Upmc Magee-womens Hospital Tcu
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 300 Halket Street, Pittsburgh, Pennsylvania 15213
- CMS Provider Number
- 396098
- Inspections on file
- 13
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Upmc Magee-womens Hospital Tcu during CMS and state inspections, most recent first.
The facility did not provide or document the offering of COVID-19 booster vaccines to several residents, despite policy requirements to establish immunization status and offer vaccines upon admission. Clinical records and staff interviews confirmed that no documentation existed to show that eligible residents with various chronic conditions were offered the COVID-19 booster.
The facility did not notify the Office of the State Long-Term Care Ombudsman when two residents, one discharged home with home health services and another transferred to a nursing facility, left the facility. Both residents had significant medical histories, and required notifications were not completed as confirmed by staff and record review.
A resident receiving continuous tube feeding did not have their enteral feeding formula and water bag labeled with the date or time they were hung, contrary to facility policy. This lapse was confirmed by an RN and represents a failure to provide appropriate care and services to prevent potential complications.
A resident with a peripheral IV catheter did not have the insertion site labeled with the date or time, as required by facility policy. An LPN confirmed the omission during an interview, resulting in a deficiency in IV therapy administration and monitoring.
Surveyors observed that the microwave oven in the TCU Dining Room's Resident Pantry area had dried food particles and debris on its interior surfaces. Facility policy requires all kitchen equipment to be cleaned and sanitized after each use, but this was not followed, as confirmed by the NHA.
The facility failed to implement Enhanced Barrier Precautions for four residents with conditions increasing their risk of MDROs, and an LPN did not follow proper infection control practices during a dressing change, leading to cross-contamination risks.
The facility failed to document necessary details for urinary catheters, such as size and balloon inflation fluid, for two residents. One resident with a history of thyroid disorder, Parkinson's disease, and coronary artery disease had a foley catheter without documented size in the physician's orders. Another resident with congestive heart failure, atrial fibrillation, and COPD had a catheter order lacking size and balloon fluid details, and their care plan did not include catheter care instructions.
A facility failed to provide adequate care for a resident's peripherally inserted catheter, as required by professional standards. The resident, with diagnoses of CHF, atrial fibrillation, and COPD, had an IV site that was not labeled with a date or time, had a lifting dressing, and noticeable dried blood. A nurse confirmed these deficiencies, acknowledging the failure to adhere to the facility's IV therapy policy.
A facility failed to maintain sanitary conditions for a resident's respiratory equipment. The resident, with diagnoses including CHF, atrial fibrillation, and COPD, had a BIPAP mask that was found unlabeled and not in a bag, contrary to facility policy. A nurse confirmed the oversight, indicating non-compliance with the required sanitary standards.
The facility failed to properly store and label medications on two medication carts, with several items lacking opening dates, risking cross-contamination. RN confirmed the observations, indicating non-compliance with pharmacy and nursing service regulations.
The facility failed to ensure the presence of all required multidisciplinary members, specifically a community member, at Infection Control Meetings for four consecutive quarters, as mandated by the MCARE Act. This deficiency was confirmed by the Infection Preventionist.
The facility failed to maintain the automatic sprinkler system, with deficiencies observed in six instances affecting four smoke compartments. Issues included insulation on sprinkler lines, gaps greater than 1/8 inch in various rooms, and flexible ductwork on a sprinkler line. These deficiencies were confirmed by interviews with the Unit Director of TCU, Facility Staff, and the Safety Manager.
The facility failed to maintain corridor doors according to NFPA 101 standards. A door to a room did not latch properly, and several doors had decorations covering more than 50% of their surface, which violates fire safety regulations. These issues were confirmed by facility staff.
The facility was found to have deficiencies in maintaining smoke barrier walls, affecting four smoke compartments. Observations revealed an unsealed penetration in the Level 6300 Elevator Room and a missing fire sealant above the double doors near Data Room 2400.22. These issues were confirmed by facility staff.
A facility failed to properly store gas cylinders, as an unsecured cylinder was found in a storage room on the first floor. This deficiency was confirmed through an interview with the Unit Director of TCU, Facility Staff, and the Safety Manager. The incident affected one of the 27 smoke compartments, indicating non-compliance with NFPA 101 standards for gas cylinder storage.
The facility failed to maintain proper electrical wiring systems by allowing two electric coffee pots to be plugged into a power strip in a patient care area, which is against the regulations for electrical equipment usage. This deficiency was confirmed by the Unit Director of TCU, Facility Staff, and Safety Manager.
Failure to Document Offering of COVID-19 Booster Vaccines
Penalty
Summary
The facility failed to provide accurate and timely documentation regarding the offering of COVID-19 booster vaccines to five residents. According to the facility's policy, immunization status should be established upon admission and vaccines, including COVID-19, should be offered to residents. Clinical record reviews for five residents revealed that each had not received a COVID-19 booster vaccine, and there was no documentation in their records indicating that a booster was offered. The Minimum Data Set (MDS) assessments for these residents showed they were not up to date with COVID-19 vaccinations, and their last recorded vaccinations were dated well before the review. During interviews, facility staff confirmed that COVID-19 vaccines were not being offered to residents and acknowledged the lack of documentation related to the offering of booster vaccines. The residents involved had various medical conditions, including hypertension, diabetes, anemia, heart failure, edema, osteoporosis, chronic pain, epilepsy, cellulitis, and GERD. The deficiency was identified through a combination of policy review, clinical record examination, and staff interviews, all of which confirmed the failure to document the offering of COVID-19 booster vaccines as required.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman upon the discharge of two residents, as required by facility policy and state regulations. Review of the facility's admission, transfer, and discharge policy indicated that discharges should be conducted in an organized manner with a focus on continuity of care, including required notifications. However, documentation and notifications related to the discharges of two residents were missing from the records sent to the Ombudsman office. One resident was discharged home with his wife and home health services, and his medical history included diabetes, hypertension, and coronary artery disease. Another resident, who had a left clavicle fracture, hypertension, and osteoporosis, was discharged to another nursing facility. Staff interviews and record reviews confirmed that the required notifications to the Ombudsman office were not completed for these discharges.
Failure to Label Enteral Feeding Equipment
Penalty
Summary
The facility failed to ensure that a resident with an enteral feeding tube received appropriate treatment and services to prevent potential complications. According to the facility's policy, enteral feeding and tubing are to be changed every 24 hours or when a new bottle is hung, and the feeding bag or bottle must be labeled with the date and time it was hung. Clinical record review showed that the resident was admitted with diagnoses including breast cancer, hypotension, and abdominal discomfort, and was receiving continuous tube feeding at a specified rate with scheduled water flushes. During observation, it was noted that the resident's enteral feeding formula and water bag were infusing via pump but were not labeled with the date or time they were hung, as required by policy. A registered nurse confirmed that the formula had been hung the previous night and acknowledged the failure to follow labeling procedures. This deficiency was identified for one of three residents reviewed for enteral feeding tube care.
Failure to Label IV Site per Policy
Penalty
Summary
The facility failed to provide adequate treatment and care for a peripherally inserted catheter in accordance with professional standards of practice for one resident. Facility policy requires that all registered nurses and LPNs who complete the IV therapy program are responsible for inspecting IV sites at least every shift, maintaining a clean, dry, and intact dressing over the insertion site, and documenting the date and time of insertion. During a review of clinical documentation, it was found that a resident with a history of hernia repair, muscular deconditioning, and obesity had a 22-gauge peripheral catheter inserted in the left wrist. On observation, the resident was seen with a peripheral IV access site on the left wrist, but the dressing was not labeled with the date or time of insertion. During an interview, an LPN confirmed that the IV access site dressing did not contain the required date or time of insertion. This failure to label the IV site as required by facility policy and professional standards constituted a deficiency in the administration and monitoring of IV therapy for the resident.
Failure to Maintain Cleanliness of Kitchen Equipment
Penalty
Summary
The facility failed to maintain the cleanliness and sanitation of equipment in the Transition Care Unit (TCU) Dining Room, specifically in the Resident Pantry area. During an observation, the interior cooking surfaces of the microwave oven were found to be covered with dried food particles and splatters of dried food debris. According to facility policy, all kitchen equipment is required to be cleaned and sanitized after each use, and all employees are responsible for keeping equipment and the department clean. The Nursing Home Administrator confirmed that the microwave oven needed to be cleaned and sanitized, indicating that the facility did not adhere to its own sanitation standards, which could lead to cross-contamination or foodborne illness.
Failure to Implement Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for four residents, which is a critical infection control intervention aimed at reducing the transmission of multidrug-resistant organisms (MDROs). The residents involved had conditions such as surgical wounds, catheters, and recent surgeries, which increased their risk of MDRO acquisition. Despite these risks, the facility's policies did not include EBP, and there were no orders or care plans for EBP for these residents. Additionally, during a dressing change for one resident, the facility failed to adhere to proper infection control practices. The LPN involved did not perform hand hygiene after removing gloves and before donning new ones, which is a crucial step in preventing cross-contamination. This oversight occurred multiple times during the dressing change process, indicating a lapse in maintaining aseptic technique as outlined in the facility's wound care policy. Interviews with the Director of Nursing and the Infection Preventionist revealed a lack of awareness and implementation of EBP within the facility. The Director of Nursing acknowledged the absence of EBP in care plans, while the Infection Preventionist admitted to being unaware of the need for such precautions. This lack of knowledge and implementation contributed to the deficiencies observed during the survey.
Plan Of Correction
Residents R65, R115, R118 and R123 were discharged. At the time of the findings, all residents were assessed for the need to implement Enhanced Barrier Precautions (EBP) during high-contact resident care activities, and an EBP order and care plan was initiated as indicated. At the time of the findings, Employee E4 and all staff on duty were reminded to wash their hands after doffing soiled gloves and prior to donning a new pair of gloves during dressing changes to prevent cross-contamination. Facility policies HS-IC0609 and SRC-Infection Control-2.1 Transmission Based Precautions-A were reviewed and verified to include EBPs. All RNs, LPNs, and CNAs will be educated by the Administrator and/or designee to use EBPs during high-contact care activities for residents with: 1. Indwelling Medical Devices (such as but not limited to central line, urinary catheter, feeding tube, tracheostomy/ventilator), and when they should be implemented for residents. 2. Wounds 3. Colonization or Infection with a MDRO (Multi-Drug Resistant Organism). DON and/or designee will provide all RNs and LPNs education regarding the need to wash their hands after doffing soiled gloves and prior to donning a new pair of gloves during dressing changes to prevent cross-contamination. NHA and/or designee will audit/observe 4 residents per week to ensure EBPs are being implemented during high-contact resident care activities, and that there is an MD order and a care plan in place as indicated. Audits will be conducted weekly for 4 weeks, then monthly for 2 months or until substantial compliance is obtained. DON and/or designee will audit/observe 4 dressing changes per week to ensure RN and/or LPN providing care wash their hands after doffing soiled gloves and prior to donning a new pair of gloves during dressing changes to prevent cross-contamination. Audit will be completed weekly for 4 weeks, then monthly for 2 months or until substantial compliance is obtained. The results will be reviewed at the Quarterly QAA meetings.
Deficiency in Urinary Catheter Documentation and Care Planning
Penalty
Summary
The facility failed to ensure that physician orders for urinary catheters included necessary details such as the size of the catheter and the amount of fluid required for balloon inflation for two residents. Resident R66, who has a history of thyroid disorder, Parkinson's disease, and coronary artery disease, had a foley catheter inserted without documentation of the catheter size in the physician's orders. Observations confirmed the presence of the catheter, but the necessary details were missing from the clinical records. A registered nurse confirmed this oversight during an interview. Similarly, Resident R118, diagnosed with congestive heart failure, atrial fibrillation, and chronic obstructive pulmonary disease, had a foley catheter order that lacked information on the catheter size and balloon inflation fluid. Additionally, the baseline care plan for Resident R118 did not include care instructions for the foley catheter. This deficiency was also confirmed by a registered nurse during an interview, highlighting the facility's failure to provide comprehensive documentation and care planning for residents with urinary catheters.
Plan Of Correction
R66 and R118 have been discharged. All current residents with catheters have been reviewed and appropriate care plans and orders have been entered to include size and amount of fluid needed. All RNs and LPNs will be educated by the Director of Nursing and/or designee that when a catheter is ordered or present, the MD order must state the appropriate size and fluid needed. There must also be care plans in place for all residents with catheters. The Director of Nursing and/or designee will review all residents with catheters present weekly for one month and monthly thereafter or until substantial compliance is achieved to ensure the MD order notes the appropriate size and fluid needed and that there is a care plan in place. Results will be reviewed at the Quarterly QAA meeting.
Inadequate IV Catheter Care for a Resident
Penalty
Summary
The facility failed to provide adequate treatment and care for a peripherally inserted catheter for a resident, identified as Resident R118, in accordance with professional standards of practice. The facility's policy on Intravenous (IV) Therapy requires registered nurses and licensed practical nurses to inspect IV sites at least every shift and maintain a clean, dry, and intact dressing over the insertion site. However, during an observation, it was noted that Resident R118's IV access site on the right wrist was not labeled with a date or time, the dressing was lifting, and there was noticeable dried blood around the insertion site. Resident R118 was admitted with diagnoses of congestive heart failure, atrial fibrillation, and chronic obstructive pulmonary disease. The resident had a physician's order for cefepime to be administered intravenously every eight hours for seven days. During an interview, a registered nurse confirmed the deficiencies in the dressing and acknowledged that the facility failed to provide adequate care for the catheter. This incident was a violation of the facility's policy and professional standards of practice.
Plan Of Correction
R118 has been discharged. On the day of the findings, residents with IVs were assessed to ensure dressing sites were labeled with a date and time, and that all dressings were intact without any signs or symptoms of complications. All RNs and LPNs will be educated by the Director of Nursing and/or designee that when an IV is in place, the dressing must be labeled appropriately with a date and time, and that all dressings should be inspected at least once a shift to ensure the dressing is intact and without any signs or symptoms of complications. The Director of Nursing and/or designee will audit all residents with an IV in place to ensure that the dressing is labeled appropriately with a date and time, and that all dressings are being inspected at least once a shift to ensure the dressing is intact and without any signs or symptoms of complications. Audits will be completed weekly for 4 weeks, then monthly for 2 months, or until substantial compliance is achieved. Results will be reviewed at the Quarterly QAA meetings.
Failure to Maintain Sanitary Conditions for Respiratory Equipment
Penalty
Summary
The facility failed to maintain sanitary conditions of respiratory equipment for Resident R118, who was diagnosed with congestive heart failure, atrial fibrillation, and chronic obstructive pulmonary disease. According to the facility's policy on Respiratory Equipment Maintenance, BIPAP/CPAP equipment should be changed as needed for soiling or equipment integrity, and the equipment should be stored in a labeled bag. However, during an observation, Resident R118's fitted face mask was found in a basket on a cart without a label or bag. A Registered Nurse confirmed that the facility did not adhere to the policy, resulting in unsanitary conditions for the respiratory equipment of one of the four residents reviewed.
Plan Of Correction
R118 has been discharged. On the day of the findings, all residents with BIPAP/CPAP therapy were reviewed to ensure all BIPAP/CPAP masks not in use were in an equipment treatment bag with the residents last name, room number and date. All RNs and LPNs will be educated by the Director of Nursing and/or designee that when a BIPAP/CPAP machine is not in use that the mask should be placed in an equipment treatment bag with the residents last name, room number and date. The Director of Nursing and/or designee will audit BIPAP/CPAP equipment when not in use to ensure the BIPAP/CPAP mask is placed in an equipment treatment bag with the residents last name, room number and date. Audits will be completed weekly for 4 weeks, then monthly for 2 months, or until substantial compliance is achieved. Results will be reviewed at the Quarterly QAA meeting.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to properly store and label medications and treatments on two of three medication carts, specifically the front hall and back hall medication carts. During an observation, it was noted that the front hall medication cart contained two dispensing bottles of nystatin powder, one tube of hydrocortisone cream, one vial of brimonidine eye drops, and one bottle of calcitonin nasal spray, all of which were not labeled with the date they were opened. Similarly, the back hall medication cart contained one tube of lidocaine and prilocaine (EMLA cream), one tube of lidocaine gel, one vial of polyvinyl eye drops, and one vial of Lantus insulin, also without the date of opening. These observations were confirmed by RN Employee E5, who acknowledged the improper storage and labeling. The deficiency was identified as a failure to prevent cross-contamination and ensure proper labeling of medications upon opening, as required by professional principles and facility policy. The lack of proper labeling and storage was observed during a survey, and the facility's non-compliance with the relevant Pennsylvania Code sections regarding pharmacy services, resident care policies, and nursing services was noted. The report does not mention any specific residents affected or any immediate consequences resulting from these deficiencies.
Plan Of Correction
The vial of eye drops, bottle of calcitonin nasal spray, polyvinyl eye drops and Lantus insulin were disposed of on 12/18/2024. The Nystatin powder and Hydrocortisone cream were placed in the treatment cart. On the day of the findings, the remaining medication cart was inspected and no other open/undated items were found, and no other treatments were found in the medication cart. DON and/or designee will educate RNs and LPNs on the need to store medications and treatments separately to prevent cross contamination, and the need to label medications such as but not limited to eye drops and calcitonin spray when opened. DON and/or designee will audit medication/treatment carts and med rooms to ensure medications and treatments are stored separately to prevent cross contamination, and that medications are labeled when opened. Audits will be completed weekly for 4 weeks, then monthly for 2 months, or until substantial compliance is achieved. Results of the audits will be reported at the Quarterly QAA meeting.
Infection Control Meeting Deficiency
Penalty
Summary
The facility failed to meet the minimum standards for infection control as required by the Medical Care Availability and Reduction of Error (MCARE) Act. Specifically, the facility did not ensure that all required multidisciplinary members were present at the Infection Control Meetings for four consecutive quarters. The MCARE Act mandates that a health care facility's infection control plan must include a multidisciplinary committee with representatives from various sectors, including medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plant personnel, patient safety officer, a community member, and a member of the infection control team. Upon reviewing the facility's Infection Control Meeting attendance records for all four quarters of 2024, it was found that a community member was consistently absent from these meetings. This deficiency was confirmed during an interview with the Infection Preventionist, who acknowledged the absence of the community member in the meetings. This oversight indicates a failure to comply with the infection control plan requirements as stipulated by the MCARE Act.
Plan Of Correction
A new community member representative has been identified. An individual meeting with the new Infection Control Committee Meeting community member representative has been coordinated to provide a summary of the last meeting and the next meeting date. The NHA has re-educated the Infection Prevention Coordinator regarding the need to have a community member at the quarterly Infection Control Committee Meeting, and the need to confirm availability and attendance in advance of the meeting date. Audits will be completed monthly by the NHA and/or designee to ensure a meeting invite has been sent to the community member representative. Attendance will be confirmed following each quarterly meeting. Audits will be completed for 2 meetings or until substantial compliance is achieved. Results will be reviewed at the quarterly QAA meeting.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in six instances, affecting four of twenty-seven smoke compartments. On December 16, 2024, observations revealed deficiencies such as insulation supported by the sprinkler line in the 6300 attic and gaps greater than 1/8 inch in rooms #5328, #4116, and #4118. On December 17, 2024, further deficiencies were observed, including a gap greater than 1/8 inch in the track of the ceiling tile outside room 4321 and flexible insulated ductwork laying on a sprinkler line above the double doors next to room 4172. Interviews with the Unit Director of TCU, Facility Staff, and the Safety Manager confirmed these deficiencies.
Plan Of Correction
The insulation will be relocated off of the sprinkler pipe in the 6300 attic. The ceiling tile will be replaced in rooms 5328, 4116, 4118, and 4321. The insulated ductwork will be relocated off of the sprinkler pipe in room 4172. All of these resolutions will be reported to the hospital safety committee and included in the hospital quality assurance program. All sprinkler lines are monitored and will continue to be monitored annually as part of the "Annual Fire and Smoke barrier above the ceiling program." Ceiling tiles are monitored and will continue to be monitored during hazard surveillance rounds by a multi-disciplinary team including representatives from safety, infection control, facilities, and environmental services.
Corridor Door Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain corridor doors in compliance with NFPA 101 standards, as observed during a survey on December 17, 2024. Specifically, the door to room #3430 did not latch properly when tested, which is a requirement for doors protecting corridor openings to resist the passage of smoke. This deficiency was noted at 10:17 a.m. and indicates a failure in ensuring that the door hardware functions correctly to provide the necessary fire protection. Additionally, several doors throughout the facility were found to have decorations covering more than 50% of the door surface. This observation was made at 10:30 a.m. and violates the standards for corridor doors, which must remain free of obstructions that could impede their function in resisting smoke passage. These findings were confirmed in an interview with the Unit Director of TCU, Facility Staff, and the Safety Manager later that day.
Plan Of Correction
The door to room 3430 will be repaired to close and latch. The door decorations will be removed. This will be reported to the hospital safety committee and included in the hospital quality assurance program. Door maintenance and functionality is monitored and will continue to be monitored during hazard surveillance rounds by a multi-disciplinary team including representatives from safety, infection control, facilities, and environmental services.
Smoke Barrier Wall Deficiencies Identified
Penalty
Summary
The facility failed to maintain smoke barrier walls in two specific locations, impacting four out of twenty-seven smoke compartments. During an observation on December 17, 2024, it was noted that there was an unsealed penetration in the smoke wall of the Level 6300 Elevator Room. Additionally, there was a previously sealed penetration above the double doors next to Data Room 2400.22, where the fire sealant had either been removed or had fallen out. These deficiencies were confirmed through an interview with the TCU Unit Director, Facility Staff, and the Safety Manager on the same day.
Plan Of Correction
The penetration in the Elevator Room will be sealed to prevent the passage of smoke. The penetration above the double doors next to room 2400.22 will be sealed to prevent the passage of smoke. This will be reported to the hospital safety committee and included in the hospital quality assurance program. Door maintenance is monitored and will continue to be monitored during hazard surveillance rounds by a multi-disciplinary team including representatives from safety, infection control, facilities and environmental services.
Improper Storage of Gas Cylinders
Penalty
Summary
The facility failed to properly store gas cylinders, as evidenced by an observation on December 17, 2024. During the inspection, a gas cylinder was found unsecured in a storage room on the first floor, specifically in room 1213. This observation was made at 11:10 a.m. and was confirmed through an interview with the Unit Director of TCU, Facility Staff, and the Safety Manager later that day at 1:00 p.m. The deficiency affected one of the 27 smoke compartments in the facility. The report highlights that the facility did not adhere to the requirements for gas cylinder storage as outlined in NFPA 101, which mandates that cylinders must be secured to prevent accidents and ensure safety. The unsecured cylinder represents a failure to comply with these safety standards, posing potential risks to the facility's safety protocols.
Plan Of Correction
The cylinder will be secured in room 1213. This will be reported to the hospital safety committee and included in the hospital quality assurance program. Gas cylinders are monitored and will continue to be monitored during hazard surveillance rounds by a multi-disciplinary team including representatives from safety, infection control, facilities and environmental services.
Improper Use of Power Strips in Patient Care Area
Penalty
Summary
The facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of twenty-seven smoke compartments. During an observation on December 17, 2024, at 11:25 a.m., it was noted that two electric coffee pots were plugged into a power strip/surge protector in room 1119. This setup did not comply with the requirements for electrical equipment usage in patient care areas, as power strips in these vicinities should only be used for movable patient-care-related electrical equipment (PCREE) and not for non-PCREE such as personal electronics. The deficiency was confirmed during an interview with the Unit Director of TCU, Facility Staff, and Safety Manager later that day at 1:00 p.m.
Plan Of Correction
Staff will be informed to plug the coffee pots into the wall in room 1119. This will be reported to the hospital safety committee and included in the hospital quality assurance program. The use of surge protectors are monitored and will continue to be monitored during hazard surveillance rounds by a multi-disciplinary team including representatives from safety, infection control, facilities and environmental services.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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