Sugar Creek Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Franklin, Pennsylvania.
- Location
- 351 Causeway Drive, Franklin, Pennsylvania 16323
- CMS Provider Number
- 395777
- Inspections on file
- 26
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Sugar Creek Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain complete and accurate documentation of scheduled showers for four residents with conditions including diabetes, hypertension, Parkinson’s disease, hypothyroidism, and GERD. Review of the shower task records for two consecutive months showed multiple dates where showers were scheduled but had no corresponding documentation that they were provided or completed, despite facility policies requiring detailed recording of bathing care. The DON confirmed that the clinical records were incomplete and that showers were expected to be done as scheduled and documented when finished.
A resident with complex medical conditions received a G-tube flush using a hydrogen peroxide and water mixture, as instructed by a physician via telephone order. However, the physician's order for this one-time intervention was not documented in the clinical record, despite facility policy requiring such documentation. Both the Medical Director and DON confirmed the absence of the order in the record.
The facility did not provide scheduled baths or showers according to resident preferences for several individuals with complex medical needs, as confirmed by documentation, resident interviews, and observations. Additionally, communal dining and group activities were suspended for multiple residents despite slowed infection rates, impacting their psychosocial well-being. Facility leadership confirmed these deficiencies during interviews.
A resident with impaired mobility and incontinence was left in a wheelchair for several hours without being checked, changed, or repositioned, resulting in feces overflowing from two incontinence briefs onto clothing and skin, and severe skin redness. Staff and the NHA confirmed that this did not follow facility policy and failed to maintain the resident's dignity.
Two residents with significant mobility impairments were not repositioned or provided with timely incontinence care as required by their care plans and facility policy. One resident remained in a wheelchair for over seven hours without being checked or changed, resulting in severe skin redness and soiling, while another sat in a recliner for hours without a pressure-relieving cushion, leading to skin breakdown. Staff confirmed these lapses and acknowledged that facility protocols were not followed.
A resident reported that meals were often served cold, and resident council minutes documented complaints about cold food and delayed tray delivery. Observations showed that food left the kitchen at safe temperatures but sat in the hallway before being served, resulting in a test tray being unpalatable and below acceptable temperature standards. The Dietary Manager confirmed these findings.
Staff failed to follow infection control protocols during incontinence care for two residents by placing soiled briefs and clothing containing urine and feces directly on the floor, then walking across the contaminated area without sanitizing it. Facility policy requires immediate disposal of such items in designated containers, and the DON confirmed this was not followed.
A resident with a history of GERD, diabetes, and hypertension had conflicting documentation regarding life-sustaining treatment preferences, with a POLST indicating Full Code and physician orders indicating DNR. An LPN confirmed that the most recent POLST and nurse report sheet did not match the physician's orders, resulting in inconsistency between the resident's advance directives and medical orders.
An LPN administered G-Tube medications to a resident without closing the door or privacy curtain, leaving the resident exposed and visible from the hallway. The LPN confirmed the lack of privacy during the procedure.
The facility did not provide required written bed-hold policy notifications to several residents or their representatives at the time of hospital transfer, failed to communicate necessary clinical information to a receiving healthcare provider during a transfer, and did not complete or provide discharge summaries for multiple residents upon discharge. These deficiencies were confirmed through record review and staff interviews.
A resident's care plan was not updated to reflect changes in their condition, including the removal of a PICC line, discontinuation of IV antibiotics, and resolution of a C-Diff infection. Despite a care plan meeting and changes in the resident's clinical status, the care plan continued to list outdated problems and interventions, as confirmed by the DON.
Surveyors found that open insulin and Victoza pens on two medication carts were not dated, and expired loratadine tablets were not discarded as required. An LPN also left a medication cart unlocked and out of view while administering medications to a resident, contrary to facility policy. These actions resulted in deficiencies related to medication labeling, storage, and security.
A resident with multiple medical conditions had all lower teeth extracted and was left without lower dentures for nearly a year, despite repeated documentation by clinical staff and physician orders to follow up with dental services. The resident experienced ongoing eating difficulties and dissatisfaction, and interviews confirmed the delay in receiving dentures.
A resident with significant respiratory conditions returned from the hospital, but physician orders were not entered into PCC for about 18 hours, resulting in delayed medication administration and lack of breathing treatments during a documented episode of respiratory distress. The DON confirmed that the RN did not fulfill the responsibility to enter orders upon admission.
A resident with significant respiratory diagnoses returned from the hospital, but their medication orders were not entered into the electronic health record for approximately 18 hours. As a result, scheduled and PRN respiratory medications were not administered, and the resident experienced respiratory distress with low oxygen saturation. The DON confirmed the delay in entering orders led to a delay in treatment.
Two residents with PICC lines did not have complete documentation of their scheduled dressing changes, as required by facility policy and physician orders. Treatment records lacked evidence of weekly dressing changes for both individuals over several weeks, and this was confirmed by the Regional Clinical Director.
The facility did not ensure that the assigned IP had completed the required specialized infection prevention and control training, as no certificate of completion could be provided for the RN who covered the IP role during the relevant period.
A resident with chronic pain and rheumatoid arthritis did not receive multiple doses of prescribed Oxycodone due to a nursing order entry error, as confirmed by the NHA. The medication was not administered as ordered by the physician.
A resident with multiple diagnoses, including depression and Parkinson's disease, exhibited suicidal ideation and was placed on frequent safety checks. Despite a psychiatric evaluation recommending continued behavioral health services, the facility did not update the resident's comprehensive care plan to address these needs, as confirmed by facility leadership.
The facility did not have an RN available during an overnight shift, resulting in a resident missing prescribed IV antibiotics through a PICC line and two residents receiving post-fall assessments from an LPN instead of an RN, as required by state regulations. Staffing records and staff interviews confirmed the absence of an RN, leading to noncompliance with nursing service and assessment requirements.
A resident with depression, Parkinson's disease, and a history of suicidal ideation did not receive the recommended ongoing behavioral health services after a psychiatric evaluation, despite documentation of self-harm risk and a facility policy requiring such services.
The facility did not meet the required NA staffing ratios during the evening shift on two days. With a census of 97 residents, 7.96 NAs worked instead of the required 8.82, and with 95 residents, 8.13 NAs worked instead of 8.64. This was confirmed by the Nursing Home Administrator.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident per day on four occasions. The nursing staffing documents revealed that the care hours were below the required minimum, with recorded hours of 3.19, 3.14, 3.05, and 3.03 PPD. This was confirmed by the Nursing Home Administrator.
The facility did not meet the required nurse aide (NA) staffing ratios on several occasions, failing to provide the mandated number of NAs per residents during day, evening, and overnight shifts. The Nursing Home Administrator confirmed the shortfall in staffing, which occurred over multiple days within the review period.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day for ten days, with recorded hours ranging from 3.07 to 3.17 PPD. This was confirmed by the Nursing Home Administrator.
Two residents did not receive their prescribed ABHR gel due to the facility's failure to ensure timely delivery from the pharmacy. One resident, with a psychotic disorder and anxiety, missed multiple doses over several days, while another resident with bipolar disorder and anxiety missed doses over two days. The Nursing Home Administrator confirmed the medication was not available and should have been administered as ordered.
The facility failed to store food safely in two unit freezers, where ice packs used on residents' bodies were found next to food items like popsicles and ice cream. Staff, including LPNs and the DON, confirmed this improper storage practice, which violated the facility's food safety policies.
A facility failed to ensure proper foley catheter care for a resident, as the catheter was not emptied and the amount was not documented every shift per physician's orders. Despite the facility's policy requiring observation and documentation of urine levels, records showed non-compliance on multiple occasions. The DON confirmed the deficiency.
A facility failed to track and safely dispose of controlled medications for a resident, as required by policy and regulations. The resident's record lacked evidence of a controlled substance tracking log for Morphine, Ativan, and Diazepam, and there was no documentation of the destruction or return of these medications. The Director of Nursing confirmed the deficiency, which violates state regulations.
A resident with diabetes received Humalog insulin despite having blood sugar levels below the prescribed threshold, contrary to physician orders. The facility's policy requires verification of medication administration, but staff failed to hold the insulin as directed, leading to significant medication errors.
The facility failed to store Schedule II-V medications, such as Lorazepam, in a separately locked, permanently affixed compartment, as observed in the West medication room. Additionally, an open vial of Tubersol lacked an open date, preventing staff from determining the discard date. These actions violate the facility's policies on medication storage and labeling.
Incomplete Documentation of Scheduled Showers in Clinical Records
Penalty
Summary
Surveyors identified a deficiency in the facility’s documentation of showers and hygiene care, as required by its own policies and state regulations. The facility’s Bath, Shower/Tub policy required documentation of the date and time a shower or tub bath was performed and the name and title of the staff who assisted, and the ADL policy required appropriate support and assistance with hygiene, including bathing. Review of the electronic shower task documentation for four residents showed multiple dates on which showers were scheduled but lacked any documentation that the showers were provided or completed. For one resident with diabetes and hypothyroidism, the shower task records for February and March 2026 lacked documentation of showers on six specified dates. For a second resident with diabetes and hypertension, the shower task records for February and March 2026 lacked documentation of showers on six specified dates. For a third resident with hypertension and GERD, the shower task records for February and March 2026 lacked documentation of showers on nine specified dates. For a fourth resident with Parkinson’s disease, overactive bladder, and diabetes, the February 2026 shower task records lacked documentation of showers on seven specified dates. During an interview, the DON confirmed that the clinical records for all four residents did not contain complete documentation regarding showers and acknowledged that showers should be completed as scheduled in the task system and documented when done.
Incomplete Documentation of Physician's Order for G-Tube Flush
Penalty
Summary
The facility failed to maintain complete and accurate documentation regarding physician's orders for a gastrostomy tube (G-tube) flush for a resident with significant medical needs. Specifically, the clinical record for a resident with spastic quadriplegic cerebral palsy, intellectual disabilities, and diabetes did not contain a physician's order for a one-time G-tube flush using a 50/50 mixture of hydrogen peroxide and hot water, which was performed to clear a clogged tube. Nurse's notes documented that the flush was completed as instructed, but there was no corresponding physician's order in the resident's clinical record for this intervention on the date it was performed. During interviews, the Medical Director confirmed that a verbal order for the G-tube flush had been given and that the practice was considered safe. However, the Director of Nursing acknowledged that the resident's clinical record lacked evidence of the physician's order for the procedure. This deficiency was identified through review of facility policy, clinical records, and staff interviews, and it was determined that the facility did not adhere to its own policy requiring all telephone orders to be recorded in the resident's clinical record.
Failure to Provide Resident-Preferred Bathing and Maintain Psychosocial Well-Being
Penalty
Summary
The facility failed to honor resident preferences for bathing and did not provide scheduled baths or showers for four residents over a specified period. Documentation showed that these residents, who had various medical conditions such as spastic hemiplegia, depression, chronic kidney disease, and anoxic brain damage, were scheduled for baths or showers on specific days but did not receive them as planned. Interviews with these residents confirmed that they did not receive their preferred number of baths or showers, and observations noted that some had greasy hair, indicating a lack of personal hygiene care. The Nursing Home Administrator confirmed that showers were not provided according to the residents' preferences and schedules during the review period. Additionally, the facility did not support residents' psychosocial well-being by suspending communal dining and group activities for six residents. These residents expressed that they enjoyed eating meals in the dining room and participating in group activities, but these opportunities were not available due to ongoing COVID-19 precautions. Despite the facility's policy requiring daily review of outbreak status to lift restrictions as soon as possible, records indicated that the spread of infection had slowed, yet communal activities remained suspended. Observations during the survey period showed residents engaging in therapy and interacting with staff, but there were no observations of residents participating in individual or socially distanced activities, nor were meals served in a socially distanced manner in the dining room. Facility leadership confirmed that communal dining and group activities were not occurring at the time of the survey due to COVID-19 in the building.
Failure to Maintain Resident Dignity and Provide Timely Incontinence Care
Penalty
Summary
The facility failed to maintain resident dignity and provide appropriate incontinence care for one resident with spastic hemiplegia, depression, and anxiety, who required assistance with personal care. According to the resident's care plan, staff were to clean the peri-area with each incontinence episode and provide incontinence products to promote skin integrity and dignity. However, observations revealed that the resident remained in a wheelchair from 6:30 a.m. until 1:45 p.m. without being checked, changed, or repositioned, despite facility policy requiring checks every two hours. At 1:45 p.m., the resident was found with two incontinence briefs filled with feces overflowing onto clothing and skin, and with extremely reddened peri-area and buttocks. Staff confirmed that the resident had not been checked or changed as required and that the use of two briefs was not in accordance with facility protocol. The Nursing Home Administrator also acknowledged that placing two briefs on a resident was not facility policy and that the resident's dignity was not maintained. The failure to provide timely incontinence care and proper use of incontinence products resulted in soiled clothing, skin irritation, and a lack of dignity for the resident.
Failure to Provide Timely Repositioning, Pressure Relief, and Incontinence Care
Penalty
Summary
The facility failed to provide care in accordance with professional standards for repositioning, pressure relief, and incontinence care for two residents. One resident with spastic hemiplegia, limited mobility, and a history of skin integrity issues was observed sitting in a wheelchair for over seven hours without being repositioned or checked for incontinence. This resident was found with two incontinence briefs filled with feces overflowing onto their clothing and skin, and exhibited extremely reddened skin in the peri area and buttocks. Staff confirmed that the resident should have been checked and changed every two hours and that the use of two briefs was not in accordance with facility protocol. Another resident with Parkinson's disease and peripheral vascular disease, who was dependent for mobility and had existing wounds on the right buttock and hip, was observed sitting in a recliner without a pressure-relieving cushion for several hours. The care plan for this resident included the use of a pressure-relieving cushion and a turning and repositioning schedule, but these interventions were not implemented. Upon incontinence care, the resident was found to have an open area on the right buttock and redness on both buttocks. Interviews with staff, including a nursing assistant, LPN, DON, and regional clinical director, confirmed that residents unable to reposition themselves should be repositioned by staff, pressure-relieving devices should be in place, and incontinence care should be provided in a timely manner. The facility's own policies on repositioning, perineal care, and activities of daily living were not followed, resulting in the deficiencies observed for both residents.
Failure to Serve Palatable Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food that was palatable and at an appetizing temperature, as required by its own policy and regulatory standards. Facility policy stated that food should be prepared to conserve nutritive value, flavor, and appearance, and served as close to tray service as possible to ensure acceptable temperatures. Resident council and food committee minutes documented complaints about cold food and significant delays in meal tray delivery, with reports of trays being served up to 45 minutes late. During an interview, a resident reported that their food was often served cold. On the day of observation, kitchen temperature logs showed that food items were at appropriate temperatures when leaving the kitchen. However, direct observation revealed that meal carts sat in the hallway before trays were distributed, resulting in a significant delay. When a test tray was checked at the end of the delivery process, food temperatures had dropped well below the initial readings, and the items were found to be unpalatable due to being cool. The Dietary Manager confirmed the unacceptable temperatures and poor palatability at the time of tray testing.
Failure to Prevent Cross-Contamination During Incontinence Care
Penalty
Summary
Facility staff failed to follow infection prevention and control protocols during incontinence care for two residents. During observed care, nursing assistants and an LPN removed soiled briefs and pants containing urine and feces and placed them directly onto the floor, contrary to facility policy which requires immediate disposal of such items into designated containers. After completing care, staff picked up the soiled items from the floor and disposed of them, but walked across the area where the contaminated items had been lying without sanitizing the floor. Staff interviews confirmed that the soiled briefs were placed on the floor and that the area was not sanitized afterward. The Director of Nursing acknowledged that this practice was not in accordance with facility policy, which prohibits placing soiled briefs on the floor and requires their disposal in designated containers. The actions observed created a potential for cross-contamination, as outlined in the facility's infection control policies.
Inconsistent Advance Directive and POLST Documentation
Penalty
Summary
The facility failed to ensure that a resident's physician orders and Pennsylvania Order for Life Sustaining Treatment (POLST) were consistent, as required by facility policy and state regulations. The resident in question had multiple documents in their clinical record, including a Living Will indicating Do Not Resuscitate (DNR) status and a POLST indicating Full Code status. Physician orders in the record were conflicting, with some indicating Full Code and others indicating DNR. Progress notes from both social services and nursing documented changes in the resident's code status, but the most recent POLST available in the unit binder and on the nurse report sheet still indicated Full Code, while physician orders indicated DNR. Interviews with an LPN confirmed that the documentation in the binder and on the nurse report sheet did not match the most current physician orders. The LPN acknowledged that the most recent POLST, signed by the resident and physician, indicated Full Code, while the physician's orders indicated DNR. This inconsistency between the resident's advance directives, POLST, and physician orders resulted in a failure to honor the resident's documented treatment preferences as required by policy.
Failure to Maintain Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to maintain resident privacy during medication administration for one resident. During an observation, an LPN administered medications through a G-Tube while the resident's nightgown was pulled up, exposing the resident's legs, incontinence care product, and stomach. The resident was visible from the hallway because the door and privacy curtain were not closed. The LPN confirmed during an interview that the resident was exposed and acknowledged that the door and/or privacy curtain should have been closed to maintain privacy during the procedure.
Failure to Provide Bed-Hold Policy Notification and Discharge Summaries
Penalty
Summary
The facility failed to provide required written notification of its bed-hold policy, including the duration a bed can be held during a leave of absence and the associated daily cost, to residents and/or their representatives at the time of transfer to a hospital. This deficiency was identified for multiple residents whose clinical records lacked evidence of such notification upon their transfer. Additionally, the facility did not ensure that necessary clinical information was communicated to the receiving healthcare provider during the transfer process for at least one resident. These failures were confirmed by the Director of Nursing, who acknowledged the absence of documentation in the affected residents' records. Furthermore, the facility did not complete or provide discharge summaries for several residents who were discharged, including one resident discharged to home. The discharge summaries, which should include a recapitulation of the resident's stay and a final summary of their status, were missing from the clinical records and were not provided to the residents or receiving facilities as required by facility policy. The deficiencies were identified through review of facility policies, clinical records, and staff interviews.
Failure to Update Resident Care Plan to Reflect Current Status
Penalty
Summary
The facility failed to review and revise the care plan for a resident to reflect the resident's current condition and care needs. The resident was admitted with diagnoses including cellulitis of the left lower leg, diabetes, and high blood pressure. The care plan included problems such as being on enhanced barrier precautions due to a PICC line and wounds, and receiving IV antibiotics for cellulitis. However, the clinical record showed that the PICC line was dislodged and removed, and the last dose of IV antibiotics was administered on a specific date, but the care plan was not updated to reflect these changes. Additionally, the care plan included a focus on C-Difficile infection, but the clinical record indicated that the resident's C-diff results were negative and isolation was discontinued. Despite a care plan meeting being held, the Director of Nursing confirmed that the care plans were not updated to accurately reflect the resident's current status and care needs. This failure was identified through review of facility policy, clinical records, and staff interview.
Medication Labeling, Storage, and Security Deficiencies
Penalty
Summary
Surveyors identified that the facility failed to ensure proper labeling and timely disposal of medications, as well as secure storage of medication carts. During review of two medication carts, it was observed that open pens of Aspart Insulin and Victoza did not have dates indicating when they were opened, making it impossible for staff to determine appropriate discard dates. Additionally, an open bottle of loratadine tablets was found to be past its expiration date. Staff interviews confirmed that these medications should have been discarded and that the required labeling and dating procedures were not followed according to facility policy and manufacturer guidelines. Further observations revealed that an LPN prepared medications from a cart parked in the hallway and then entered a resident's room to administer the medications, leaving the cart unlocked and out of view. The LPN confirmed that the cart was left unsecured while out of sight, which is contrary to facility policy requiring medication carts to be locked when not in direct view of the administering nurse. These findings demonstrate lapses in medication management and security protocols as required by facility policy and state regulations.
Failure to Provide Timely Dental Services and Dentures
Penalty
Summary
The facility failed to provide timely dental services for one resident, as required by its own policy and state regulations. The resident, who had diagnoses including major depressive disorder, cerebral infarction, and hypothyroidism, had all remaining lower teeth extracted and was left without lower dentures for nearly a year. Clinical records showed repeated documentation by the speech therapist and physician regarding the resident's ongoing difficulties with eating and dissatisfaction due to the absence of lower dentures. Despite multiple physician orders to follow up with dental services, the resident continued to be without lower dentures for an extended period. Resident council minutes further confirmed the resident's ongoing concerns and the delay in receiving dentures, with documentation that the dental provider had reduced the frequency of visits, potentially contributing to the delay. Interviews with the resident and the Director of Nursing confirmed that the resident had not received lower dentures in a timely manner, resulting in ongoing eating difficulties and dissatisfaction with quality of life.
Failure to Timely Enter Physician Orders Delays Medication Administration
Penalty
Summary
The facility failed to follow nursing standards of practice by not ensuring that physician orders were entered into the Point Click Care (PCC) system upon a resident's admission, resulting in a delay in medication availability and administration. Specifically, after returning from the hospital, a resident with diagnoses including idiopathic pulmonary fibrosis, sleep apnea, and acute and chronic respiratory failure did not have their medication orders entered into PCC for approximately 18 hours. This delay prevented floor nurses from being alerted to scheduled and PRN medications that were due, and the resident did not receive prescribed breathing treatments during this period. Clinical records indicated that the resident experienced shortness of breath and a low pulse oximetry reading of 76% on room air, well below the desired threshold. Nurses had to contact the physician for treatment orders because the necessary medications were not available in the system. The Director of Nursing confirmed that it was the RN's responsibility to enter orders into PCC upon admission and acknowledged the failure to do so in this instance.
Delay in Entering Physician Orders Led to Missed Respiratory Treatments
Penalty
Summary
The facility failed to enter a physician's medication orders in a timely manner for a resident who returned from the hospital. According to facility policy, medications are to be administered safely, timely, and as prescribed. However, after the resident was readmitted with diagnoses including idiopathic pulmonary fibrosis, sleep apnea, and acute and chronic respiratory failure, their medication orders were not entered into the electronic health record system (PCC) until approximately 18 hours after their return. This delay meant that floor nurses were not alerted to scheduled or PRN medications that needed to be administered. During this period, the resident experienced an episode of respiratory distress, with a documented oxygen saturation of 76% on room air, which is below the desired level. The resident reported not having received any breathing treatments since returning from the hospital. The necessary medications, including Albuterol and Budesonide, were not available for administration during the episode because the orders had not been entered. The DON confirmed that the delay in entering the physician's orders resulted in a delay in treatment for the resident.
Incomplete Documentation of PICC Line Dressing Changes
Penalty
Summary
The facility failed to maintain complete and accurate documentation regarding Peripherally Inserted Central Catheter (PICC) dressing changes for two residents. Facility policy required PICC line dressings to be changed at least every seven days or sooner if the dressing became damp, loosened, or soiled. Physician orders for both residents specified weekly PICC line dressing changes. However, review of the treatment administration records showed missing documentation for several scheduled dressing changes for both residents over multiple weeks. One resident, admitted with diagnoses including hypertension, cellulitis, and diabetes, had no documented evidence of PICC line dressing changes on several specified dates in May and June. Another resident, admitted with osteomyelitis, bacteremia, and gastroesophageal reflux disease, also lacked documentation of PICC line dressing changes on multiple scheduled dates in April and May. The Regional Clinical Director confirmed that the treatment records for both residents were incomplete and that dressing changes should be performed and documented as ordered by the physician.
Infection Preventionist Lacked Required Specialized Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) was qualified with specialized training in infection prevention and control during the period from 4/10/25 to 5/25/25. Review of the facility's policy indicated that the IP must have specialized IPC training beyond initial professional training, with evidence provided by a certificate of completion. Registered Nurse (RN) Employee E2 served as the facility's IP from 4/16/25 to 5/21/25, but the facility was unable to produce documentation or a certificate confirming that RN Employee E2 had completed the required specialized IP training. Interviews with the Regional Clinical Director and the Nursing Home Administrator confirmed that there was no evidence of the required training for RN Employee E2 during the time they covered the IP position.
Failure to Administer Physician-Ordered Pain Medication
Penalty
Summary
The facility failed to ensure that medication was obtained and administered as ordered by the physician for one resident. According to the clinical record, the resident, who had diagnoses including rheumatoid arthritis and chronic pain, had a physician's order for Oxycodone 5 mg every six hours while awake for pain. Review of the Medication Administration Record showed that the resident did not receive Oxycodone for three doses on two consecutive days and missed an additional dose on a third day. The Nursing Home Administrator confirmed that the medication was not given as ordered due to nursing staff entering the order incorrectly, resulting in the resident not receiving the prescribed pain medication.
Failure to Update Care Plan for Behavioral Health Needs
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for one resident to reflect current care needs and services. According to facility policy, care plans must be updated as residents' conditions change and should be reviewed by an interdisciplinary team. However, documentation revealed that a resident with multiple diagnoses, including muscle wasting, depression, diabetic foot ulcer, and Parkinson's disease, exhibited significant behavioral health concerns, such as wrapping a call bell cord around their neck and expressing suicidal ideation. Progress notes indicated the resident was placed on every 15-minute safety checks, and a psychiatric evaluation recommended ongoing behavioral health services. Despite these documented changes and recommendations, there was no evidence that the facility developed or implemented a comprehensive care plan addressing the resident's behavioral health interventions and services. This deficiency was confirmed by both the Regional Clinical Consultant and the Nursing Home Administrator during an interview, who acknowledged the failure to update the care plan in response to the resident's current needs.
Failure to Provide Sufficient RN Staffing for Medication Administration and Resident Assessments
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate skill sets to meet the needs of residents, specifically by not having a Registered Nurse (RN) available during an overnight shift. This resulted in missed administration of prescribed intravenous antibiotics through a PICC line for a resident with complex medical needs, including a partial foot amputation, wound dehiscence, bloodstream infection, and gangrene. The resident's medication administration record showed that two doses of antibiotics were not given as ordered because there was no RN present to administer medications via the PICC line, as required by state regulations. Additionally, two residents who experienced unwitnessed falls during the same overnight shift did not receive post-fall written assessments by an RN, but rather by an LPN, contrary to state requirements. Staffing records confirmed that no RN was scheduled for the shift in question, and interviews with staff and administration corroborated that the RN who had been working was sent home after a 16-hour shift, and the DON was unable to stay to provide coverage. These actions led to the facility's failure to comply with regulations regarding nursing services and resident assessments.
Failure to Provide Recommended Behavioral Health Services After Suicidal Ideation
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of depression and a history of expressing suicidal ideation received the recommended behavioral health services. The resident, who had multiple diagnoses including muscle wasting, depression, diabetic foot ulcer, and Parkinson's disease, was admitted on 12/14/24. Documentation in the clinical record showed that the resident had wrapped a call bell cord around their neck and expressed a desire not to live. Following this incident, there were notations indicating that the resident was placed on every 15-minute checks for safety. A psychiatric evaluation conducted on 3/04/25 recommended that the resident continue with behavioral health services. However, further review of the clinical record did not show evidence that these recommended services were provided after the evaluation. During an interview, the Nursing Home Administrator confirmed that there was no documentation indicating the continuation of behavioral health services for the resident, despite the recommendation and the resident's ongoing risk factors.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required Nurse Aide (NA) staffing ratios during the evening shift on two specific days, February 2 and February 4, 2025. On February 2, with a census of 97 residents, the facility employed 7.96 NAs, falling short of the required 8.82 NAs. Similarly, on February 4, with a census of 95 residents, 8.13 NAs were employed, whereas 8.64 were required. This deficiency was confirmed by the Nursing Home Administrator during a telephone interview on February 6, 2025, acknowledging the failure to meet the minimum NA ratios on the specified days and shifts.
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 or Federal regulatory requirements. 1. The facility cannot correct that the nurse aide staffing ratio was not met on 2/2 and 2/4/25. 2. System changes will be put into place to ensure minimum requirements to be put into place will include: 3. Facility currently has multiple nursing assistant staff members in the onboarding process to start employment at the facility. 4. All nursing assistant positions are actively posted in recruitment. 5. Bonuses are offered on an as needed basis to nursing assistants. 6. Staff are mandated as appropriate. 7. Call offs will continue to be monitored, and disciplines will be issued, as appropriate. 8. When call offs occur, all available staff members will be called to ask if they will fill the vacancy to ensure the appropriate staffing levels. 9. On a daily basis, the Director of Nursing and/or Administrator reviews the ability to take admissions based on the staffing numbers; if not meeting staffing numbers, admissions are held for the day. 10. All RN's (Registered Nurse's) and staffing coordinator will be educated on staffing ratios. Education will be done by the Director of Nursing or designee. 11. RN supervisors will be educated that they will need to mandate staff for call off to make sure facility does not fall below staffing ratios per DOH (Department of Health) regulations. 12. Daily meetings will be held, with Director of Nursing, admission coordinator, staffing coordinator, and Administrator to review schedule with ratios. 13. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios, the nursing supervisor/or designee will call off duty facility staff, will notify Director of Nursing, and will utilize pick-up bonuses. DON (Director of Nursing) or designee will monitor staffing ratios/PPD by reviewing the current working schedule and assignment sheets prior to the day and after the day is complete to ensure compliance daily x 10 days then weekly x 6 weeks, then Q (once) monthly x2 to ensure compliance. This will be reviewed at the Quarterly QAPI (Quality Assurance/Performance Improvement) meetings.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day for four out of eleven days reviewed. Specifically, on the dates of 1/26/25, 2/01/25, 2/02/25, and 2/04/25, the facility's nursing staffing documents showed that the general nursing care hours were below the required minimum, with recorded hours of 3.19, 3.14, 3.05, and 3.03 PPD, respectively. This deficiency was confirmed during a telephone interview with the Nursing Home Administrator on 2/06/25, who acknowledged that the facility did not meet the required nursing care hours on the specified dates.
Plan Of Correction
1. The facility cannot correct that the State required PPD (per patient day) minimum hours of 3.20 was not met on 1/26, 2/1, 2/2, and 2/4/25. 2. Nursing supervisors will be re-educated regarding the daily PPD by the Director of Nursing/or Designee. 3. Daily meetings will be held to review the schedule with PPD. 4. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing PPD, the scheduler/or designee will call off duty facility staff, notify the Director of Nursing, and will utilize pick-up bonuses. 5. All nursing positions are actively posted in recruitment. 6. Call offs will continue to be monitored, and disciplines will be issued, as appropriate. 7. On a daily basis, the facility reviews the ability to take admissions based on the staffing numbers. DON or designee will monitor staffing PPD by reviewing the current working schedule and assignment sheets prior to the day and after the day is complete to ensure compliance daily x 10 days, then weekly x 6 weeks, then Q monthly x2 to ensure compliance. This will be reviewed at the Quarterly QAPI (Quality Assurance/Performance Improvement) meetings.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios on multiple occasions during the review period from December 18, 2024, to December 31, 2024. Specifically, the facility did not have enough NAs on the day shift for four days, the evening shift for four days, and the overnight shift for one day. The required ratio of one NA per 10 residents during the day, one NA per 11 residents during the evening, and one NA per 15 residents overnight was not met. For instance, on December 19, 2024, with a census of 96 residents, only 9.43 NAs worked when 9.60 were required for the day shift. The deficiency was confirmed during a telephone interview with the Nursing Home Administrator on January 3, 2025, who acknowledged that the facility did not meet the minimum NA ratios on the specified days and shifts. The report provides detailed staffing numbers for each day where the facility fell short of the required NA ratios, highlighting the specific shortages in staffing that led to the deficiency.
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 or Federal regulatory requirements. 1. The facility cannot correct that the nurse aide staffing ratio was not met on 12/19, 12/22, 12/24, 12/25, 12/26, 12/28, and 12/29/24. 2. System changes will be put into place to ensure minimum requirements to be put into place will include: 3. Facility currently has multiple nursing staff members in the onboarding process to start employment at the facility. 4. All nursing positions are actively posted in recruitment. 5. Holding open interview day. 6. Bonuses are offered on an as needed basis. 7. Staff are mandated as appropriate. 8. Call offs will continue to be monitored, and disciplines will be issued, as appropriate. 9. When call offs occur, all available staff members will be called to ask if they will fill the vacancy to ensure the appropriate staffing levels. 10. On a daily basis, the facility reviews the ability to take admissions based on the staffing numbers. 11. All RN's and staffing coordinator will be educated on staffing ratios. 12. RN supervisors will be educated that they will need to mandate staff for call off to make sure facility does not fall below staffing ratios per DOH regulations. 13. Daily meetings will be held to review schedule with ratios. 14. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios the nursing supervisor/or designee will call off duty facility staff, will notify Director of Nursing and will utilize pick-up bonuses. DON (Director of Nursing) or designee will monitor staffing ratios by reviewing the current working schedule and assignment sheets prior to the day and after the day is complete to ensure compliance daily x 10 days then weekly x 6 weeks, then Q monthly x2 to ensure compliance. The DON (Director of Nursing), NHA (Nursing Home Administrator), and staffing coordinator will be in the daily meetings to monitor staffing ratios. This will be reviewed at the Quarterly QAPI meetings.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day for ten out of fourteen days reviewed. Specifically, on the dates of 12/19/24, 12/21/24, 12/22/24, 12/23/24, 12/24/24, 12/25/24, 12/26/24, 12/28/24, 12/29/24, and 12/31/24, the facility's nursing staffing documents showed that the provided hours of care were below the required minimum. The recorded hours ranged from 3.07 to 3.17 hours per patient day (PPD), falling short of the mandated 3.2 PPD. This deficiency was confirmed by the Nursing Home Administrator during a telephone interview on 1/03/25.
Plan Of Correction
1. The facility cannot correct that the State required PPD (per patient day) minimum hours of 3.20 was not met on 12/19, 12/21, 12/22, 12/23, 12/24, 12/25, 12/26, 12/28, 12/29, and 12/31/24. 2. Nursing supervisors will be re-educated regarding the daily PPD by the Director of Nursing/or Designee. 3. Daily meetings will be held to review the schedule with PPD. 4. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing PPD, the scheduler/or designee will call off duty facility staff, notify the Director of Nursing, and will utilize pick-up bonuses. 5. All nursing positions are actively posted in recruitment. 6. Call offs will continue to be monitored, and disciplines will be issued, as appropriate. 7. On a daily basis, the facility reviews the ability to take admissions based on the staffing numbers. DON or designee will monitor PPD by reviewing the current working schedule and assignment sheets prior to the day and after the day is complete to ensure compliance daily x 10 days, then weekly x 6 weeks, then Q monthly x2 to ensure compliance. The DON (Director of Nursing), NHA (Nursing Home Administrator), and staffing coordinator will be in the daily meetings to monitor PPD. This will be reviewed at the Quarterly QAPI meetings.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medication was obtained and provided as ordered by the physician for two residents. Resident R1, diagnosed with a psychotic disorder with delusions and anxiety, had a physician's order for ABHR gel to be applied topically four times a day. However, the medication was not administered for multiple doses from December 16 to December 22, 2024, due to the medication not being available and awaiting delivery from the pharmacy. Nursing documentation confirmed the unavailability of the medication during this period. Similarly, Resident R2, who has bipolar disorder and gastroesophageal reflux disease, also had a physician's order for ABHR gel to be applied four times a day for anxiety. The medication was not administered for several doses on December 26 and December 27, 2024, due to the same issue of awaiting delivery from the pharmacy. The Nursing Home Administrator confirmed that both residents did not receive their medication as ordered, acknowledging the failure in ensuring the medication was available and administered per physician orders.
Improper Storage of Ice Packs with Food in Unit Freezers
Penalty
Summary
The facility failed to ensure that food was stored in accordance with food safety standards in two unit refrigerators, specifically the East Unit and [NAME] Unit. Observations revealed that ice packs used for treatments on residents' bodies were stored next to food items such as popsicles and ice cream in the freezers of these units. This practice is against the facility's policy, which mandates the safe and sanitary storage, handling, and consumption of all food, including those brought in by family and visitors. Interviews conducted with staff members, including two Licensed Practical Nurses (LPNs) and the Director of Nursing, confirmed the inappropriate storage of ice packs with food items. The staff acknowledged that ice packs used on residents' bodies should not be stored in the same freezer as food. This deficiency was identified during a review of the facility's policies, observations, and staff interviews, highlighting a failure to adhere to professional standards for food service safety.
Failure to Document Foley Catheter Care
Penalty
Summary
The facility failed to ensure proper care for a resident with a foley catheter, as the catheter was not emptied and the amount was not documented every shift according to physician's orders. The facility's policy on urinary catheter care, dated 5/1/24, requires observation of urine levels and documentation of input and output. However, the clinical records for a resident with diagnoses including urine retention, heart failure, and hypertension showed that the catheter was not emptied and documented on multiple occasions in August and September 2024. The Director of Nursing confirmed the lack of evidence in the clinical record for compliance with the physician's orders.
Failure to Track and Dispose of Controlled Medications
Penalty
Summary
The facility failed to implement procedures for the accurate tracking and safe disposition of controlled medications for a resident, identified as CR87, whose closed record was reviewed. The facility's policy, dated 5/1/24, requires that Schedule II, III, and IV controlled substances be disposed of according to state and federal guidelines, with a detailed medication disposition record. However, the review of Resident CR87's clinical record revealed a lack of evidence of a controlled substance tracking log for medications including Morphine, Ativan, and Diazepam. These medications are used for pain management, anxiety, and seizures, respectively. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of documentation for the tracking and disposition of the controlled substances in Resident CR87's record. The record did not show evidence of the destruction or return to the pharmacy of the remaining doses of these medications. This failure to maintain proper records and follow procedures for controlled substances is a violation of the facility's policy and state regulations, as outlined in 28 Pa. Code 211.9(a) and 28 Pa. Code 211.12(d)(3).
Failure to Adhere to Insulin Administration Orders
Penalty
Summary
The facility failed to ensure that it was free from significant medication errors for one resident, identified as Resident R75. The facility's policy on administering medications requires that medications be administered in accordance with prescriber orders, including verifying the right resident, medication, dosage, time, and method of administration. However, a review of Resident R75's clinical records and medication administration records (MAR) revealed that staff did not adhere to the physician's order to hold Humalog insulin when the resident's blood sugar (BS) was less than 120 mg/dL. On multiple occasions in August and September 2024, Resident R75 received 5 units of Humalog despite having BS levels below the specified threshold. Resident R75, who was admitted with diagnoses including diabetes, hypertension, and anxiety, had specific physician orders for the administration of Humalog insulin. The orders clearly stated that the insulin should be held if the resident's BS was less than 120 mg/dL. Despite this, the MAR showed that the insulin was administered on several dates when the BS was below the threshold. The Director of Nursing confirmed during an interview that the insulin was not administered according to the physician's orders, acknowledging the medication errors.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to its own policies regarding the storage and labeling of medications, specifically Schedule II-V controlled substances and multi-dose containers. During a review of the West medication room, it was observed that Schedule II-V medications, specifically Lorazepam, were not stored in a separately locked, permanently affixed compartment as required. Instead, the Lorazepam was found in a clear plastic box on a shelf within the refrigerator, which was not permanently affixed, allowing for easy removal. This is a direct violation of the facility's policy dated 5/1/24, which mandates that such medications be stored securely. Additionally, the facility failed to properly label and manage the discard dates of multi-dose containers. An open vial of Tubersol was found in the medication room refrigerator without a date indicating when it was opened, making it impossible for staff to determine the appropriate discard date. This oversight was confirmed by an LPN during the observation, who acknowledged that the vial should have been dated upon opening. These deficiencies highlight lapses in the facility's adherence to its medication storage and labeling policies, as outlined in their own procedures.
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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