St Martha Center For Rehabilitation & Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Downingtown, Pennsylvania.
- Location
- 470 Manor Ave, Downingtown, Pennsylvania 19335
- CMS Provider Number
- 395815
- Inspections on file
- 20
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at St Martha Center For Rehabilitation & Healthcare during CMS and state inspections, most recent first.
A resident with urinary and cardiac conditions had physician orders for Foley catheter care every shift, continuous O2 at 2L via nasal cannula, and head-of-bed elevation for SOB that were not carried out on multiple day and evening shifts over an extended period, as evidenced by gaps in the MAR and confirmed by the DON.
The facility failed to follow physician orders for two residents. One resident with dysphagia and malnutrition did not receive the prescribed amount of enteral nutrition via a Kangaroo pump, as the pump was often disconnected early. Another resident with Type II Diabetes Mellitus missed several doses of Insulin Aspart, with no parameters for holding the insulin or physician notification documented. These deficiencies were confirmed by the DON.
The facility failed to ensure appropriate indications and non-pharmacological interventions before administering as-needed anti-anxiety medications for two residents. One resident received Ativan gel without proper indication or non-pharmacological attempts, while another received Clonazepam without appropriate indication or non-pharmacological interventions. These deficiencies were confirmed with the DON.
The facility failed to ensure corridor doors positively latch and resist smoke passage, affecting two smoke compartments. Observations revealed that the Main Street Cafe doors did not latch, and the Sunflower Cafe door had a gap over 1/2 inch, compromising smoke resistance. These issues were confirmed by the Director of Plant Operations.
The facility failed to maintain a fire-rated door separating Nursing Care from Assisted Living, compromising fire safety. The door had been modified, resulting in gaps and unauthorized repairs, affecting one of ten smoke compartments. The Director of Plant Operations confirmed these deficiencies.
The facility was found to be non-compliant with NFPA 101 standards as soiled linen was improperly stored on the floor under the sink in the 300 Wing Tub Room, outside a rated room or container. This was confirmed by the Director of Plant Operations.
Failure to Follow Physician Orders for Catheter Care and Oxygen Therapy
Penalty
Summary
The facility failed to follow multiple physician orders for one resident with diagnoses including obstructive and reflex uropathy, urine retention, and atrial fibrillation. Physician orders dated September 5, 2025, directed that Foley catheter care be provided every shift. Review of the resident’s December 2025 and January 2026 MARs showed numerous shifts on which Foley catheter care was not documented as provided, including multiple day and evening shifts across both months. The resident also had physician orders dated October 30, 2025, for continuous oxygen at 2 liters via nasal cannula every shift for shortness of breath, and orders dated September 4, 2025, to keep the head of the bed elevated every shift to prevent shortness of breath while lying flat. Review of the December 2025 and January 2026 MARs revealed that these oxygen and head-of-bed elevation orders were not followed on the same multiple day and evening shifts where Foley care was missed. During an interview on January 8, 2026, at 10:05 a.m., the DON was presented with this information and confirmed that the physician orders had not been followed.
Failure to Follow Physician Orders for Enteral Nutrition and Insulin Administration
Penalty
Summary
The facility failed to follow physician orders for two residents, leading to deficiencies in care. Resident 86, who has medical diagnoses including dysphagia, muscle wasting, and severe protein-calorie malnutrition, was prescribed Jevity 1.5 at 40ml per hour for 20 hours via a Kangaroo pump, totaling 800ml per day. Observations on two separate days revealed that the pump was disconnected and turned off before the prescribed amount was administered. A review of the resident's Medication Administration Record (MAR) for February showed that the resident never received the full prescribed amount of tube feed on any day. The Director of Nursing confirmed that the amounts documented on the MAR did not match the physician's orders. Resident 164, diagnosed with Type II Diabetes Mellitus, had a physician's order for Insulin Aspart to be administered every six hours. However, the insulin was not administered seven times between February 1 and February 18. The MAR indicated that the insulin was held due to blood sugar levels being within limits or other unspecified reasons, but there were no parameters provided for holding the insulin. Additionally, there was no documentation that the physician was notified about the missed doses. The deficiencies were confirmed with the Director of Nursing, who acknowledged the discrepancies between the physician's orders and the care provided. The facility's failure to administer the prescribed treatments as ordered for both residents highlights a significant lapse in following medical directives, which is crucial for maintaining the health and well-being of residents with complex medical needs.
Failure to Ensure Appropriate Use of As-Needed Anti-Anxiety Medications
Penalty
Summary
The facility failed to ensure that appropriate indications and non-pharmacological interventions were provided before administering as-needed anti-anxiety medications for two residents. Resident 3 had a physician's order for Ativan gel to be applied topically for anxiety, both routinely and as needed. However, from November 1 to November 30, 2024, the as-needed Ativan gel was administered seven times without appropriate indication and five times without attempting non-pharmacological interventions. Similarly, Resident 22 had a physician's order for Clonazepam to be administered as needed for anxiety. From January 17 to January 31, 2025, the as-needed Clonazepam was administered nine times without appropriate indication, and non-pharmacological interventions were not attempted before its administration. These deficiencies were confirmed with the Director of Nursing, indicating a failure in the facility's protocol for administering psychotropic medications.
Deficiency in Corridor Door Maintenance
Penalty
Summary
The facility failed to maintain the corridor doors to positively latch and resist the passage of smoke, affecting two of ten smoke compartments. During an observation on February 5, 2025, at 2:10 PM, it was noted that the double doors to the Main Street Cafe, located by the Activity Room door, did not positively latch. This observation was confirmed through an interview with the Director of Plant Operations at the same time. Additionally, another observation on February 5, 2025, at 2:15 PM, revealed that the door to the Sunflower Cafe had a gap on the strike side greater than 1/2 inch, which compromised its ability to resist the passage of smoke. This deficiency was also confirmed in an interview with the Director of Plant Operations at the time of the observation.
Plan Of Correction
K-0363 (E) Corridor- Doors This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. It is the practice of the facility to ensure smoke, fire, and corridor doors will operate as per design. 1. The doors by room, the sunflower café, and double doors by main street café have had the doors repaired and now they close, latch, and are gap free as design. 2. Doors throughout the facility were checked to allow for closure; all residents are free from hazards and all systems are operating as designed as of 2/7/2025. 3. Education completed with maintenance staff regarding monitoring doors and rating labels to ensure they close properly on 2/7/2025. 4. Every quarter for a year, the Maintenance Director or designee will check random doors throughout the facility to ensure the doors are fully closed. This information will then be entered on a log and will be presented to the monthly QAPI meeting.
Fire-Rated Door Deficiency in Smoke Compartment
Penalty
Summary
The facility failed to maintain the integrity of a fire-rated door, which is crucial for ensuring safety in the event of a fire. During an observation, it was noted that the corridor fire-rated door, which separates the Nursing Care area from the Assisted Living area at the breezeway end of the 600 Wing, had been improperly modified. The door had been planed on the strike edge, resulting in gaps greater than 1/8 inch, and a hole in the door had been filled with an unauthorized product. These modifications compromised the door's fire-rating capabilities. The Director of Plant Operations confirmed these deficiencies during an interview conducted at the time of the observation. This issue affected one of the ten smoke compartments within the component, indicating a lapse in maintaining the required fire safety standards as per NFPA 101 guidelines.
Plan Of Correction
This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. It is the practice of the facility to have proper fire rated doors separating Nursing and Assisted Buildings. 1. Replacement of the fire-rated door separating six hundred wings from the assisted living building has been ordered. New fire rated latching hardware will be installed as well. Residents are free from hazards. 2. All rated doors have been inspected, and confirmation of latching and free from gaps completed on 2/7/2025. 3. Education is completed with Maintenance staff to confirm proper door operation of doors on 2/7/2025. 4. Every quarter for a year the Maintenance Director or designee review random doors throughout the building for proper operations. This information will then be entered on a log and will be presented to the QAPI meeting.
Improper Storage of Soiled Linen in Facility
Penalty
Summary
The facility failed to comply with NFPA 101 standards regarding the storage of soiled linen and trash containers. Specifically, the deficiency was observed in two of ten smoke compartments within the facility. On February 5, 2025, at 2:25 PM, soiled linen was found on the floor under the sink in the 300 Wing Tub Room. This observation was confirmed through an interview with the Director of Plant Operations, who acknowledged that the soiled linen was stored outside a rated room or container, which is a violation of the requirement that soiled linen or trash collection receptacles exceeding 32 gallons must be located in a protected space when not attended.
Plan Of Correction
This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. It is the practice of the facility to ensure no excess of receptacles are utilized. 1. The trash containers exceeding thirty-two gallons that were being utilized to store items have been removed and are no longer utilized in the facility and have been replaced with proper storage containers. The linen under the sink in three hundred wing tubs has been removed as well. 2. Facility wide inspection of any trash containers and under sink storage was completed on 2/7/2025. 3. Education with facility wide staff regarding improper disposal of soiled linen and containers needing to be under 32 gallons in shower and tub rooms, to be completed by 3/21/2025. 4. Weekly random audits to be completed for 12 months by Maintenance Director or designee for compliance. This information will then be entered on a log and will be presented to the QAPI meeting.
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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