Sterling Health Care And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Media, Pennsylvania.
- Location
- 318 South Orange Street, Media, Pennsylvania 19063
- CMS Provider Number
- 396083
- Inspections on file
- 18
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Sterling Health Care And Rehab Center during CMS and state inspections, most recent first.
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
A resident with dementia and a femur fracture experienced a significant unplanned weight loss of nearly 9% in less than a month. Although the weight loss was identified and confirmed by nursing and the dietitian, the physician was not notified until three weeks later, contrary to facility policy requiring prompt notification of significant changes in condition.
A resident with severe cognitive impairment was physically abused by staff during care, resulting in facial bruising and a hematoma. The abuse was not reported immediately, allowing the involved staff to continue working and putting residents at risk. The facility's delay in addressing the incident led to an Immediate Jeopardy situation.
A resident with dementia and coordination issues was injured during a transfer when a CNA attempted to use a Hoyer lift alone, contrary to the facility's two-person assist policy. The resident fell, sustaining a head laceration requiring 10 staples.
The facility failed to maintain sanitary conditions in the kitchen, with a black substance on the ceiling and lint on the vent above the dishwasher. Despite previous maintenance, these issues persisted, and staff could not specify when the vent was last cleaned.
The facility failed to maintain a sanitary environment on the patio and loading dock, as evidenced by multiple observations of cigarette butts scattered on the floor. Despite daily cleaning routines, these areas were not cleaned on the morning of the observations, as confirmed by the Housekeeping Director.
A resident's personal clothing went missing after being sent to an outsourced laundry service, and the facility failed to investigate or document the incident as per policy. Despite the resident and family reporting the issue, no grievance form was completed, and the inventory sheet was not updated. The NHA and DON were unaware of the missing items until the survey, highlighting a lapse in communication and adherence to procedures.
A facility failed to follow physician's orders for wound treatment for a resident with a surgical incision on their right hip. The resident's bandage, dated several days prior, had not been changed according to the prescribed schedule. The Treatment Administration Record indicated missed treatments, which was confirmed by the NHA.
The facility failed to monitor significant weight changes for two residents, leading to deficiencies in nutritional care. One resident experienced a significant weight gain, which was inaccurately recorded due to excessive clothing, while another resident had a significant weight loss. Despite the dietitian's requests for reweights, the facility did not conduct them, failing to adhere to its policy.
The NHA and DON failed to manage the facility effectively, resulting in an environment where residents were not protected from abuse or potential abuse. They did not ensure timely reporting of abuse situations, failing to fulfill their job duties, which include compliance with regulations and enforcement of facility policies.
A facility failed to implement Enhanced Barrier Precautions for a resident with a feeding tube, as required by their policy. Observations showed that a nurse did not wear a gown during a high-contact activity, and there was no PPE or signage indicating the resident was on EBP. The DON and Administrator confirmed the oversight.
A resident with severe cognitive impairment was found with a sheet tied around their waist in a wheelchair, used by a CNA to prevent falls. The facility's policy defines this as a physical restraint, which the resident could not remove easily. The incident led to the suspension of two CNAs and was confirmed as a deficiency by the DON.
The facility failed to ensure timely delivery of medications for two residents, resulting in missed doses. One resident did not receive prescribed eye drops for six days, while another did not receive several medications due to a late admission and pharmacy delivery delays.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Failure to Timely Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to timely notify the physician of a significant change in a resident's condition, specifically a notable weight loss. According to the facility's policy, a weight loss of more than 5% in one month is considered significant and requires physician notification. A resident with dementia and a femur fracture experienced an 8.98% weight loss in less than a month, dropping from 153.6 pounds to 139.9 pounds. The dietitian's assessment noted the weight loss and decreased oral intake, and nursing progress notes confirmed the weight was taken twice to verify accuracy. Despite these findings, clinical records did not show that the physician was notified of the significant weight loss until three weeks after it was identified. The DON confirmed that it was the nurses' responsibility to inform the physician, but this was not done in a timely manner. The deficiency was cited under 28 Pa. Code 211.12(d)(1)(3)(5) for nursing services.
Failure to Prevent and Report Resident Abuse
Penalty
Summary
The facility failed to provide an environment free from physical abuse and timely abuse reporting for a resident, resulting in the resident being sent to the hospital for facial bruising and a hematoma on the forehead. The resident, who had a severe cognitive impairment due to dementia, bipolar disorder, and psychosis, was unable to remember the events leading to the injuries. The incident occurred when the resident became combative during care, and a staff member allegedly punched the resident in the face. The facility's policy required immediate reporting of suspected abuse to the administrator and other officials according to state law. However, the abuse was not reported in a timely manner, as the incident was witnessed by another employee who did not report it until the following day. This delay in reporting allowed the involved staff members to continue providing care, putting the resident and others at risk for further abuse. The facility's documentation revealed that the abuse incident was witnessed by an employee who saw two nursing assistants punch the resident in the face multiple times. Despite this, the facility did not initiate an investigation until physical signs of trauma were observed the next day. The failure to promptly report and address the abuse placed the residents in an Immediate Jeopardy situation, as the involved staff continued to work with residents until they were relieved of duty pending the investigation.
Removal Plan
- Assessment of Resident 78, notifying the physician, and sent to the hospital for further assessment and possible treatment as the resident was on an anticoagulant.
- The facility has terminated the employment of non-licensed Employee E3 and E4.
- Re-education of Employee E5 on abuse and neglect.
- A comprehensive house review of all residents was conducted to determine any residents who have injuries of unknown origin to investigate and rule out for abuse.
- Education was provided to staff before the start of the shift.
- Reviewed facility policy to ensure appropriateness and completion of the abuse policy, identifying, and reporting of suspected abuse. The policy was reviewed and was deemed appropriate.
- Monitoring the effectiveness of staff training such as auditing for specified (determined by the facility administration) (questionnaire, on-the-spot, teach back, live drills, etc.) with the results of the audits going to QAPI meeting for review and recommendations.
Inadequate Supervision During Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance during resident transfers, resulting in an accident involving a resident with multiple medical conditions, including unspecified dementia, lack of coordination, and muscle weakness. The resident, who required a two-person assist with a Hoyer lift for transfers, was being transferred by a single certified nurse aide (CNA) when they fell and sustained a laceration to the forehead, necessitating 10 staples. The facility's policy, last updated in 2016, mandates that two staff members assist with Hoyer lift transfers, but this protocol was not followed. The incident occurred when the CNA attempted to transfer the resident alone, as other aides were occupied with resident trays. The CNA admitted to using the Hoyer lift independently, contrary to the resident's care plan and facility policy. The resident was assessed by a nurse after the fall and was sent to the emergency room for evaluation. The facility's investigation confirmed the CNA's failure to adhere to the required two-person assist protocol, leading to the resident's injury.
Sanitation Deficiency in Kitchen Area
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in the kitchen area, as observed during a tour conducted on October 22, 2024. During the inspection, a black-colored substance was noted on the ceiling with peeling white paint above the sink in the dishwasher machine area. Additionally, a moderate amount of black lint was observed covering the edges of the vent above the dishwasher. Employee E8, the Dining Director, was present during the tour and mentioned that maintenance had addressed the ceiling a few months prior but could not specify how long the black substance had been present. Further observations on October 25, 2024, confirmed that the black-colored substance and lint on the vent remained. Maintenance staff Employee E11 was interviewed and reported that the ceiling had been painted in April 2024, and the black substance was attributed to steam marks, estimated to be 20 feet long. Employee E11 also stated that the vent was cleaned a few times a year but could not recall the last cleaning date. This information was communicated to the Nursing Home Administrator on October 25, 2024.
Failure to Maintain Sanitary Conditions on Patio and Loading Dock
Penalty
Summary
The facility failed to maintain a safe and sanitary environment on the patio and loading dock area. During an observation on the loading dock area, 11 cigarette butts were found scattered on the floor, which were subsequently removed by Employee E8. A similar observation on the side patio revealed 10 cigarette butts, which Employee E9 attributed to employees. Another observation on the loading dock area found 16 cigarette butts scattered on the floor. Employee E10, the Housekeeping Director, stated that these areas were cleaned daily but had not been cleaned that morning. These observations indicate a failure to ensure a clean and safe environment in these areas.
Failure to Investigate Missing Personal Property
Penalty
Summary
The facility failed to thoroughly investigate the missing personal property of a resident, identified as Resident 136, who was admitted with diagnoses including Major Depression, Anxiety Disorder, and Altered Mental Status. Despite having a BIMS score of 15, indicating no cognitive impairment, Resident 136 reported that ten clothing outfits brought in by family were labeled with the resident's name but went missing after being sent to the outsourced laundry service. The resident and their family reported the missing clothes to the nursing staff, but the facility did not document any grievance or concern forms related to the missing items. Instead, clothes from the facility's lost and found were provided as substitutes, and the missing clothes were neither found nor reimbursed. Interviews with staff, including Employee E7, revealed awareness of the missing clothes, but no formal grievance was filed, and the inventory sheet was not updated to reflect the additional clothing items brought in after admission. The Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the complaints should have been reported to the DON and documented, but they were not aware of the issue until the survey. The facility had previously experienced issues with lost clothes and had implemented color-coded laundry bags to prevent such occurrences. However, the failure to report and document the missing clothes of Resident 136 was a clear deviation from the facility's policies.
Failure to Follow Physician's Orders for Wound Treatment
Penalty
Summary
The facility failed to ensure that physician's orders for wound treatments were followed for a resident. The resident, identified as Resident 9, had a bandage on their right hip covering a surgical incision and reported that the bandage had not been changed in a few days. Observations confirmed that the bandage had a date of October 17, 2024, written on it. A review of the resident's clinical medical record revealed an active physician order dated October 6, 2024, which instructed that the wound be cleansed with normal saline solution, patted dry, and a border dressing applied daily on Monday, Wednesday, and Friday, and as needed. However, the Treatment Administration Record (TAR) for October showed that the resident did not receive the prescribed wound treatments on October 18, 2024, or October 21, 2024. An interview with the Nursing Home Administrator confirmed the facility's failure to provide the physician-ordered wound treatment on these dates.
Failure to Monitor Significant Weight Changes
Penalty
Summary
The facility failed to adequately monitor significant weight changes for two residents, leading to deficiencies in nutritional care. Resident 94 experienced a significant weight gain of 10.76% over 15 days, which was questioned by the dietitian due to potential inaccuracies. Despite the dietitian's request for a reweight, the facility did not conduct one, and the resident's weight continued to show an unexplained increase. The dietitian later identified that the weight gain was falsely elevated due to the resident wearing excessive clothing during the weighing process, yet no reweight was performed to confirm the actual weight. Similarly, Resident 116 experienced a significant weight loss of 7.39% over 25 days. The dietitian questioned the accuracy of this weight change and requested a reweight, but the facility failed to conduct one. Subsequent weights showed fluctuations, but no further action was taken to verify the accuracy of these weights. Interviews with the dietitian confirmed that the facility did not perform the necessary reweights following the significant weight changes for both residents, as required by the facility's policy.
Failure to Manage Abuse Reporting and Prevention
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility, resulting in an environment where residents were not adequately protected from abuse or the potential for abuse. The report highlights that the NHA and DON did not ensure that staff reported abuse situations in a timely manner. This failure is linked to their inability to fulfill essential job duties, which include operating the facility in compliance with federal, state, and local regulations, and establishing systems to enforce facility policies and procedures. The job descriptions of both the NHA and DON outline specific responsibilities that were not met. The NHA is responsible for acting as a liaison to the governing body, supervising department supervisors, and ensuring compliance with regulations. Similarly, the DON is accountable for developing nursing service objectives, implementing policies, and ensuring compliance with regulations. The report indicates that these responsibilities were not adequately executed, leading to the identified deficiencies.
Failure to Implement Enhanced Barrier Precautions for Resident with Feeding Tube
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures, specifically Resident 95, who was admitted with a diagnosis of Progressive Supranuclear Ophthalmoplegia and Dysphagia. The facility's policy, revised on April 23, 2024, mandates the use of gown and gloves during high-contact activities for residents needing EBP, such as those with feeding tubes. However, observations revealed that these precautions were not followed for Resident 95, who utilized tube feeding. On October 23, 2024, a Licensed Nurse, identified as Employee E12, was observed performing a high-contact activity involving the resident's feeding tube without wearing a gown, violating the EBP protocol. Additionally, there was no personal protective equipment or signage indicating the resident was on EBP outside the room during the survey. The Director of Nursing and Nursing Home Administrator confirmed that Resident 95 was not on EBP at the time of the survey, despite meeting the criteria.
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 R1. The resident, who had a Brief Interview of Mental Status (BIMS) score of 2 out of 15, indicating severe cognitive impairment, was found with a white sheet tied around their waist while seated in a wheelchair. This action was taken by CNA Employee E1, who stated that the sheet was used to prevent the resident from falling, as the resident was taking off their clothes and bending over to the floor. The resident was assessed for injuries after the sheet was removed, and none were observed. The incident was reported by the unit manager, and both CNA Employee E1 and CNA Employee E2 were suspended pending investigation. The Director of Nursing confirmed that the facility did not ensure the resident was free from physical restraint. The facility's policy defines physical restraints as any device that restricts freedom of movement and cannot be easily removed by the resident. The deficiency was identified during a review of facility policy, clinical records, facility documents, and staff interviews.
Failure to Ensure Timely Delivery of Medications
Penalty
Summary
The facility failed to ensure timely delivery of medications for two residents, resulting in missed doses. Resident R1, admitted with conditions including acute angle-closure glaucoma and hypertension, did not receive the prescribed Dorzolamide HCl Ophthalmic Solution for six days. Progress notes indicated repeated delays and communication issues with the pharmacy, culminating in the resident's family providing the medication. The Director of Nursing (DON) confirmed the lapses in medication administration and the need for reauthorization from the pharmacy for a new bottle of eye drops. Resident R2, admitted with multiple diagnoses such as hypothyroidism, multiple sclerosis, and respiratory failure, also did not receive several prescribed medications. The January 2024 Medication Administration Record (MAR) showed that the medications were not administered as ordered, with progress notes indicating a delay in delivery from the pharmacy. The DON confirmed that Resident R2's late admission did not meet the pharmacy's cut-off time for medication delivery, resulting in the resident not receiving the necessary medications.
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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