Wayne Woodlands Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Waymart, Pennsylvania.
- Location
- 37 Woodlands Drive, Waymart, Pennsylvania 18472
- CMS Provider Number
- 395936
- Inspections on file
- 28
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Wayne Woodlands Manor during CMS and state inspections, most recent first.
Two residents did not receive individualized pain management consistent with professional standards, as staff failed to attempt non-pharmacological interventions before administering as-needed pain medications and repeatedly gave pain medications outside of prescribed pain scale parameters without documenting clinical reasoning. Orders for medication type, dose, and pain scale were not followed, and non-pharmacological interventions were not documented.
A resident was given antibiotics for a suspected UTI based on abnormal urinalysis results and family request, despite no documented urinary symptoms or clinical criteria being met. The antibiotic was started before culture confirmation and was later found to be ineffective against the identified organism, with the DON confirming that the medication was initiated without proper clinical justification.
A resident with chronic lung disease and muscle weakness experienced pain after a fall and underwent a cervical spine x-ray, which revealed a right-lung infiltrate and recommended a follow-up chest x-ray. The facility did not document that the physician was notified of these abnormal findings or that the follow-up test was completed, and the DON could not explain the lack of communication.
The facility did not thoroughly investigate or submit a complete report to the State Survey Agency within the required timeframe after two residents were found to have missing controlled substances following discharge. The initial investigation report was incomplete, lacked necessary documentation, and was not resubmitted after being rejected, with facility leadership unable to provide evidence of a completed investigation.
A resident with cerebral palsy and other conditions suffered a serious injury due to the failure of two agency Nurse Aides to use a Hoyer lift as required by the care plan. Despite being trained, the aides neglected to follow proper transfer protocols, leading to an impacted fracture of the resident's right humerus. The incident was confirmed through internal investigation and interviews with the resident and her roommate.
Wayne Woodlands Manor failed to address resident grievances regarding the inconsistent delivery of fresh water, as reported by six residents during Resident Council meetings. Despite repeated complaints documented in meeting minutes from late 2024 to early 2025, the facility did not provide evidence of corrective actions. Interviews with the NHA and DON confirmed the lack of documented responses to these grievances.
The facility failed to implement its abuse prohibition procedures by not adequately screening five employees, including LPNs, a Nurse Aide, a Dietary Aide, and the DON. The facility did not document contacting former employers to verify past employment, as required by their policy. This was confirmed by the Administrator, indicating a failure to adhere to the facility's own procedures.
The facility failed to provide timely and necessary behavioral health care to two residents with dementia, leading to a deficiency in maintaining their mental and psychosocial well-being. Both residents exhibited escalating behaviors, but their care plans were not updated, and no follow-up interventions were implemented despite worsening symptoms. The NHA could not provide evidence of psychological services aimed at improving the residents' well-being.
A facility failed to prevent the misappropriation of narcotic medications for a resident with chronic pain. Despite receiving a delivery of Tramadol, the medication went missing the same day. An LPN signed for the delivery and informed another LPN of the medication's location, but it was left unattended. Video footage showed unsecured handling of the medication cart. The facility's investigation lacked witness statements and failed to identify the perpetrator, although the resident did not miss any doses.
A facility failed to prevent urinary tract infections for a resident with an indwelling catheter. The resident's care plan did not document the use of a leg bag for daytime urinary drainage, and the urinary drainage bag was improperly stored, posing a risk for cross-contamination. The DON confirmed the lack of adherence to infection control guidelines and absence of staff education on urinary drainage system care.
A resident with multiple diagnoses, including cerebral palsy and contractures, did not receive effective pain management as the facility failed to attempt non-pharmacological interventions before administering pain medication. Despite having a comprehensive care plan, the resident was repeatedly given medication without prior non-pharmacological attempts, as confirmed by the DON.
A facility failed to provide a written notice of a hospital transfer to a resident and their representative, as required by regulations. The deficiency involved a resident with atrial fibrillation, heart disease, and a fracture, who was transferred to the hospital and later readmitted. The facility did not document that the resident's responsible party was informed in writing about the transfer, as confirmed by the Administrator.
The facility did not report cases of Influenza A to the appropriate health agencies for 13 residents who tested positive. The infection control documentation showed positive tests over several weeks, and staff confirmed that the required notifications were not made.
A resident with cognitive impairment was sexually assaulted during the night shift in an LTC facility. The resident reported the incident to a nurse aide, and a subsequent hospital examination confirmed injuries consistent with sexual assault. The facility's investigation revealed that a male agency nurse aide was on duty during the incident, but the resident could not identify the assailant due to darkness. The facility failed to protect the resident, resulting in psychosocial harm.
The facility failed to provide abuse prevention training to agency nursing staff, including an agency nurse aide and an agency RN. The staffing coordinator confirmed that while credentials are verified, abuse training is not requested. The facility relies on agency staff for adequate staffing but lacks evidence of abuse training for them.
A resident reported an alleged sexual assault to a nurse aide, but the facility failed to conduct a thorough investigation. The resident, who was moderately cognitively impaired, was sent to the hospital, but the facility did not interview all staff on duty or document a completed investigation. The DON confirmed the lack of investigation and documentation.
A facility failed to update a care plan for a resident with dementia, leading to an incident where the resident exhibited aggressive behavior during an outing with her son. The care plan did not address the resident's aggressive tendencies, and the son was unprepared to manage the situation, resulting in physical injuries to the resident.
A resident with moderate cognitive impairment reported a sexual assault incident to a nurse aide, which was then reported to an LPN and the DON. Attempts to assess the resident were unsuccessful due to her distress. The incident was not fully documented in the clinical records, as confirmed by the DON, indicating a failure to maintain complete and accurate records.
A resident with dementia and severe cognitive impairment was allegedly abused by a nurse aide, who was reported to have held the resident by their sweater and screamed at them. Despite the incident being witnessed by other staff, the facility failed to report the alleged abuse to the State Survey Agency within the required 24-hour period, as per their policy. The report was only made after surveyor inquiry, highlighting a deficiency in the facility's abuse reporting procedures.
A facility failed to promptly investigate and report an alleged abuse incident involving a resident with dementia. A nurse aide was reported to have physically and verbally abused the resident, but the facility did not follow its abuse prevention policy. Although the aide was initially removed, she returned to duty without a completed investigation, and the incident was not reported to the State Survey Agency within the required timeframe.
The facility failed to provide restorative nursing services and devices to maintain mobility and range of motion for a resident with difficulty in walking, abnormal posture, osteoarthritis, and muscle weakness. Despite recommendations for a restorative nursing program and a physician's order for an ankle stirrup, the facility did not implement the RNP or apply the ankle support, as confirmed by observations and staff interviews.
The facility failed to maintain infection control practices for three residents, including those with urinary tract infections, pressure ulcers, and indwelling catheters. Observations revealed the absence of Enhanced Barrier Precautions (EBP) and improper handling of medical supplies, confirmed by the Director of Nursing and Nursing Home Administrator.
A resident with Parkinson's disease experienced a significant weight loss of 12.4% over six months. Although the attending physician was notified, there was no documented evidence that the resident's representative was informed. This deficiency was confirmed during an interview with the Nursing Home Administrator.
A resident with Parkinson's disease experienced a 12.4% weight loss over six months, but the facility's care plan did not address this decline in nutritional status. This deficiency was confirmed by the Nursing Home Administrator and DON.
The facility failed to timely identify, assess, and treat pressure sores for two residents. One resident with a history of hypertension, diabetes, and heart failure had an untreated pressure sore on the right buttock, while another resident with a hip fracture and dementia developed a pressure wound due to inconsistent monitoring of a knee immobilizer. These deficiencies were confirmed through clinical record reviews, staff interviews, and observations.
The facility failed to administer oxygen as ordered and maintain sanitary oxygen delivery systems for a resident with COPD and respiratory failure. Observations revealed undated nasal cannula tubing and the resident not receiving oxygen as prescribed. Interviews confirmed non-compliance with physician orders and facility policy.
Failure to Follow Pain Management Protocols and Physician Orders
Penalty
Summary
The facility failed to develop and implement individualized pain management programs consistent with professional standards of practice for two residents. Clinical record reviews revealed that staff did not attempt non-pharmacological interventions prior to administering as-needed pain medications, despite explicit physician orders requiring such interventions. Additionally, staff repeatedly administered pain medications outside of the prescribed pain scale parameters and did not document clinical reasoning for these deviations. For one resident with diagnoses including spinal stenosis and an open wound, physician orders specified the use of acetaminophen for mild pain and tramadol for moderate to severe pain, with clear instructions to attempt non-pharmacological interventions before medication administration. However, documentation showed that tramadol was administered multiple times for pain ratings below the ordered threshold, and non-pharmacological interventions were not attempted or documented. There were also instances where the incorrect dose of tramadol was given, and acetaminophen was not administered as ordered during certain periods. Another resident with chronic obstructive pulmonary disorder and muscle weakness had an order for hydrocodone/acetaminophen to be given for pain rated 1-5. Despite this, the medication was administered on numerous occasions for pain ratings above the ordered range, with over 40 instances documented outside the provider's parameters. There was no documentation explaining the clinical reasoning for these actions. Interviews with the DON confirmed the findings related to the failure to follow physician orders, lack of non-pharmacological interventions, and inconsistency with professional standards of pain management.
Unnecessary Antibiotic Administration Without Clinical Indication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotics, as required by their Antibiotic Stewardship Program policy. The policy mandates that clinical symptoms of infection must be present before collecting cultures or starting antibiotics, and that empiric antibiotics should only be initiated if the resident meets specific clinical criteria and appears systemically ill. In the case reviewed, a resident with chronic obstructive pulmonary disorder and muscle weakness was administered Macrobid for a suspected urinary tract infection (UTI) at the request of the family, despite multiple progress notes and standardized urinary change forms documenting no signs or symptoms of a UTI. The resident's clinical record did not contain documentation of urinary symptoms that would meet the criteria for starting empiric antibiotic therapy, nor was there evidence that McGeer's criteria were met. The resident received two doses of Macrobid before laboratory confirmation of infection and before sensitivity results were available, which later showed resistance to Macrobid. The antibiotic was started solely based on abnormal urinalysis results and family request, without supporting clinical evidence or symptoms. The Director of Nursing acknowledged that antibiotics were initiated prior to culture confirmation and in the absence of documented clinical symptoms, contrary to facility policy and established infection surveillance criteria.
Failure to Promptly Notify Physician of Abnormal Diagnostic Results
Penalty
Summary
The facility failed to ensure that laboratory and diagnostic test results were promptly communicated to the ordering physician for a resident. The resident, who had a history of chronic obstructive pulmonary disorder and muscle weakness, was admitted to the facility and had intact cognition as assessed by a BIMS score of 13. Following a fall, the resident experienced uncontrolled head and neck pain, prompting a cervical spine x-ray. The x-ray, completed later that day, revealed an apparent right-lung infiltrate and recommended a follow-up chest x-ray for further evaluation. A review of the clinical record showed no documentation that the physician was notified of the abnormal x-ray findings or that the recommended follow-up chest x-ray was completed. During an interview, the DON was unable to provide an explanation for the lack of documentation regarding physician notification or review of the x-ray results. The DON confirmed that it is the facility's responsibility to ensure prompt communication of laboratory and diagnostic test results to the physician.
Failure to Complete and Submit Timely Investigation of Misappropriation Allegations
Penalty
Summary
The facility failed to ensure that all allegations of resident abuse and misappropriation were thoroughly investigated and that complete investigation results were submitted to the State Survey Agency within five working days, as required by policy. Specifically, an incident was reported in which a resident was discharged home with a prescription for Oxycodone, but upon arrival, the responsible party discovered that 11 tablets were missing. The responsible party contacted the facility and spoke with an LPN who had been assigned to the resident on the day of discharge. The LPN stated she had the remaining pills in a prescription bottle, which was not the facility's standard practice, as medications are typically dispensed on a unit-dose card. An internal review also revealed that another resident, recently discharged to the hospital, was missing 32 Hydrocodone tablets, and the required controlled substance sign-out sheets for both residents' medications were missing. Although the facility initiated an investigation and submitted a report through the Electronic Reporting System, the report was incomplete and lacked required supporting documentation such as witness statements and confirmation that all necessary components were included. The incomplete report was rejected by the State Survey Agency, and the facility did not submit a revised, complete investigation for review. During interviews, facility leadership was unable to provide documented evidence that the investigation was completed in full and submitted within the required timeframe.
Failure to Use Mechanical Lift Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident was free from neglect by not utilizing a mechanical lift as planned, resulting in a major injury for a resident. The resident, who had cerebral palsy, dysphagia, contractures, and cerebral infarction, required assistance with activities of daily living and was dependent on staff for transfers. The resident's care plan specified the use of a Hoyer lift for all transfers to ensure safety and prevent injury. On the evening of January 26, 2025, two agency Nurse Aides were providing care to the resident. During this time, the resident began complaining of pain in her right arm, which intensified when her shirt and bra were removed. Despite the resident's care plan requiring the use of a Hoyer lift, the aides failed to use it during the transfer from the wheelchair to the bed. This improper transfer led to a serious injury, an impacted fracture of the right humerus, as confirmed by a mobile x-ray. The facility's internal investigation revealed that both aides had completed training on the proper use of Hoyer lifts and were aware of the facility's abuse and neglect policy. However, they neglected to follow the established protocols, directly leading to the resident's injury. Interviews with the resident and her roommate confirmed that the mechanical lift was not used during the transfer, and the resident experienced significant pain and discomfort as a result.
Plan Of Correction
Preparation and/or execution of this plan of correction in general, or this corrective action does not constitute an admission of agreement by this facility of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with State and Federal laws. Upon completion of the facility's investigation, the two nursing assistants, Employee 1 and Employee 2 were DNR (Do Not Rehire) because the CNAs failed to follow the training provided through their certification, agency and facility training regarding proper use of assistive devices for transfers and abuse training. Include on the current nursing assistant Daily CNA Report the names of residents with transfer requirements for the use of lifts, e.g., safety concerns, positioning techniques, and necessary assistive devices. The Daily CNA Report will be signed by the certified nursing assistant and the charge LPN/RN. The report sheets will be given to the RN Supervisor at the end of each shift. All clinical nursing staff will be trained on the proper use of assistive devices for transfers and abuse training. Lift training will focus on hands-on practice and residents with a wide range of limitations. An approved acceptable provider has been selected to direct in-service education for F600. The Interdisciplinary Team will create a list of residents that require the use of assistive lifts for transfers. The facility will implement a system of regular observation of staff, including checking if the correct lift is being used for each resident, proper sling selection and placement, correct operation of the lift, and documenting each lift use, while providing ongoing training and education to staff on safe lift practices and report any concerns regarding lift usage. The Therapy Department will conduct a mandatory education for clinical staff on proper use of assistive devices, including the lifts. Random checks will be conducted by Director of Nursing/designee to ensure proper lift and transfer technique is being followed. All incident reports will be reviewed by the Risk Team to ensure no other evidence of noncompliance of lift usage and/or abuse has occurred. The results of the random audit checks and investigation of incident reports will be presented to QAPI monthly x 12 months.
Failure to Address Resident Grievances on Fresh Water Delivery
Penalty
Summary
Wayne Woodlands Manor was found to be non-compliant with specific requirements of 42 CFR Part 483 Subpart B and the 28 PA Code during a survey completed on February 14, 2025. The facility failed to adequately address and resolve grievances expressed by residents during Resident Council meetings. Specifically, six residents consistently reported issues with the inconsistent delivery of fresh water, a concern that was documented in the minutes of meetings held in November 2024, December 2024, and January 2025. Despite these repeated complaints, there was no documented evidence of corrective actions taken by the facility to address the issue. Interviews conducted with the Nursing Home Administrator and the Director of Nursing confirmed the absence of documented actions to resolve the grievances raised by residents. The facility's grievance policy, last revised in August 2021, states that residents have the right to voice grievances concerning their care and treatment. However, the facility failed to demonstrate efforts to resolve the complaints regarding fresh water delivery, as evidenced by the lack of documentation and the continued dissatisfaction expressed by the residents.
Plan Of Correction
Preparation and/or execution of this plan of correction in general, or this corrective action does not constitute an admission of agreement by this facility of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with State and Federal laws. The facility will review the last three Resident Council Meeting Minutes and identify resident concerns that need to be addressed and follow-up to ensure all concerns have been addressed. A policy review to reflect evidence-based practice and a performance improvement plan will be created to address the resident's concern with fresh water distribution. An audit will be done on each wing daily x 4 weeks. Water distribution will be addressed and reviewed in QAPI x 3 months. An official grievance will be filed for fresh water distribution throughout the facility for any resident who expresses a concern with their water. For Resident #15, the facility will determine her preference for water distribution and ensure her preferences and any other residents with similar issues are accommodated. The Administrative Team will review the last three months of Resident Council Meeting minutes and provide a summation of residents' issues to review with the residents in the next month's meeting. The Activities Director/designee is assigned to the Resident Council Meeting monthly. Upon completion of the meeting, the Activities Director/designee will respond and compile a list of resident issues and/or grievances expressed during the meeting. The administrative staff, to the extent practicable, will consider their recommendations and attempt to accommodate them, including revising or developing new policies related to resident life and care. Any grievances will be investigated by the Grievance Officer. After the meeting, the Activities Director/designee will ask the meeting attendees if they would like to file an official written grievance(s) related to issues discussed during the meeting. The Administrator/designee will ensure all issues addressed by the Resident Council have a documented plan of action written, signed, and dated within one week following the Resident Council concerns. Previous month plan of actions will be discussed with the Resident Council at every Resident Council Meeting by the Activities Director/designee. Following the monthly Resident Council Meeting, the Administrative Team will review concerns brought by the residents at each meeting and perform a random survey of five residents in each wing to ascertain if they are having the same concerns. The Administrative Team will review the Grievance Process. Mandatory training for all staff will be conducted by the social worker on the grievance process. A random water audit will be conducted to ensure fresh water is passed three times daily and the cup contains the initials of the resident, room number, and date. The results of the audit will be present at QAPI monthly x3. The Resident Council minutes will be reported by the Activities Director/designee at QAPI monthly for the next 12 months; concerns will be tracked, and trends will be discussed with the Interdisciplinary Team. The results of the random survey will be monitored for trends and reported to QAPI monthly x 12 months.
Failure to Implement Employee Screening Procedures
Penalty
Summary
The facility failed to fully develop and implement its established abuse prohibition procedures by not adequately screening five employees for employment. The regulatory requirements under §§483.12(a)(3) and 483.12(b)(1) mandate that the facility must have written procedures for screening prospective employees, which include reviewing employment history, obtaining information from former employers, and checking documentation of status and any disciplinary actions from licensing or registration boards. However, the facility's Resident Abuse policy, last reviewed in December 2023, required obtaining references from current or previous employers, which was not adhered to. A review of employee personnel files revealed that for five employees, including two LPNs, a Nurse Aide, a Dietary Aide, and the DON, there was no documentation showing that the facility had contacted any former employers to verify past employment. Interviews with the Administrator confirmed that there was no evidence of previous employers being contacted for information regarding the employees' past work history. This lack of verification indicates a failure to follow the facility's own abuse prohibition policy.
Plan Of Correction
Preparation and/or execution of this plan of correction in general, or this corrective action does not constitute an admission of agreement by this facility of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with State and Federal laws. Prior deficiency cannot be corrected as the identified individuals are established employees. For all potential employment candidates, the Human Resources Coordinator will contact former employers for information regarding former employment history and professional references for feedback regarding affirmation of employment. The Human Resources Coordinator will create a spreadsheet to track all new candidates and monitor the receipt of personal and professional employment references monthly. The Human Resources Coordinator will report monthly at QAPI x3.
Failure to Provide Timely Behavioral Health Care
Penalty
Summary
The facility failed to provide timely and necessary behavioral health care to two residents, leading to a deficiency in maintaining their highest practicable mental and psychosocial well-being. Resident 33, admitted with dementia, exhibited behaviors such as yelling, auditory, and visual hallucinations, which increased in frequency and intensity as noted in nursing progress notes from January and February 2025. Despite these observations, the resident's care plan, last revised in October 2024, was not updated to address the worsening symptoms, and no follow-up interventions were implemented after a psychological progress note in January 2025. Similarly, Resident 8, also diagnosed with dementia, showed behaviors including yelling, restlessness, anxiety, aggression, and crying, which escalated in early 2025. The resident's care plan, last updated in September 2024, did not reflect these changes, and no additional psychological interventions were documented following a psychological evaluation in January 2025. The Nursing Home Administrator was unable to provide evidence of psychological services aimed at maintaining or improving the residents' mental and psychosocial well-being, highlighting a failure to update care plans and provide necessary psychological services.
Plan Of Correction
Preparation and/or execution of this plan of correction in general, or this corrective action does not constitute an admission of agreement by this facility of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with State and Federal laws. Review and update Resident #33 and Resident #8 care plans to reflect any changes in behavior to ensure all interventions are person-centered based on behaviors identified. An audit will be conducted, by Social Services or designee, on all residents exhibiting behaviors to ensure individualization of person-centered care plans. All new residents, with diagnoses reflecting behavioral issues or concerns, will have individualized, person-centered care plans. The residents will be reviewed at the weekly Behavioral Meeting. Social Services will present and report at monthly QAPI monthly x3.
Failure to Prevent Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to implement procedures to prevent the misappropriation of resident property, specifically narcotic medications, for one resident. Resident 16, who was admitted with multiple rib fractures, a periprosthetic fracture, and dysphagia, had a physician order for Tramadol 50mg for chronic pain. On January 27, 2025, the pharmacy delivered 30 tablets of Tramadol 50mg to the facility for Resident 16, but the medication card and sign-out sheet went missing the same day. An investigation revealed that Employee 8, an LPN, received and signed for the delivery and placed the medications in the medication room, informing Employee 11, another LPN, of their location. However, the medications were left unattended, and Employee 11 did not recall handling the Tramadol. Video footage showed Employee 11 leaving the narcotic drawer open and unsecured while stepping away from the medication cart. Despite the controlled substance shift-to-shift count sheets confirming medications were accounted for, discrepancies were noted after the pharmacy alerted the facility of the missing medications. The facility's investigation did not include written witness statements from Employees 8 or 11, nor from other nursing staff assigned to the medication cart during the relevant period. Although Resident 16 did not miss any doses due to an existing supply, the misappropriation of medication was confirmed, and the investigation failed to identify the perpetrator responsible for the missing controlled substances.
Plan Of Correction
Preparation and/or execution of this plan of correction in general, or this corrective action does not constitute an admission of agreement by this facility of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with State and Federal laws. Prior deficiency cannot be corrected as the Tramadol was not found and the perpetrator not identified. The delivery of all narcotic medications will be checked and co-signed by the RN Supervisor/licensed designee and the LPN Charge Nurse assigned to the resident(s). If the LPN Charge Nurse is unavailable, another LPN can co-sign the narcotics. A copy of the narcotic(s) sheet, from the pharmacy will be copied and placed in a binder for the Director of Nursing. The RN Supervisor/licensed designee and LPN assigned to the resident(s) will place the narcotic in the appropriate medication cart(s) and the narcotic sheet(s) in the narcotic binder(s) located on the medication carts. The RN Supervisor and LPN co-sign placement of the narcotic in the locked box in the medication cart and on the Narcotic Medication Sheet. Educate employees on diversion awareness and recognizing indicators of impairment and diversion activity. The education program will be discipline specific and done on new employee orientation and annual mandatory education. Training will be conducted in a classroom setting and online learning modules. All incident reports will be reviewed by the Risk Team to ensure no other evidence of noncompliance of lift usage and/or abuse has occurred. The results of the random audit checks and investigation of incident reports will be presented to QAPI monthly x 12 months. The weekly Risk Management Committee will include narcotic oversight and will be responsible for developing and maintaining policies to prevent and respond to potential drug diversion while ensuring system standardization in practice, detection, security, and investigation related to controlled substances. The pharmacy will audit the Omnicell, secure dispensing cabinet and a camera above the Omnicell will be installed to identify staff members, verify opioid counting, identify a theft, and establish a time frame for investigation. The pharmacy will utilize monthly user reports to provide a list of users, wasting, overrides, and the number of controlled substances pulled. The pharmacy will notify the Director of Nursing and the Administrator of any trends or errors and report findings monthly in QAPI x 12 months. A list of all residents on narcotics will be compiled and a random audit of five residents per week will be audited for individual narcotic log maintenance and accurate narcotic counts. Weekly, a random medication cart will be inspected checking each drawer and compartment to ensure all medications are properly stored, labeled, within their expiration dates, and the cart is clean, functional, and secure, including the locking mechanism. The results of the random narcotic count audits, medication cart inspections, and narcotic sheets will be a Performance Improvement Project for Nursing and presented at QAPI monthly x 12 months.
Failure to Prevent UTIs in Resident with Indwelling Catheter
Penalty
Summary
The facility failed to provide necessary care and services to prevent urinary tract infections for a resident with an indwelling urinary catheter. Resident 65, who was admitted with a urinary tract infection and benign prostatic hyperplasia, required the use of an indwelling catheter. The facility did not document the use of a leg bag for urinary drainage during daytime hours in the resident's care plan, despite it being part of the resident's routine care. This lack of documentation indicates a failure to individualize care to meet the resident's specific needs. Additionally, during an observation, the resident's urinary drainage bag was improperly stored inside a clear garbage bag tied to the railing beside the toilet, next to another resident's drainage bag, posing a risk for cross-contamination. The Director of Nursing confirmed that the urinary drainage bags were not being cleaned or stored according to infection control guidelines, and the facility could not provide evidence of staff education on the care and maintenance of urinary drainage systems. Furthermore, the facility lacked a policy or procedure outlining infection control practices specific to urinary catheters and drainage systems.
Plan Of Correction
Preparation and/or execution of this plan of correction in general, or this corrective action does not constitute an admission of agreement by this facility of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with State and Federal laws. Prior deficiency cannot be corrected as the resident has expired. Establish a list of residents who have bedside urinary drainage bags and convert to leg bags during the daytime hours. Review the resident list to ensure their individual care plans are up-to-date. Revision of Intermittent Use of Urinary Leg Drainage Bags to include protocol for conversion to leg bag, aftercare, and storage of bedside urinary collection bags. Staff will be educated on the proper protocol for urinary leg bag conversion, emptying, cleaning, and storage of the bedside urinary drainage bag. Develop an audit tool to monitor the residents who utilize leg drainage bags to ensure their care plans are up-to-date, and audit proper disposal, cleaning, and placement of the bedside drainage bag daily. An audit of residents with indwelling Foley Catheter devices with leg bag conversions will be conducted daily, five x per week, x 3 months and results present to QAPI monthly x3.
Failure in Pain Management Protocols
Penalty
Summary
The facility failed to provide effective pain management for a resident, as evidenced by the administration of pain medication without attempting non-pharmacological interventions first. The facility's policy on pain management, which was reviewed, requires the development and implementation of both non-pharmacological and pharmacological interventions tailored to the resident's needs. However, the facility did not adhere to this policy for one resident, who was administered pain medication without documented attempts of non-pharmacological interventions. The resident in question, admitted with multiple diagnoses including cerebral palsy, dysphagia, and contractures, had a comprehensive person-centered care plan that included goals for adequate pain relief. Despite this, the facility's records showed repeated instances where pain medication was administered without prior non-pharmacological interventions. This occurred multiple times over a period from January to February 2025, with pain levels documented as moderate to severe. Interviews with the Director of Nursing confirmed the lack of adherence to physician's orders and the absence of documented non-pharmacological interventions. The facility's failure to follow its own pain management policy and physician's orders resulted in a deficiency in providing appropriate care for the resident's pain management needs.
Plan Of Correction
Preparation and/or execution of this plan of correction in general, or this corrective action does not constitute an admission of agreement by this facility of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with State and Federal laws. Identify and care plan nonpharmacological interventions for the resident's current pain management strategy. Using an interdisciplinary approach, review residents who currently receive pain medications, scheduled or as needed. Implement nonpharmacological interventions, relaxation techniques, back rub, lights, toilet, food/drink, and reposition. Education for all nursing staff to improve the quality of pain management to ensure resident outcomes enhance safety, physical and emotional functioning, and quality of life. In the development of a resident's individualized plan of care for pain management, consider a multidisciplinary approach, therapeutic, nonpharmacological interventions, and medication management. Educate clinical staff on the use of strategies for the management of pain including developing and implementing both nonpharmacological and pharmacological interventions to pain management. The Interdisciplinary Care Team will conduct five random audits weekly to review the clinical practice of pain management, including the application of nonpharmacological interventions and assessment of decrease in pain intensity, improved functional mobility, and reduction in pain-related distress. The audits will be reviewed weekly in the Risk Meeting and present monthly x3 in QAPI.
Failure to Provide Written Notice of Hospital Transfer
Penalty
Summary
The facility failed to provide a written notice of a facility-initiated hospital transfer to a resident and their representative, which is a requirement under §483.15(c)(3)-(6)(8). This deficiency was identified during a review of clinical records and facility-initiated transfer notices, as well as through staff interviews. Specifically, the deficiency involved Resident 46, who was admitted to the facility with diagnoses including atrial fibrillation, heart disease, and a fracture of the left radius and ulna styloid process. The resident was transferred to the hospital on January 6, 2025, and readmitted to the facility on January 12, 2025. Upon reviewing the clinical record, it was found that there was no documented evidence that the facility provided the resident and their responsible party with a written notice of the transfer and the reason for it. This was confirmed in an interview with the Administrator, who acknowledged the lack of documentation indicating that the resident's responsible party was informed in writing about the transfer. This failure to provide the required notice constitutes a violation of the regulatory requirements for transfer and discharge notifications.
Plan Of Correction
Preparation and/or execution of this plan of correction in general, or this corrective action does not constitute an admission of agreement by this facility of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with State and Federal laws. Deficient practice cannot be corrected as the missing transfer form cannot be located or replaced. Re-educate the nursing staff on completion of the Transfer/Discharge Form. The Business Office Manager/designee will create a spreadsheet to monitor the receipt of all Transfer/Discharge Forms compared to the Daily Census. The Business Office Manager/designee will report results of the audit to QAPI monthly x 3 months.
Failure to Report Influenza A Cases
Penalty
Summary
The facility failed to report cases of Influenza A to the appropriate health agencies and the Division of Nursing Care Facilities field office for 13 residents who tested positive. The infection control documentation revealed that residents tested positive for Influenza A on various dates from December 27, 2024, to January 18, 2025. An interview with the facility's Infection Control Practitioner and the Director of Nursing confirmed that the mandated state agencies were not notified of these positive cases, indicating a lapse in the facility's reporting protocol for reportable diseases.
Plan Of Correction
Preparation and/or constitution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. The Administrator corrected the deficiency by reporting the influenza cases to the DOH on 12/27/24 at 0800, Event Number: 1066952. The Infection Control Nurse, Director of Nursing, Administrator, and Assistant Administrator reviewed and were educated on the PA regulations regarding ERS reporting requirements. § 27.21a. Reporting of cases by health care practitioners and health care facilities. (2) Influenza is reportable within 5 working days after being identified by symptoms, appearance, or diagnosis. Examination of the prior 24-hour clinical report and the daily Interdisciplinary Clinical Team Meeting will discuss any residents who exhibit signs of influenza, e.g., fever, chills, cough, sore throat, rhinorrhea, muscle/body aches, headaches, fatigue, vomiting, or diarrhea, and the need for diagnostic testing. If diagnosis is confirmed, treatment, isolation, and state reporting within 5 working days will be completed. Facility follows the Infection Control Guidance set for by the Centers for Disease Control and Prevention. The Infection Control Nurse has created a log of any reportable diseases, infections, and conditions. An additional checkbox will be added to the Infection Preventionist's Infection Control Log to indicate any reportable diseases have been or need to be submitted to the Department of Health. Infection Control and Nursing Administration reviewed all cases; there were no additional reportable events required. The Infection Preventionist will report monthly x three months to QAPI to ensure regulatory compliance in reporting infectious diseases has been met. The Infection Preventionist's log will be reviewed by QAPI team and the Administrator to ensure reporting requirements have been met.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, resulting in psychosocial harm. The incident involved a resident who was moderately cognitively impaired, with a BIMS score of 7, and had medical conditions including atherosclerotic heart disease and diabetes. The resident reported to a nurse aide that a man entered her room during the night, pinned her down, and sexually assaulted her. The resident was found with her pajama bottoms at her knees and expressed pain and fear, refusing a physical assessment at the facility. The facility's investigation revealed that the resident was taken to the hospital for a SANE examination, which documented abrasions, lacerations, and bruising consistent with sexual assault. The facility's deployment sheet indicated that there was one male agency nurse aide on duty during the shift when the incident occurred. The resident's statement and subsequent interviews confirmed the assault, although the resident could not describe the assailant due to the darkness in the room. The facility's documentation and witness statements from staff members did not provide a clear account of the events during the night shift. The Director of Nursing confirmed the occurrence of the sexual assault and the resulting psychosocial harm to the resident. The facility's failure to protect the resident from abuse was a significant deficiency, as outlined by the relevant Pennsylvania Code sections.
Failure to Provide Abuse Prevention Training to Agency Staff
Penalty
Summary
The facility failed to provide abuse prevention training to agency nursing staff, specifically for two employees, Employee 3 and Employee 8. Employee 3, an agency nurse aide, began working at the facility on November 13, 2023, and has been working steadily since then. Employee 8, an agency registered nurse, stated during an interview on August 5, 2024, that he had been working at the facility for three months without receiving training on the facility's abuse prohibition policy. There was no documentation to confirm that Employee 8 was trained on the facility's abuse prohibition policies and procedures as part of staff orientation. The facility staffing coordinator confirmed that while she verifies agency staff credentials, such as background checks and nursing licenses, she does not request any abuse training. The facility relies on agency staff to maintain adequate staffing ratios but could not provide evidence of abuse training for any agency staff currently working at the facility. The Director of Nurses confirmed that agency staff are not trained on the facility's policy and procedures as part of staff orientation before assuming their duties.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to submit a timely and thorough investigation of an alleged sexual abuse incident involving a resident. The resident, who was moderately cognitively impaired, reported to a nurse aide that a man had entered her room during the night and sexually assaulted her. The nurse aide and an LPN reported the incident to the Director of Nursing (DON), who attempted a physical assessment, but the resident was too distressed to proceed. The resident was then sent to the hospital for evaluation, and relevant authorities were notified. However, the facility did not conduct interviews with all staff on duty during the alleged incident, and there was no documented evidence of a completed investigation in the resident's clinical record. The DON confirmed that the facility had not conducted a thorough investigation into the incident, despite the resident's allegations and symptoms. There was no documented evidence of a completed abuse investigation or corrective actions taken to prevent further potential abuse. The lack of documentation and follow-up was confirmed during an interview with the DON, indicating a failure to adhere to the facility's policy on abuse prevention and investigation.
Failure to Update Care Plan for Aggressive Behaviors
Penalty
Summary
The facility failed to timely develop and implement a person-centered care plan to address the aggressive behaviors of a resident diagnosed with dementia with behavioral disturbance. The resident, who was severely cognitively impaired with a BIMS score of 3, required assistance for activities of daily living. Despite these needs, the resident's care plan, initially dated July 4, 2023, did not include any reference to her physically aggressive behaviors. This oversight was highlighted following an incident on July 26, 2024, when the resident exhibited aggressive behavior during an outing with her son, resulting in physical altercations and injuries. The incident report revealed that the resident's son, who had not seen his mother in a while, was unprepared to manage her aggressive behavior. Upon returning to the facility, the son reported that the resident had become violent, leading to a physical confrontation. The nursing staff documented bruising and a skin tear on the resident, who had no recollection of the event. The Director of Nursing confirmed that the resident's aggressive behaviors were not addressed in her care plan, and there was no evidence that the son had been informed or educated about these behaviors prior to the outing.
Incomplete Documentation of Resident Incident
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who was moderately cognitively impaired and had a history of atherosclerotic heart disease and diabetes. During a quarterly Minimum Data Set assessment, the resident was found to have a BIMS score of 7, indicating moderate cognitive impairment. An incident occurred where the resident reported to a nurse aide that a man had entered her room during the night and sexually assaulted her. The nurse aide reported this to an LPN, and both informed the Director of Nursing (DON). Attempts to conduct a physical assessment were unsuccessful as the resident became distressed and refused to undress. The resident's brief, which was soaked with urine, was preserved as evidence, and the State Police, Physician, responsible party, and Department of Aging were notified. The resident was subsequently taken to the hospital for evaluation. The deficiency was identified during a review of the resident's clinical records and staff interviews, which revealed that the facility did not document the incident comprehensively. The DON confirmed that the clinical record lacked complete and accurate documentation regarding the incident. The absence of detailed documentation in the resident's clinical record was a significant oversight, as it failed to provide a full account of the events and actions taken following the reported incident. This lack of documentation was a violation of accepted professional standards for maintaining medical records.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to timely report an alleged abuse incident involving a resident with dementia, depression, and muscle weakness, who was severely cognitively impaired and used a wheelchair for mobility. On May 16, 2024, a nurse aide, identified as Employee 1, was reported to have held the resident by the back of their sweater and screamed at them. Despite being escorted out of the building, Employee 1 was later allowed to return to duty. The incident was witnessed by other staff members, who provided statements describing the resident's distress and Employee 1's actions, including pulling the resident by their sweater and wheelchair down the hallway. The facility's policy required that allegations of abuse be reported to the State Survey Agency within 24 hours, but this was not done until May 28, 2024, after surveyor inquiry. The nursing home administrator and director of nursing confirmed the incident and the failure to report it in a timely manner. The facility's policy also required immediate notification of the Area Agency on Aging and local law enforcement in cases of abuse, but there was no documented evidence that these steps were taken promptly. The deficiency was identified as a failure to adhere to the facility's abuse prevention and reporting procedures.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to promptly conduct a thorough investigation and report an alleged abuse incident involving a resident to the State Survey Agency within the required timeframe. The incident involved a nurse aide, Employee 1, who was reported to have physically and verbally abused a resident with dementia, depression, and muscle weakness. The resident was severely cognitively impaired and used a wheelchair for mobility. On the day of the incident, Employee 1 was seen holding the resident by the back of her sweater and screaming at her, which led to the resident crying and expressing distress. Despite the severity of the allegations, the facility did not follow its own abuse prevention policy, which mandates immediate investigation and reporting of such incidents. Although Employee 1 was initially removed from the building, she was later allowed to return to duty without a completed investigation. The facility obtained statements from staff on the day of the incident but failed to report the alleged abuse to the State Survey Agency within the required five working days. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the facility's failure to provide evidence of a timely and complete investigation. The facility did not submit the results of the investigation to the State Survey Agency as required, violating several state codes related to the responsibility of the licensee, management, and resident rights.
Failure to Implement Restorative Nursing Program and Apply Ankle Support
Penalty
Summary
The facility failed to provide restorative nursing services and devices to maintain mobility and range of motion for Resident 34. The resident, who was admitted with diagnoses including difficulty in walking, abnormal posture, osteoarthritis, and muscle weakness, was discharged from physical therapy with recommendations for a restorative nursing program (RNP). However, there was no documented evidence that an RNP was developed or implemented. Additionally, the resident had a physician's order for an ankle stirrup to be applied when out of bed, but observations revealed that the device was not being used as required. Interviews with the resident and staff confirmed that the ankle support was not being applied, and the resident expressed concerns about the lack of an RNP and the potential impact on her mobility. Further observations and interviews confirmed that the facility did not follow through with the physical therapy recommendations or the physician's order for the ankle stirrup. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) acknowledged that the RNP was not implemented and that the support device was not being applied by staff. The Director of Therapy also confirmed that the resident was supposed to use the ankle support device for stability during ambulation and transfers, but this was not being done. The facility's failure to provide the necessary restorative nursing services and devices resulted in a deficiency in maintaining the resident's level of function.
Failure to Implement Infection Control Practices
Penalty
Summary
The facility failed to maintain infection control practices to prevent the spread of infection for three residents. Resident 75, who had a urinary tract infection and multiple pressure ulcers, was observed without Enhanced Barrier Precautions (EBP) for his pressure ulcer and indwelling catheter. Despite a physician's order for an indwelling catheter and subsequent complications, including septic shock and a urinary tract infection caused by Serratia marcescens, the facility did not implement the necessary infection control measures. Resident 70, diagnosed with diabetes mellitus and urinary retention, also had an indwelling catheter and a left gluteal fold abrasion. Observations revealed an opened bottle of normal saline solution on the resident's dresser without a date or time of opening, contrary to facility policy. There was no evidence that EBP was implemented for the resident's wound and indwelling catheter, as required. Resident 24, with diagnoses including Guillain Barre Syndrome, chronic stage 4 pressure ulcers, a suprapubic indwelling catheter, and a colostomy, was also not provided with EBP. Multiple observations confirmed the absence of EBP for the resident, despite the need due to the presence of external devices and chronic conditions. The Director of Nursing and the Nursing Home Administrator confirmed the facility's failure to identify and implement the necessary precautions for these residents.
Failure to Notify Resident's Representative of Significant Weight Loss
Penalty
Summary
The facility failed to timely notify the resident's interested representative of a significant weight loss for Resident 26. Resident 26, who was admitted with a diagnosis of Parkinson's disease, experienced a weight decrease from 149 lbs on June 3, 2023, to 130.2 lbs on December 3, 2023, amounting to a 12.4% loss of body weight over six months. Although the resident's attending physician was informed of the weight loss on December 20, 2023, there was no documented evidence that the resident's representative was notified. This deficiency was confirmed during an interview with the Nursing Home Administrator on April 4, 2024.
Failure to Address Significant Weight Loss in Care Plan
Penalty
Summary
The facility failed to address a significant weight loss in a resident's comprehensive care plan. Resident 26, who was admitted with a diagnosis of Parkinson's disease, experienced a weight loss from 149 lbs to 130.2 lbs over six months, a 12.4% decrease in body weight. Despite this significant weight loss, the resident's care plan did not include any measures to address the decline in nutritional status. This deficiency was confirmed during an interview with the Nursing Home Administrator and Director of Nursing, who acknowledged that the care plan did not address the resident's weight loss and nutritional needs.
Failure to Timely Identify and Treat Pressure Sores
Penalty
Summary
The facility failed to timely identify, assess, and treat a pressure sore for Resident 24. The resident, who had a history of hypertension, type II diabetes, and congestive heart failure, was found to have an open area on the right buttock. Despite the discovery, there was no documented evidence that a thorough assessment was completed by a registered nurse (RN) or that timely treatment orders were obtained and implemented. The facility also lacked documentation of consistent monitoring and wound tracking for the resident's pressure sore, as confirmed by the Assistant Director of Nursing (ADON) and the Nursing Home Administrator (NHA). For Resident 13, who had a history of a left hip fracture and dementia, the facility failed to consistently monitor skin integrity related to the use of a knee immobilizer. The resident was admitted with a left knee immobilizer and was at moderate risk for skin breakdown. Despite this, there was no evidence that the facility monitored the resident's skin during the application and removal of the immobilizer. This oversight led to the development of a pressure wound on the left calf, which was later identified and treated by a wound care physician. The deficiencies were confirmed through clinical record reviews, staff interviews, and observations. The facility was unable to provide documented evidence of timely and thorough assessments, consistent monitoring, and appropriate treatment for the pressure sores of both residents. These failures were acknowledged by the ADON and the Director of Nursing during the survey.
Failure to Administer and Maintain Oxygen Therapy
Penalty
Summary
The facility failed to consistently administer oxygen as ordered and maintain sanitary oxygen delivery systems for Resident 85. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease (COPD) and acute and chronic respiratory failure with hypoxia, had a physician's order for continuous oxygen therapy at three liters per minute via nasal cannula. Facility policy required that the oxygen setup, including the nasal cannula and humidifier, be changed and dated weekly. However, observations on multiple occasions revealed that the nasal cannula tubing was not dated according to facility policy, and the resident was not receiving oxygen as ordered. Specifically, on one occasion, the nasal cannula was found under three blankets on the bed next to the resident, who was seated in a wheelchair without the nasal cannula on, despite the oxygen concentrator being turned on. Interviews with the Certified Nurse Aide (CNA), Director of Nursing (DON), and Nursing Home Administrator (NHA) confirmed that the physician's order for supplemental oxygen was not followed for Resident 85 and that the oxygen equipment was not maintained as per the facility's policy. The facility's failure to adhere to the prescribed oxygen therapy and maintain sanitary oxygen delivery systems was in violation of the facility's own policies and state regulations, specifically 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services and 28 Pa. Code 211.10 (a)(c)(d) Resident care policies.
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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