ensure the resident was free from physical restraints. The deficiency was cited under several Pennsylvania Code regulations, including those related to the responsibility of the licensee, management, resident rights, and nursing services.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to implement its written policies and procedures to ensure a complete and thorough investigation and timely reporting of abuse allegations for four residents. The facility's policy, dated 08/30/24, mandates that all incidents of actual, alleged, or suspected abuse, neglect, theft, or injury of unknown origin be promptly reported and thoroughly investigated. However, the facility did not adhere to these policies, as evidenced by the lack of investigation and reporting of abuse allegations made by Residents R3, R4, R5, and R6. These residents reported instances of rough handling and inappropriate behavior by staff, but their concerns were not identified as abuse, and no investigations or reports were made to the State. Resident R3 reported that aides were rough and rude, treating her impersonally. Resident R4 described rough handling that resulted in pain and inappropriate conversations among staff in her presence. Resident R5 mentioned rough care, and Resident R6 reported staff being unkind and improperly handling her during a lift. Despite these allegations, the Director of Nursing confirmed that the facility did not conduct investigations or report these incidents as required by their policies and federal regulations. The Nursing Home Administrator and DON acknowledged the failure to implement the necessary procedures for these abuse allegations.
Failure to Complete Elopement Evaluations and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that elopement evaluations were completed as required for a resident, leading to an elopement incident. The resident, who was admitted with diagnoses including dementia, bradycardia, and anxiety, was initially assessed as not being at risk for elopement. However, a nursing progress note indicated the resident required frequent redirection and constant monitoring. Despite this, there was no documentation of wandering behaviors or the application of a Wanderguard. On a subsequent day, the resident exited the facility through a malfunctioning door, which opened despite the presence of a Wanderguard. The resident was outside for a brief period before being escorted back by a visitor. The door was supposed to be locked and equipped with a Wanderguard reader, but it malfunctioned due to incorrect programming by the door alarm company. The facility's maintenance director confirmed that no prior monitoring of the doors had been conducted before the elopement. Interviews with staff revealed that the Director of Nursing had instructed the application of a Wanderguard for the resident, but there was no documentation to confirm this action. Additionally, the facility did not reassess the resident for elopement risk after the incident. The Nursing Home Administrator acknowledged the failure to complete required elopement evaluations and provide adequate supervision, resulting in the resident's elopement.
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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