Vibra Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mechanicsburg, Pennsylvania.
- Location
- 707 Sheperdstown Rd, Mechanicsburg, Pennsylvania 17055
- CMS Provider Number
- 396133
- Inspections on file
- 20
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Vibra Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not have an infection prevention and control program in place, resulting in a deficiency related to infection control practices.
The facility did not verify state residency status to ensure accurate criminal background checks for multiple new hires and failed to validate the active status and standing of a nurse's compact license, as required by policy. Staff interviews confirmed that only state background checks were performed and that licensure verification documentation was lacking.
Multiple food items in the kitchen, nourishment center, and creamery were found open, not securely closed, and lacking date markings or proper labeling. Additionally, the ice machine in the creamery was observed with a black moist substance and had not received required preventive maintenance, and a damp towel with brown stains was left under the sink. Staff confirmed these practices did not meet facility policy or professional standards for food safety and sanitation.
The facility's governing body did not ensure proper oversight of the QAPI program, as neither the NHA nor the MD attended QAPI meetings for a six-month period. The on-site administrator confirmed that required communications and documentation regarding QAPI activities were not consistently shared with the NHA or governing body.
Required members of the QAPI Committee, including the Medical Director and NHA, did not attend any meetings in two out of three quarters reviewed. The Executive Director signed in as the NHA but later confirmed he was not the NHA, and neither the NHA nor the Medical Director participated in the QAPI meetings. Communication with the NHA occurred by phone, but QAPI minutes were not routinely shared.
A resident with multiple medical conditions was admitted to hospice, but the required comprehensive MDS assessment following this significant change in condition was not completed on time. Staff confirmed that the assessment was still incomplete during the review and had only just been submitted.
A resident did not receive treatment and care in accordance with physician orders and their documented preferences and goals, as observed by surveyors and confirmed through record review.
Surveyors found that an insulin pen in use for a resident was not labeled with the date it was opened, and a box of single-use eye drop applicators on a medication cart contained items with lot numbers that did not match the box. The DON confirmed that both practices were not in line with facility policy and accepted standards.
Several residents with diabetes were not provided with their prescribed no concentrated sweets diet, receiving pudding instead of the required fruit cup during meal service. This failure to follow physician orders was confirmed by staff and noted during meal observation.
A review of staff records and interviews revealed that one nurse aide did not complete the required 12 hours of annual in-service training, and another did not receive any dementia management education. Facility leadership confirmed these training deficiencies.
A resident with chronic health conditions suffered skin tears and bruising due to rough treatment by a CNA during toileting assistance. The CNA was verbally aggressive and physically rough, leading to the resident feeling scared and shaken. The incident was witnessed by another CNA, who intervened and reported the mistreatment. The resident was later hospitalized due to a decline in condition.
The facility did not forward information about 32 of 37 residents transferred to the hospital to the State LTC Ombudsman over eight months. The Director of Social Services was aware of this oversight.
The facility did not complete a required annual performance review for a nurse aide, Employee 6, whose last appraisal was in December 2022. Despite the policy of annual evaluations, the facility could not find a more recent review for this employee, as confirmed by the DON and Nursing Home Administrator.
The facility did not ensure residents could view the most recent survey results. The survey book in the lobby contained outdated information from November 2023, while the latest survey was from February 2024. The Nursing Home Administrator confirmed the oversight during an interview.
The facility failed to conduct necessary pre-employment checks, including background checks, nurse aide registry verification, and reference checks, for two employees. Employee 4 began working before a background check was completed, and there was no evidence of registry verification until months later. Employee 5 was hired without reference checks. These actions violated the facility's policies and state regulations.
A resident with hypertension and Diabetes Mellitus Type II reported that a Nurse Aide was rude and refused to assist her in transferring to a wheelchair. The facility failed to conduct a thorough investigation as per their policy, lacking witness statements and timely interviews. The Assistant Director of Nursing and Nursing Home Administrator acknowledged the concern but did not provide sufficient investigative information.
The facility failed to provide required in-service training for nurse aides, specifically in dementia management and resident abuse prevention. A review of training records for a nurse aide, Employee 7, showed no documentation of such training. The Nursing Home Administrator confirmed the absence of these records during an interview.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors.
Failure to Verify Background Checks and Nursing Licensure
Penalty
Summary
The facility failed to implement its written policies and procedures designed to prohibit and prevent abuse, neglect, and exploitation of residents, as well as misappropriation of resident property, by not determining residency status to perform accurate criminal history background checks prior to hiring. Personnel file reviews for five employees showed that while Pennsylvania State Criminal Background checks were completed, there was no documentation verifying the employees' state residency status to determine if additional or different background checks were required. Staff interviews confirmed that the facility relied on applicants to enter their own address history into a hiring database, but no one at the facility reviewed this information to ensure the correct type of background check was performed. The Human Resources Director stated that only state background checks were completed for all new hires, regardless of residency history. Additionally, the facility failed to validate and verify the licensure status for one nurse. The personnel file for this nurse included a copy of a Florida compact nursing license, but there was no documentation that the license was verified as active and in good standing, nor that it was free from allegations of abuse, neglect, exploitation, or misappropriation of resident property. The Human Resources Director indicated that licensure verification was generally handled by a corporate recruiter, but could not provide documentation that this process was completed for the nurse in question. The Executive Director and Director of Nursing confirmed that no further information was available for the employees involved.
Failure to Store and Serve Food in Accordance with Professional Standards
Penalty
Summary
The facility failed to store and serve food and beverages in accordance with professional standards for food safety in multiple areas, including the kitchen, a nourishment center, and the creamery. Observations revealed several food items in the walk-in freezer, refrigerator, and dry storage that were open, not securely closed, and lacked date markings. Items such as muffins, marble cake, cheeses, ziti, raisins, granola, cookies, and onions were found either uncovered, not dated, or not properly labeled. Additionally, individually wrapped sugar cookies and a vanilla shake in the nourishment center refrigerator were not dated, and a Styrofoam container of buffalo wings and celery lacked both a resident identifier and a date. Facility policy requires all food items to be labeled with content and date, and for foods to be monitored for use-by dates, but these procedures were not followed as confirmed by staff interviews. In the creamery, a damp towel with brown liquid marks was found under the sink, and the drip shield inside the ice machine contained a black moist substance that could be wiped away, indicating inadequate cleaning. The ice machine's preventive maintenance was overdue, with no documentation of recent service, despite facility policy and manufacturer guidelines requiring bi-annual cleaning. Staff confirmed that the ice machine needed cleaning and that food items should be date marked and labeled. The towel and soiled drip shield remained unaddressed upon re-observation, further demonstrating non-compliance with food safety and sanitation standards.
Failure of Governing Body to Oversee QAPI Program
Penalty
Summary
The facility failed to ensure that its governing body was responsible and accountable for the Quality Assurance Performance Improvement (QAPI) program. Documentation review showed that the QAPI Plan assigned ultimate oversight of the QAPI committee to the governing body, with the owner/president having direct oversight and the QAPI committee, including the medical director, responsible for compliance and quality improvement. However, attendance records for QAPI meetings from January through June 2025 revealed that neither the Medical Director (MD) nor the Nursing Home Administrator (NHA) attended any of the monthly meetings during this period. A memorandum indicated that the designated NHA had appointed another employee (Employee 3) as the full-time, on-site administrator, while the NHA remained engaged with facility operations and communicated regularly with Employee 3. Despite this arrangement, Employee 3 confirmed that the NHA and MD did not attend QAPI meetings and that he did not consistently share QAPI meeting minutes or updates with the NHA. No written documentation was provided to show communication between Employee 3 and the NHA or governing body regarding QAPI matters or ensuring MD attendance at QAPI meetings.
Required QAPI Committee Members Absent from Meetings
Penalty
Summary
The facility failed to ensure that the required members of the Quality Assurance Performance Improvement (QAPI) Committee, specifically the Medical Director and the Nursing Home Administrator (NHA), attended at least one meeting in two out of three quarters reviewed. Attendance sign-in sheets for the QAPI meetings from January through June 2025 did not show participation by either the Medical Director or the NHA. Instead, the Executive Director (Employee 3) signed in as the NHA, but later confirmed during a staff interview that he is not the NHA and that neither the NHA nor the Medical Director had attended the QAPI meetings. Employee 3 also stated that while he communicates with the NHA regularly by phone, he does not necessarily send QAPI meeting minutes for review.
Failure to Complete Timely Comprehensive Assessment After Significant Change
Penalty
Summary
The facility failed to complete a comprehensive assessment following a significant change in condition for one resident. The resident, who had diagnoses including cerebrovascular disease, atrial fibrillation, and hypertension, was admitted to hospice services. Review of the clinical record showed that the Minimum Data Set (MDS) assessment, which is required to evaluate all care areas after a significant change, was not completed in a timely manner. At the time of review, the MDS assessment was still in progress with several sections incomplete, and staff interviews confirmed that the significant change MDS had not been submitted as required.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the established care plan or documented resident wishes. Specific details regarding the nature of the care or the resident's medical history and condition at the time of the deficiency are not provided in the report.
Improper Medication Storage and Labeling on Medication Cart
Penalty
Summary
Surveyors observed that the facility failed to store drugs and biologicals in accordance with accepted professional standards on the 300/400 hall medication cart. Specifically, an insulin pen that had been opened and previously used for a resident was found without an open date written on the pen, contrary to facility policy which requires insulin products to be labeled with the date when first used. Additionally, the medication cart contained a manufacturer's box of single-use polyvinyl alcohol 1.4% eye drop applicators, but the lot number on the box did not match the lot numbers printed on the individual applicators inside. These findings were confirmed in the presence of the DON, who acknowledged that insulin pens should be labeled with the date of opening and that medications should remain in their original manufacturer's containers with matching lot numbers. The observations were made during a review of the medication cart and through staff interviews, indicating non-compliance with both facility policy and professional standards for medication storage and labeling.
Failure to Provide Physician-Ordered Therapeutic Diets to Diabetic Residents
Penalty
Summary
The facility failed to ensure that five residents with diabetes mellitus received their prescribed therapeutic diets as ordered by their physicians. Clinical record reviews showed that these residents had physician orders for a no concentrated sweets diet, yet during meal service, they were served pudding instead of the required fruit cup for dessert. This discrepancy was observed during tray line service, and it was confirmed by the Food Service Director that the correct substitution should have been made. One resident expressed concern that the meals were carbohydrate heavy, which was consistent with the observed failure to follow the prescribed diet orders.
Deficient Nurse Aide Training and Missing Dementia Education
Penalty
Summary
The facility failed to ensure that nurse aides received the required annual in-service training, as evidenced by a review of personnel training records and staff interviews. Specifically, one nurse aide had only completed 9.5 hours of annual training, falling short of the mandated 12 hours, and another nurse aide had not completed any training in dementia management. These deficiencies were confirmed by the Human Resources Director and the DON during staff interviews, who acknowledged the lack of compliance with training requirements for nurse aides. The findings were based on a review of employee records and direct confirmation from facility leadership.
Resident Harmed Due to Rough Treatment by CNA
Penalty
Summary
The facility failed to ensure that residents were free from abuse, resulting in actual harm to a resident. The incident involved a Certified Nurse Aide (CNA), identified as Employee 1, who was responsible for providing care to a resident with chronic congestive heart failure and B-cell lymphoma. The resident required assistance with toileting and had a potential for bleeding complications due to anticoagulant use. During care, Employee 1 was reported to have been verbally aggressive and physically rough, leading to skin tears and bruising on the resident's left hand, forearm, and shin. The incident was witnessed by another CNA, Employee 2, who intervened and reported the mistreatment to the Licensed Practical Nurse (LPN) and Registered Nurse (RN) supervisor. Employee 2 described Employee 1's behavior as inappropriate and aggressive, noting that the resident was very weak and had difficulty standing. The resident expressed feeling scared and shaken after the incident, and the skin tears were observed to be bleeding and of significant size. The RN supervisor and Assistant Director of Nursing (ADON) were informed of the incident, and the resident was assessed to have additional bruising and was later hospitalized due to a decline in condition. The resident's roommate corroborated the account of rough treatment, describing Employee 1 as rude and impatient. Despite having received abuse prevention training, Employee 1's actions resulted in physical and emotional harm to the resident.
Plan Of Correction
1. The facility implemented quick and decisive action in accordance to our abuse policy upon abuse allegations from Resident 1 regarding Employee 1. Employee 1 was immediately suspended, and RN performed a skin check on Resident 1, the provider was notified, and statements were obtained. Within 24 hours the Department of Health was notified, the police department was notified and intent to press charges occurred; the Cumberland County Office of Aging was notified as well as the Pennsylvania Department of Aging. Resident 1 was immediately tended to by staff regarding his skin tears and first aide was administered appropriately. 2. The facility will continue to perform weekly skin checks on remaining residents, observe the grievance policy, and conduct routine care plan meetings in order to determine any other residents who may be at risk for similar issues. We did interview other residents on Employee 1 assignment and no other residents had complaints. 3. The facility provides annual mandatory abuse training to all staff with the most recent training having been completed in October of 2024. The facility conducted immediate retraining of all staff upon receiving the complaint of abuse and will increase the abuse training from annual to quarterly x 12 months to ensure all staff receive the appropriate training and understand such training. 4. The facility will continue to follow the abuse policy, will continue to perform background checks prior to hire, will continue to perform reference checks prior to hire, will continue to perform annual performance evaluations for all staff, will continue to monitor grievances submitted by residents and family for the potential for abuse, will continue to perform weekly skin checks of all residents, and will continue with routine care plan meetings with residents and family to ensure any indication of potential abuse is investigated and handled appropriately. The Director of Nursing or designee will review all grievances submitted to ensure appropriate investigation and follow up continue. The audits will include 5 random grievances weekly x 4 weeks then 5 random grievances monthly x 2 months. Findings will be discussed at QAPI. 5. Date of Compliance: 2/10/25.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to ensure that information regarding residents transferred to the hospital was forwarded to a representative of the Office of the State Long-Term Care Ombudsman. This deficiency affected 32 out of 37 residents transferred over a period of eight months, from January 2024 to August 2024. The issue was identified during a review of the facility's hospital transfer information, which revealed that the required notifications were not sent. An interview with the Director of Social Services confirmed awareness of the oversight, acknowledging that the information had not been forwarded as required.
Failure to Conduct Annual Performance Review for Nurse Aide
Penalty
Summary
The facility failed to complete a performance review for one of its nurse aides, identified as Employee 6, within the required 12-month period. Employee 6 was hired on August 10, 2021, and their most recent performance appraisal was dated December 28, 2022. During an interview with the Director of Nursing on September 18, 2024, it was confirmed that employees are supposed to be evaluated annually. However, the Nursing Home Administrator confirmed on September 19, 2024, that the facility could not locate a more recent performance evaluation for Employee 6 after the December 2022 appraisal. This deficiency is a violation of the facility's personnel policies and procedures as outlined in 28 Pa. Code 101.19 (2).
Failure to Provide Access to Recent Survey Results
Penalty
Summary
The facility failed to ensure that residents had the right to examine the results of the most recent survey conducted by Federal or State surveyors. An observation of the facility's designated survey results book revealed that it contained survey information dated November 2023, while the most recent survey was conducted on February 16, 2024. This discrepancy was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the survey book did not contain the most recent survey for resident review. This failure was identified in the facility lobby area, where the survey results book was located.
Failure to Conduct Pre-Employment Checks
Penalty
Summary
The facility failed to implement its policies and procedures designed to prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. Specifically, the facility did not conduct necessary background checks, verify the nurse aide registry, or perform reference checks prior to hiring certain employees. Employee 4, a nurse aide, was hired and began working before a Pennsylvania State Police background check was completed, which was only conducted after the employee had started working. Additionally, there was no evidence that the nurse aide registry was verified until several months after the hire date, and no reference checks were completed or attempted for Employee 4. Similarly, Employee 5 was hired without any reference checks being completed or attempted. Interviews with the Human Resources Coordinator and the Nursing Home Administrator confirmed these oversights, acknowledging that the required checks were either not performed or not documented as per the facility's policy. These lapses in following established procedures were in violation of the facility's own policies and applicable state regulations, as outlined in the facility's policy titled 'Abuse, Neglect and Exploitation' dated November 1, 2017.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident, identified as Resident 153, who reported an incident to the Director of Social Services. The resident, who has a medical history of hypertension and Diabetes Mellitus Type II, alleged that a Nurse Aide, referred to as Employee 8, was rude and refused to assist her in transferring from her bed to a wheelchair to use the bathroom. The grievance log indicated that the resident reported this incident, and Employee 8 received a verbal warning for substandard work and rudeness, as documented in an Employee Warning Notice. Despite the allegation, the facility did not conduct a comprehensive investigation as required by their policy on Abuse, Neglect, and Exploitation. The Assistant Director of Nursing admitted that there were no witness statements or documentation from the alleged perpetrator, Employee 8, and the resident was only interviewed a week after the incident. The facility did not consider the allegation as abuse or neglect and lacked additional investigative information to make a final determination. The Nursing Home Administrator acknowledged the concern but did not provide further details on the investigation process.
Deficiency in Nurse Aide Training for Dementia and Abuse Prevention
Penalty
Summary
The facility failed to ensure that the required in-service training for nurse aides included dementia management training and resident abuse prevention training. This deficiency was identified during a review of the facility's annual training documentation for one of the nurse aides, referred to as Employee 7. The documentation revealed that there was no record of training related to resident abuse or dementia care for this employee. During an interview with the Nursing Home Administrator, it was confirmed that the required training documentation for Employee 7 could not be located at the time of the survey.
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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