West Park Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 4401 Haverford Avenue, Philadelphia, Pennsylvania 19104
- CMS Provider Number
- 395686
- Inspections on file
- 32
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at West Park Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, severe cognitive impairment, and identified risk for altered skin integrity developed open areas on the right buttock and right anterior thigh. Facility policy required full assessment and documentation of pressure sores, including staging and measurements, and practitioner-ordered wound treatments. However, the right buttock wound lacked measurements and staging, and the right anterior thigh wound, documented as 3 cm x 3 cm, had no further description or stage and no corresponding treatment on the MAR. The DON confirmed that no treatment was provided for the thigh wound, indicating a failure to follow the facility’s pressure ulcer assessment and treatment protocol.
Staff failed to follow infection control policies and MD orders for enhanced barrier and airborne precautions for two residents. One resident with a PEG tube and multiple neurologic and respiratory diagnoses had an order for enhanced barrier precautions, but a CNA was observed providing direct morning care without wearing a gown as required. Another resident with a positive TB test had an order for airborne precautions specifying gown, mask, face shield, and gloves, yet an RN/LPN was observed in the room in contact with the resident wearing only a mask and no gown or face shield.
The facility did not maintain a working resident call system in all required areas, as surveyors observed non-functioning call bell devices in two resident rooms on the same unit. In one room, a resident reported that the call bell had been inoperative for several days, and in another room the call bell was also found not to work. These issues were confirmed with an LPN during the survey, resulting in a deficiency under the administrator’s responsibility requirements.
A resident with dementia, impaired mobility, muscle weakness, a history of falls, and moderate cognitive impairment, who used a wheelchair for locomotion and was care planned as high risk for falls, was transported to their room by a nurse aide without wheelchair leg rests in place, contrary to facility practice. While appearing sleepy during transport, the resident placed a foot on the floor and fell forward from the wheelchair, sustaining a forehead hematoma and periorbital contusion requiring hospital evaluation. Facility documentation from the date of the incident lacked statements describing the event or contributing factors, and later staff interviews confirmed that leg rests were not applied during the transport despite policy and practice requiring their use.
Surveyors found that the facility did not maintain its fire alarm system in operable condition, with issues such as failed battery load tests, a non-functioning buzzer at the FACP, improperly connected horn strobes, missing required signage at pull stations, and malfunctioning smoke and heat detectors. Facility leadership confirmed these deficiencies were not corrected at the time of review.
Surveyors observed that a courtyard exit egress door was secured with a combination padlock, which did not meet NFPA 101 requirements. The issue was confirmed by facility leadership and had been previously identified earlier in the year.
The facility did not provide documentation of the required semi-annual inspection for the kitchen hood suppression system, as confirmed during a review and interview with facility leadership. This deficiency affected one of two inspection reports.
A portable fire extinguisher next to a resident room was found to be blocked during an observation, and this was confirmed by facility leadership during the exit interview.
Surveyors identified that the facility did not maintain required inspections or corrective actions for fourteen fire and smoke dampers in the HVAC system, with issues such as non-functioning motors, missing dampers, and inadequate fire wall protection remaining unaddressed at the time of survey.
An electrical panel inside the nurse station supply closet was found to be blocked by a large cart, making it inaccessible in violation of NFPA 70 requirements. This was confirmed by facility leadership during the survey.
Surveyors found that the facility, classified as a five-story Type II (000) unprotected non-combustible building with a basement, exceeded the maximum allowable number of stories for its construction type, despite being fully sprinklered. This non-compliance with NFPA 101 fire resistance requirements was confirmed by facility leadership and affects the entire building.
The facility did not timely update care plans for three residents, resulting in deficiencies related to fall prevention, hospice care, and oxygen therapy. One resident with osteoporosis and repeated falls did not have their care plan revised after a recent fall. Another resident receiving hospice services lacked care plan interventions for comfort and coordination with hospice. A third resident's care plan listed an incorrect oxygen flow rate compared to current orders and observed use. The DON confirmed these care plans were not updated as required.
A resident with severe cognitive impairment and a history of malnutrition and weight loss did not receive physician-ordered snacks at scheduled times. Observations and staff interviews confirmed that the required snacks were not provided, resulting in noncompliance with physician orders.
A resident with left-sided hemiplegia and hemiparesis did not receive physician-ordered ROM devices, including a left elbow extension splint and hand roll, due to inaccurate order entry and lack of staff training. The devices were not applied as required, and staff were unable to access the orders or confirm proper application procedures.
Staff did not administer pain medication according to physician orders for a resident with hemiplegia, hemiparesis, COPD, and pain. Percocet was given for pain levels lower than specified in the order, as confirmed by the DON.
A resident with a history of schizophrenia, epilepsy, and PTSD, who had disclosed past sexual abuse and violence, was not provided with a care plan that identified specific trauma triggers or individualized interventions. Despite documentation of the resident's traumatic experiences, the facility failed to implement trauma-informed care or develop strategies to prevent re-traumatization, as confirmed by interviews with the DON and administrator.
A resident discharged with ongoing care needs did not have a complete discharge summary provided to the next care provider. The summary lacked medication reconciliation and did not include the required signature from the resident or responsible party, with a nurse signing in their place. Special care instructions were reviewed with the family after discharge, and there was no evidence the summary was conveyed at the time of discharge.
A resident admitted with a tracheostomy and epilepsy did not have a baseline care plan developed to address immediate needs for tracheostomy care and seizure precautions, despite physician orders and nursing documentation indicating these interventions were performed. The care plan lacked documented goals and interventions for these conditions, contrary to facility policy.
The facility failed to serve food and drink at palatable temperatures, as required by policy. A resident reported warm juices and milk, and a resident council meeting revealed concerns about consistently cold and repetitive meals. A test tray confirmed that several food items were outside the acceptable temperature range, which was acknowledged by the Food Service Director.
The facility failed to follow food safety protocols, as observed during a kitchen tour. A cook used a green cutting board, meant for vegetables, to cut chicken, violating the protocol for preventing cross-contamination. Additionally, several food items in the refrigerator were undated and unlabeled, breaching the facility's policy on labeling and dating food items. These issues were confirmed by the Food Service Director.
A facility failed to assess a resident's ability to self-administer medication, despite a physician's order allowing unsupervised use of Asper-Flex Cream. The facility's policy requires an interdisciplinary team to evaluate a resident's capacity for self-administration, but no assessment was documented for this resident. The Director of Nursing confirmed the oversight, which was also noted in a pharmacy consultant's report.
The facility failed to maintain a clean and homelike environment, with observations of dirty rooms, mouse traps, and a shortage of essential supplies like washcloths and linens. Residents reported inadequate cleaning and supply shortages, confirmed by staff interviews and observations.
The facility failed to provide necessary bathing and feeding assistance to two residents. One resident, with intact cognitive status, received inadequate bathing support despite being scheduled for regular showers. Another resident, who required assistance due to cognitive impairment and physical limitations, was left without help during meals, leading to untouched food trays and attempts to eat independently. Staff interviews confirmed the need for assistance, yet observations showed a lack of support.
A resident with anemia and dementia was found with an open bottle of Dakin's wound care solution next to their lunch tray, which they mistakenly identified as water. An LPN confirmed the bottle contained medication and acknowledged that wound care supplies should not have been left in the resident's room.
A facility failed to provide appropriate respiratory care for a resident, as observed during a survey. The oxygen tubing was found on the floor, not stored in a treatment bag, and had not been changed as per the physician's order. Additionally, a nebulizer mask was outdated, indicating non-compliance with the facility's policy. These observations were confirmed by an LPN present during the survey.
The facility failed to implement pharmacy review recommendations for two residents. A resident was repeatedly administered Nifedipine despite a physician's order to hold the medication if the heart rate was below 60, as noted in pharmacy reviews. Another resident lacked a required assessment for medication self-administration, confirmed by the DON. These deficiencies indicate a failure in medication management.
A resident was not provided with the prescribed nectar thick liquids as per the physician's order. Observations revealed that the resident received thin liquids on two occasions, despite facility policy requiring communication of thickened liquid orders to the dietary department. Staff interviews confirmed the resident's need for nectar thick liquids, and the DON removed the incorrect liquid from the resident's room.
The facility failed to provide adequate dining space for residents on the third and fourth floors, leading to congestion and limited movement during meal services. An LPN noted that the dining room could only accommodate 12 to 14 residents, despite there being 57 residents on the floor. A resident expressed a desire to eat in the dining room, but space limitations prevented this. The Nursing Home Administrator confirmed the issue and the temporary non-use of additional dining rooms.
A resident expressed a desire to transfer to another facility, but the LTC facility failed to provide the necessary social services to assist with this request. Despite the resident's cognitive intactness and her daughter's repeated requests for assistance since admission, the social worker was unaware of the need for discharge planning. The care plan lacked a discharge plan, and there was no follow-up from social services, leading to a deficiency in meeting the resident's needs.
A resident with multiple health conditions, including a history of falls, was injured during a transfer from bed to chair using a Hoyer lift. The transfer was conducted by a single nurse aide, contrary to the facility's policy requiring two staff members. The lift tipped, causing the resident to fall and sustain a head injury. Staff statements confirmed the nurse aide did not seek assistance, leading to the incident.
A resident with multiple health conditions sustained a head injury during a transfer using a Hoyer lift when a nurse aide attempted the procedure alone, contrary to facility policy requiring two staff members. The lift tipped, causing the injury, and the incident was witnessed by the resident's roommate and confirmed by staff interviews.
The facility did not send required discharge notifications to the state LTC ombudsman for transfers and discharges from January to July 2024. This was confirmed by the Executive Director during an interview.
The facility did not ensure a resident's rights were exercised regarding their dialysis schedule. The resident preferred early morning sessions, but the facility changed it to a later time without documented evidence of mutual agreement.
The facility failed to provide adequate treatment and care for a midline catheter for a resident, as the dressing was not changed between March 13 and March 29, 2024, despite a physician's order to change it weekly. This lapse was confirmed by the DON.
The facility failed to administer oxygen therapy according to professional standards for two residents. One resident had outdated oxygen tubing, and another had a dirty oxygen condenser with a thick gray coating of dust.
The facility failed to ensure that a resident with End Stage Renal Disease received dialysis treatment and medication as ordered. The resident missed a scheduled dialysis session due to the lack of an escort and did not receive scheduled medications because they were at dialysis. These deficiencies were confirmed by the DON.
The facility failed to provide adequate pharmaceutical services for three residents, resulting in medication errors and unavailability. One resident received a double dose of medications, another did not receive a prescribed medication for four days, and a third resident's medication was unavailable during administration.
The facility failed to develop and maintain policies and procedures for timely responses to pharmacist recommendations, resulting in delays in addressing medication regimen review recommendations for a resident. Recommendations to evaluate Seroquel dosage and add a stop date for Buspar were not addressed for several weeks.
The facility failed to offer and/or provide the pneumococcal immunization to two residents, despite their eligibility and lack of contraindications. The Director of Nursing confirmed the absence of documented evidence that the vaccine was offered or administered.
Failure to Assess and Treat Resident’s Pressure-Related Wounds
Penalty
Summary
The facility failed to provide ordered treatment and complete assessment for pressure-related skin breakdown for a resident at risk for altered skin integrity. Facility policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers and to perform a full assessment of any pressure sore, including location, stage, measurements, exudate, necrotic tissue, mobility status, current treatments, and support surfaces, with practitioners ordering appropriate wound treatments. The resident had multiple diagnoses including Type 2 diabetes mellitus with hyperglycemia, chronic kidney disease stage 3, atherosclerotic heart disease, prior cerebral infarction with dysphagia, and severe cognitive impairment (BIMS score of 0). The comprehensive care plan identified risk for altered skin integrity related to incontinence and impaired mobility, with interventions such as biweekly skin audits, reporting skin changes to the physician, and use of pressure-reduction devices. Despite these identified risks and care plan interventions, documentation showed that on one date in early February an open area on the resident’s right buttock was noted without any measurements, description, or staging. Later in February, wound tracking documented an open area on the resident’s right anterior thigh measuring 3 cm x 3 cm, again without any additional description or staging. Review of the February medication administration record revealed no evidence that any treatment was obtained or provided for the right anterior thigh wound. In an interview, the DON confirmed that no treatment had been provided for this 3 cm x 3 cm wound, demonstrating a failure to follow the facility’s pressure ulcer/skin breakdown protocol and to obtain and implement wound treatment for the identified open area.
Failure to Implement Enhanced Barrier and Airborne Precautions
Penalty
Summary
The facility failed to implement its infection prevention and control policies related to enhanced barrier precautions and airborne precautions for two residents. Facility policy on Enhanced Barrier Precautions requires staff to wear gown and gloves when providing care to residents with indwelling medical devices, including feeding tubes, regardless of MDRO status. Resident R2’s record showed diagnoses including anoxic brain damage, persistent vegetative state, COPD, dysphagia following cerebral infarction, and the presence of a gastrostomy feeding tube, with a physician’s order dated January 17, 2026, for enhanced barrier precautions related to the feeding tube. On March 30, 2026, at 10:20 a.m., a nursing aide (Employee E4) was observed providing direct morning care to this resident without wearing required PPE such as a gown, and this was confirmed by the unit manager (Employee E3). The facility’s policy on Categories of Transmission-Based Precautions states that airborne precautions, in addition to standard precautions, must be implemented for residents with infections transmitted by airborne droplet nuclei, such as tuberculosis, and that these precautions are to be used when more stringent measures than standard precautions are needed. Resident R3 was placed on airborne precautions after testing positive for tuberculosis, with a physician’s order dated March 23, 2026, specifying airborne precautions for tuberculosis, including gown, face mask, face shield, and gloves. On March 30, 2026, at 10:40 a.m., a licensed nurse (Employee E5) was observed in contact with this resident in the resident’s room wearing only a mask, without the ordered gown or face shield, and this observation was confirmed by the unit manager (Employee E3). These observations demonstrated noncompliance with the facility’s own infection control policies and physician orders for both enhanced barrier and airborne precautions.
Non-functioning Call Bell Devices in Resident Rooms
Penalty
Summary
The facility failed to maintain the resident call bell system in working condition in resident bathrooms and bathing areas for two of ten rooms observed. During a tour of the fourth floor on January 28, 2026, at 11:53 a.m., the call bell device in room [ROOM NUMBER], Bed D, was found to be non-functioning. The resident in that bed (R2) stated that the call bell had not been functioning for a few days. At 11:57 a.m. the same day, the call bell device in room [ROOM NUMBER], Bed B, was also observed to be non-functioning. These findings were confirmed at 11:57 a.m. with E3, a licensed nurse. The deficiency was cited under 28 Pa Code 207.2(a), Administrator's responsibility. The deficiency centers on the inoperative call bell devices identified through direct observation and resident and staff interviews, demonstrating that the facility did not ensure that a working call system was available in each resident's bathroom and bathing area as required.
Failure to Use Wheelchair Leg Rests During Transport Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure a resident was provided with necessary wheelchair equipment, specifically leg rests, to ensure safety and proper positioning during transport. Facility policy on assistive devices and equipment stated that devices such as wheelchairs are to be provided based on comprehensive assessment and documented in the care plan, and that staff are to be trained and competent in their use. The resident involved had dementia, difficulty walking, muscle weakness, a history of falls, and used a wheelchair for locomotion. A quarterly MDS showed the resident required assistance with mobility and had moderate cognitive impairment. The resident’s care plan identified high fall risk related to confusion and psychoactive drug use, with interventions including supervised out-of-bed time and physical therapy for mobility and trunk control. On the date of the incident, nursing notes documented that the resident was taken to their room by a nurse and fell forward to the floor, resulting in a large hematoma on the left forehead and subsequent transfer to the hospital, where a left frontal scalp hematoma and periorbital contusion were diagnosed. Facility documentation from that date did not include resident or staff statements describing the incident or contributing factors. In later interviews, the OT and Director of Rehabilitation confirmed that facility practice requires wheelchair leg rests to be applied during transport by nursing staff, regardless of whether residents can self-propel. An LPN and a nurse aide both reported that while the aide was transporting the sleepy resident to their room for bedtime, the resident placed a foot down and fell forward, and both confirmed that the wheelchair leg rests were not present or applied at the time of transport. This failure to apply wheelchair leg rests during transport led to the resident’s foot contacting the floor and the subsequent fall and injury.
Failure to Maintain Operable Fire Alarm System Components
Penalty
Summary
The facility failed to maintain fire alarm system components in operable condition, as evidenced by a review of documentation and interviews. The fire alarm report identified several deficiencies, including failed load tests for Altronix BPS batteries in the first floor utility closet and electrical room, a non-functioning piezoelectric buzzer at the fire alarm control panel (FACP), and horn strobes on the fifth floor not being properly tied into the FACP soft key NAC disablements. Additionally, multiple pull stations throughout the building were missing the required 'in case of fire, call 911' signage, with approximately 23 signs absent. Further deficiencies included a smoke detector at the top of the center stairs that failed and was reported as a supervisory issue, and a heat detector in the hall by the boiler that failed and was incorrectly labeled on the FACP. During the exit interview, the administrator and maintenance directors confirmed that these fire alarm deficiencies had not yet been corrected, affecting the entire facility.
Plan Of Correction
EES was scheduled to be on site the week of January 12, 2026, to review and correct all identified fire alarm maintenance items, including panel notifications, documentation, and system reporting. A full inspection report will be retained in the Life Safety binder. The maintenance director will perform weekly audits for 4 weeks and then monthly audits for 2 months to ensure the facility fire alarm system components remain in operable conditions.
Improper Locking of Courtyard Exit Egress Door
Penalty
Summary
The facility failed to maintain proper exit egress on one of the courtyard exit doors. During an observation on the first floor, surveyors found that the exit gate door leading to the outside courtyard was secured with a combination padlock. This locking arrangement did not comply with NFPA 101 requirements for egress doors, which prohibit locks that require a tool or key from the egress side unless specific special locking arrangements are met. The deficiency was confirmed during an exit interview with the Administrator, Regional, and Local Maintenance Director, who acknowledged that the combination padlock was discovered during the survey. It was also noted that this was the second time within the same calendar year that the issue had been identified by surveyors.
Plan Of Correction
The combo pad lock on the exit gate door was immediately removed. The facility will replace this with a magnetic locking system. Plans for the magnetic locking system will be forwarded to Life Safety Plan Review for approval. The maintenance director will provide education to all staff on proper egress requirements and emergency access. The maintenance director or designated designee will perform weekly audits for 4 weeks and then monthly for 2 months on all egress doors to ensure ongoing compliance. Expected date of completion: 2/18/2026
Failure to Maintain and Inspect Kitchen Hood Suppression System
Penalty
Summary
The facility failed to maintain and inspect the kitchen hood suppression system as required. During a document review, it was found that the facility could not provide documentation of the semi-annual testing of the kitchen hood suppression system within the required six-month interval. This deficiency was confirmed during an exit interview with the Administrator, Regional, and local Maintenance Director. The lack of documentation affected one of two inspection reports reviewed.
Plan Of Correction
The kitchen hood suppression system remains operational and compliant. Inspection documentation was reviewed and updated. Preventive maintenance scheduling has been reinforced, and documentation will be maintained on site. The maintenance director and dietary director will be re-educated on the importance of maintaining documentation of the semi-annual kitchen hood suppression system testing that should occur every 6 months. The maintenance director or designated designee will perform bi-yearly audits to ensure the semi-annual kitchen hood suppression system testing is being completed and that documentation is maintained. Date of completion: 2/16/2025
Blocked Portable Fire Extinguisher Identified
Penalty
Summary
A deficiency was identified when, during an observation, a portable fire extinguisher located next to room 425 was found to be blocked. This issue was noted on one of the six levels within the facility. The finding was confirmed during an exit interview with the Administrator, Regional, and local Maintenance Director. No additional details regarding residents, staff, or specific patient conditions were provided in the report.
Plan Of Correction
The facility immediately freed the fire extinguisher next to room 425 from blockage. The maintenance director will re-educate all staff on maintaining clear access to all fire extinguishers. The maintenance director or designated designee will perform weekly audits for 4 weeks and then monthly audits for 2 months to ensure the facility is maintaining clear access to all fire extinguishers. Date of completion: 2/16/2026
Failure to Address Fire Damper Deficiencies in HVAC System
Penalty
Summary
The facility failed to maintain required inspections and corrective actions for its Heating, Ventilating, and Air Conditioning (HVAC) equipment, specifically affecting fourteen fire and smoke dampers. During a document review, it was found that a previous fire damper inspection report listed multiple deficiencies, including dampers with no power to the motor, motors that did not actuate and required replacement, missing dampers, dampers located outside of fire walls, dampers that did not fall and required replacement, and missing duct access doors. Additionally, some walls did not extend to the deck or had missing sheetrock, further compromising the integrity of the fire protection system. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Directors, who acknowledged that the issues identified in the inspection report had not been addressed or corrected at the time of the survey. The lack of corrective action for these deficiencies resulted in the facility not meeting the required standards for HVAC system maintenance and fire safety as outlined by NFPA 101.
Plan Of Correction
NotSpecified The facility reached out to LLS and Reed Electric to correct all identified fire damper deficiencies. Repairs and reinspection are due to be completed the week of January 12th, 2026. Documentation will be retained for life safety review. The maintenance director or designated designee will perform weekly audits for 4 weeks and then monthly for 2 months to ensure fire damper compliance. Date of completion: 2/16/2026
Electrical Panel Blocked by Cart in Nurse Station Supply Closet
Penalty
Summary
During an observation on the second floor of the facility, it was found that an electrical panel located inside the nurse station supply closet was blocked by a large cart. This observation was made on December 22, 2025, at 12:25 p.m. The presence of the cart obstructed access to the electrical panel, which is a violation of NFPA 70 2011 Section 110.26, requiring electrical panels to be accessible. The deficiency was confirmed during an exit conference with the Administrator and Maintenance Director later that day. No information regarding residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
The obstructing cart was removed immediately, freeing the 2nd floor electrical panel of blockage. The maintenance director will re-educate all staff on maintaining clear access to all electrical panels. The maintenance director or designated designee will perform weekly audits for 4 weeks and then monthly audits for 2 months to ensure the facility is maintaining clear access to all electrical panels. Date of completion: 2/16/2026
Non-Compliance with Fire Resistance Rating Due to Excessive Building Height
Penalty
Summary
Surveyors determined that the facility failed to maintain compliance with the fire resistance rating requirements for building construction as outlined in NFPA 101. During document review and observation, it was found that the facility is a five-story building with a basement, classified as Type II (000) unprotected non-combustible construction, and is fully sprinklered. According to the applicable code, this construction type is not permitted to exceed one story, even if sprinklered, but the facility exceeds this limit by three stories. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Directors, who acknowledged that the building's story height does not meet the maximum allowance for its construction type. The deficiency affects the entire facility, as the building's structure does not align with the required fire safety standards for its classification.
Plan Of Correction
On CMS guidance, a Time Limited Waiver will be initiated related to this deficient practice. Subsequently, CMS changed the FSES calculation, relieving health care occupancies of the NFPA standard requiring fire-protective coating for structural steel supports in buildings of five stories or more. A life safety consultant will be contracted to perform an updated FSES related to this deficient practice.
Failure to Timely Review and Revise Care Plans for Safety, Hospice, and Oxygen Needs
Penalty
Summary
The facility failed to review and revise care plans in a timely manner for three residents, resulting in deficiencies related to safety needs, hospice care, and oxygen use. For one resident with osteoporosis and a history of falls, the care plan was not updated after an unwitnessed fall in the bathroom, despite multiple falls occurring over several months. The resident was cognitively intact and required staff assistance for transfers and toileting, but the care plan did not reflect new strategies or measures to prevent further falls after the most recent incident. The Director of Nursing confirmed that care planning to prevent falls and promote safety had not been revised accordingly. Another resident had a physician's order for hospice services, but the care plan did not address hospice care, comfort treatment, pain management, psychosocial support, or coordination with the hospice agency. Additionally, a third resident with acute respiratory failure, pulmonary edema, and COPD was observed receiving oxygen at a different rate than what was documented in the care plan. The care plan listed an intervention for 5 liters of oxygen via nasal cannula, while the current physician's order and observation indicated 1 liter. The Director of Nursing confirmed that the care plan was not revised to reflect the current oxygen order.
Failure to Provide Ordered Nutritional Snacks
Penalty
Summary
A deficiency occurred when the facility failed to follow physician orders for a resident with diagnoses of malnutrition and abnormal weight loss, who also had severe cognitive impairment as indicated by a BIMS score of 3. The physician had ordered that the resident receive snacks at 10:00 a.m. and 2:00 p.m. Observations on multiple days revealed that the resident did not receive the ordered snacks at the specified times. Staff interviews confirmed that the nurse aide responsible did not provide the snacks as required, and the nurse manager corroborated that the resident missed both morning and afternoon snacks. Documentation and direct observation supported that the physician's orders were not followed for this resident.
Failure to Provide Ordered Range of Motion Devices Due to Documentation and Training Issues
Penalty
Summary
A deficiency was identified when a resident with a history of hemiplegia and hemiparesis following a stroke, affecting the left non-dominant side, did not receive appropriate treatment and services to maintain or improve range of motion (ROM) as required by facility policy and physician orders. The resident's care plan and physician orders specified the use of a left elbow extension splint and a left hand roll splint to be applied for six hours daily, with nursing staff responsible for skin checks before and after application to reduce joint stiffness and contractures. However, observations on multiple days revealed that the splints were not applied, and the equipment was found unused at the resident's bedside. Further investigation through interviews and record reviews showed that the resident had not had the splints applied for about a week and believed that nursing staff did not know how to apply the equipment. The electronic treatment administration record did not reflect the orders for the splints, and the assistant director of nursing confirmed that the orders were inaccurately placed, making them inaccessible to nursing staff during treatment administration. Additionally, there was no confirmation that nursing staff had received training on how to apply the splints. These findings were confirmed with the director of nursing.
Failure to Follow Physician Orders for Pain Medication Administration
Penalty
Summary
Facility staff failed to administer pain medication in accordance with physician orders for one resident. The resident, who had diagnoses including hemiplegia, hemiparesis, chronic obstructive pulmonary disease, and pain, had a physician's order for Percocet 5-325 mg every 6 hours as needed for severe pain rated 8-10. However, review of the medication administration record showed that Percocet was given on multiple occasions when the resident's documented pain level was below the threshold specified in the order, including pain levels of 0, 5, and 6. This was confirmed by the Director of Nursing during an interview, who acknowledged that staff did not follow the physician's orders for pain management.
Failure to Provide Trauma-Informed, Culturally Competent Care
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident with a documented history of schizophrenia, epilepsy, and post-traumatic stress disorder (PTSD). Clinical records indicated that the resident had experienced sexual abuse and violence in the past, including while incarcerated, and expressed ongoing feelings of not being safe. Despite this information being documented in progress and psychology notes, the care plan did not identify specific trauma triggers or interventions tailored to the resident's needs. Further review showed that the care plan only generally referenced the potential for behaviors resulting from past trauma but did not include individualized strategies to mitigate or prevent re-traumatization. Interviews with the DON and Facility Administrator confirmed that the facility did not adequately identify the resident's past traumatic experiences or possible triggers that could lead to re-traumatization, as required by professional standards and regulations.
Incomplete Discharge Summary and Failure to Convey Required Information at Discharge
Penalty
Summary
The facility failed to provide a complete and timely discharge summary to the continuing care provider for one of two closed records reviewed. Specifically, the discharge summary for a resident who was discharged with ongoing needs for ostomy care, PEG tube care, and an active tracheostomy did not include a reconciliation of all pre-discharge and post-discharge medications, as required by facility policy. Additionally, the discharge summary lacked documentation of the resident's or responsible party's signature acknowledging agreement with the discharge plan. Instead, the section designated for the resident or responsible party's signature was signed and dated by the licensed nurse. Further review revealed that special care instructions were reviewed with the resident's family member after the discharge date, rather than at the time of discharge. There was also no evidence that the discharge summary, including the required components, was conveyed to the continuing care provider at the time of discharge. These findings were confirmed with the Nursing Home Administrator and Director of Nursing.
Failure to Develop Baseline Care Plan for Tracheostomy and Seizure Precautions
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a baseline care plan to address the immediate needs of a resident who was admitted with a tracheostomy and a history of epilepsy. The facility's policy requires the interdisciplinary team to review practitioner orders and establish a baseline care plan to meet immediate care needs, including those specified in physician orders. Review of the resident's clinical record showed that physician orders were in place for seizure precautions and specific tracheostomy care, including site assessment, suctioning, inner cannula changes, and use of a trach collar. Nursing documentation confirmed that tracheostomy care and seizure-related interventions were performed. However, there was no evidence in the resident's care plan of documented goals or interventions related to tracheostomy care or seizure precautions, as required by facility policy. This finding was confirmed with the DON and Administrator.
Failure to Serve Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to provide food and drink that was palatable and served at appropriate temperatures, as required by their policy. The policy, revised in January 2025, mandates that hot foods be served at 135 degrees Fahrenheit or above, and cold foods, including milk and juice, be served at temperatures below 41 degrees Fahrenheit. On February 18, 2025, a resident reported that juices and milk were served warm, which should have been cold. During a resident council meeting on February 19, 2025, several residents expressed concerns about the quality of meals, noting that food was consistently cold and repetitive, with specific complaints about peas and green beans being hard and cold. A test tray observation on February 20, 2025, confirmed these issues, with meatloaf, green beans, and mashed potatoes all registering below the required temperature, and iced tea and milk above the acceptable cold temperature range. The Food Service Director confirmed that these items were outside the acceptable temperature range and not palatable.
Food Safety Protocol Violations in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen tour. The Cook, identified as Employee E13, was seen using a green cutting board, designated for vegetables, to cut chicken, which is a raw protein. This action contradicts the facility's protocol that specifies the use of a red cutting board for raw proteins to prevent cross-contamination. Additionally, the refrigerator contained several food items, including corn cakes, turkey and cheese, sliced ham, and peanut butter sandwiches, which were undated and unlabeled, violating the facility's policy on labeling and dating food items. These findings were confirmed by the Food Service Director during the tour.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to assess the ability of a resident to self-administer medications, as required by their policy. The policy mandates that an interdisciplinary team must determine if it is clinically appropriate and safe for a resident to self-administer medications. This includes evaluating the resident's mental and physical abilities, such as their ability to read and understand medication labels, comprehend the purpose and dosage of medications, and recognize risks and adverse consequences. However, for one resident, identified as R118, there was no documented assessment for medication self-administration, despite an active physician order allowing unsupervised self-administration of Asper-Flex External Cream for pain. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a medication self-administration assessment for Resident R118. Additionally, a pharmacy consultant report had previously recommended ensuring a self-administration assessment was completed, but this was not done. This oversight indicates a failure to adhere to the facility's resident care policies and pharmacy services regulations, as outlined in the relevant Pennsylvania Code sections.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in one of its nursing units, as evidenced by multiple observations and interviews. In one room, three mouse traps were found, one containing mouse droppings and another covered in dust resembling a dead mouse. The room's floors were dirty with visible crumbs and spills, and the trash can was unclean and lacked a linen trash bag. Resident R8 confirmed that housekeeping had not adequately cleaned the room. Similar issues were observed in other rooms, where trash cans were dirty and lacked linen bags. Additionally, a strong urine odor was noted in another room, where a resident's pillow was ripped and without a pillowcase, and the floor was dirty with used items scattered around. Interviews with residents revealed a shortage of essential supplies, such as washcloths, linens, and briefs. One resident reported having to use a paper towel due to the unavailability of washcloths. The housekeeping director confirmed that the facility's procedure is to provide clean washcloths during every shift, with deliveries scheduled three times a day. However, the inventory showed only a one-day supply of washcloths, prompting an emergency order. These deficiencies were confirmed by the facility's administrator and other staff members, highlighting a failure to provide a safe, clean, and comfortable environment for residents.
Failure to Provide Bathing and Feeding Assistance
Penalty
Summary
The facility failed to provide adequate bathing support and feeding assistance for two residents, leading to deficiencies in their care. Resident R73, who had an intact cognitive status with a BIMS score of 15, required substantial assistance for bathing. Despite being scheduled for showers twice a week, the resident only received two showers and one bed bath over a 30-day period. The resident expressed a desire for grooming assistance, which was not provided, as evidenced by observations of disheveled hair and an unshaven beard. Resident R39, who was cognitively impaired and required one-person assistance with meals due to conditions such as aphasia, dysphagia, and hemiplegia, was observed without the necessary feeding assistance. On multiple occasions, the resident was left with a meal tray untouched, indicating a lack of staff support. Interviews with staff confirmed the resident's need for assistance, yet observations showed the resident attempting to eat independently without the required help, highlighting a failure in providing necessary care for activities of daily living.
Wound Care Supplies Left at Bedside
Penalty
Summary
The facility failed to ensure that prescribed wound care treatments were not left at the bedside for a resident. Resident R60, who has a diagnosis of anemia and dementia, was observed sitting in bed eating lunch with an open bottle of Dakin's wound care solution next to the lunch tray. When asked about the contents of the bottle, the resident mistakenly identified it as water. A surveyor notified Employee E16, an LPN, who confirmed that the bottle contained Dakin's solution with medication inside. Additionally, wound cleanser and wound care supplies were found on the resident's nightstand. Employee E16 acknowledged that these supplies should not have been left in the resident's room.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care services for a resident, identified as R19, as observed during a survey. The deficiency involved improper management of oxygen and nebulizer equipment. Specifically, the oxygen tubing for the resident was found lying on the floor without being stored in a treatment bag, and the oxygen concentrator was running. The tubing was dated February 1, 2025, indicating it had not been changed as per the physician's order, which required weekly changes on Tuesdays during the 11-7 shift. Additionally, a nebulizer mask was found inside a bag dated January 28, 2025, suggesting it had not been replaced in accordance with the facility's policy, which mandates replacement every seven days. The observations were confirmed by a Licensed Practical Nurse, Employee E16, who was present during the survey. The facility's policies for nebulizer and oxygen administration, both dated January 2025, were not adhered to, as evidenced by the outdated equipment and improper storage. The failure to follow these protocols resulted in the deficiency, as the facility did not ensure the respiratory equipment was changed and labeled appropriately, nor was the oxygen administered as ordered by the physician.
Failure to Implement Pharmacy Review Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy review irregularities were implemented for two residents, R104 and R118. For Resident R104, a physician's order required that Nifedipine, an antihypertensive medication, be held if the systolic blood pressure was less than 100 or the heart rate was less than 60. However, the Consultant Pharmacist's review reports from December 2024 and January 2025 noted that the medication was not withheld on multiple occasions despite the heart rate being less than 60, as recorded in the medication administration record (MAR). This issue persisted into February 2025, indicating a repeated failure to adhere to the physician's hold order. For Resident R118, the facility did not complete a required assessment for medication self-administration, despite a recommendation from the pharmacy consultant report dated January 28, 2025. The absence of this assessment was confirmed during an interview with the Director of Nursing on February 21, 2025. These deficiencies highlight the facility's failure to implement pharmacy review recommendations and ensure proper medication management for the residents involved.
Failure to Provide Prescribed Nectar Thick Liquids
Penalty
Summary
The facility failed to provide food items consistent with the prescribed diet order for a resident, identified as R83. The facility's policy on thickened liquids, dated January 2025, requires that a written order for thickened liquids be communicated to the dietary department via a diet requisition form. The policy specifies three levels of thickened liquids: nectar, honey, and pudding. According to the physician's order dated November 26, 2024, Resident R83 was prescribed nectar thick liquid consistency. However, observations on February 18 and February 20, 2025, revealed that Resident R83 was provided with thin liquids instead of the prescribed nectar thick liquids. On both occasions, the resident's room number was written on the cup containing thin liquids. Interviews with Employee E16 and the Director of Nursing, Employee E2, confirmed that the resident should only have nectar thick liquid. The Director of Nursing removed the cup of thin liquid from the resident's room upon discovery.
Inadequate Dining Space for Residents
Penalty
Summary
The facility failed to provide sufficient dining space for residents on the third and fourth floors, as observed during lunch services. On the fourth floor, 12 residents were seated in a congested dining room, which lacked adequate space for staff to move around and serve meal trays. Additionally, 8 residents were seated across the door, unable to leave until others finished eating. On the third floor, 14 residents were present, and staff had to move a resident outside the dining room to create space for movement. Two residents were observed waiting outside the dining room. Interviews with staff and residents revealed that the dining rooms on both floors were not spacious enough to accommodate all residents who wished to dine there. An LPN mentioned that the dining room could only accommodate 12 to 14 residents, despite there being 57 residents on the floor. The LPN also noted that another dining room at the end of the hallway was not being utilized. A resident expressed a desire to eat in the dining room, stating that the main dining room had not been used since COVID. The Nursing Home Administrator confirmed the congestion and temporary non-use of side dining rooms on both floors.
Failure to Provide Medically-Related Social Services for Resident Transfer
Penalty
Summary
The facility failed to provide medically-related social services to assist a resident, identified as Resident R1, in achieving her goal of transferring to another facility. Resident R1, who was cognitively intact with a BIMS score of 15, expressed dissatisfaction with the current facility and a desire to transfer since her admission. Despite her daughter's request for assistance from the social worker on November 15, 2024, and subsequent documentation in nursing and physician progress notes, the social services department did not initiate or complete the necessary discharge planning to facilitate the transfer. The social worker, Employee E5, was unaware of Resident R1's request until an interview on December 5, 2024, indicating a lack of communication and follow-up on the resident's needs. The care plan initiated on November 15, 2024, did not include a discharge plan to another facility, and there were no further notes or follow-up actions documented by the social worker. Interviews with the Director of Nursing and the Unit Manager confirmed the oversight, highlighting a deficiency in the facility's provision of social services as required by regulations.
Plan Of Correction
Resident R1 was assisted by the NHA and Admissions Coordinator at her daughter's request to have her mother transferred to two specific facilities in which the daughter chose. Unfortunately, both facilities denied the resident. A subsequent conversation occurred with the daughter who is the POA to discuss options. The daughter stated that she would choose the nursing home based on location from her and other family members but never provided the facility with any information. R1 was discharged to her daughter's care to live at home. All residents can be affected by this deficient practice. A comprehensive education will be provided to the Interdisciplinary Team and the Social Worker director by the LNHA on the provisions of F-745 to ensure compliance. Requests for discharges will be discussed during the daily operations and clinical meetings to ensure the Social Services Department is aware of requests for resident transfers and assists with the details of the transfers. The Nursing Home Administrator will audit requests related to transfer requests to other facilities weekly for 4 weeks then monthly for one month to ensure compliance. The results of these audits will be reviewed with the IDT during the monthly QAPI meetings to ensure compliance.
Neglect During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident R1, was free from neglect during a transfer from bed to chair using a mechanical lift. The resident, who had a history of chronic obstructive pulmonary disease, morbid obesity, osteoarthritis, lack of coordination, muscle weakness, and a history of falling, required substantial assistance with mobility and was dependent on transfers. The care plan and physician orders specified that transfers should be conducted with the assistance of two staff members using a Hoyer lift. However, on the day of the incident, a nurse aide, identified as Employee E3, attempted to transfer the resident alone, without the required assistance. During the transfer, Employee E3 was positioning the Hoyer pad in the wheelchair when the lift tipped to the side, causing the resident to fall and sustain a head injury. The incident resulted in a laceration and contusion to the resident's forehead, which required treatment with surgical glue. The resident was transported to the hospital for evaluation and treatment. Statements from staff and the resident confirmed that the nurse aide did not seek assistance from another staff member, as required by the facility's policy for Hoyer lift transfers. Interviews with staff members, including a Licensed Practical Nurse and the Unit Manager, revealed that the nurse aide did not follow the protocol of having two staff members present during the transfer. The incident was attributed to the failure to have the lift's legs properly positioned, which contributed to the tipping. The facility's policy clearly required two staff members for all Hoyer lift transfers, and the failure to adhere to this policy resulted in actual harm to the resident.
Failure to Ensure Safe Transfer Using Mechanical Lift
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards, specifically during the transfer of a resident using a mechanical lift. The incident involved Resident R1, who had a history of chronic obstructive pulmonary disease, morbid obesity, osteoarthritis, lack of coordination, muscle weakness, and a history of falling. The resident required substantial assistance with mobility and was dependent on transfers from bed to chair, as indicated in their care plan and physician orders, which specified the use of a Hoyer lift with the assistance of two staff members. On the day of the incident, Nurse Aide Employee E3 attempted to transfer Resident R1 using the Hoyer lift without the required assistance of a second staff member. During the transfer, the lift tipped to the side, causing the resident to sustain a head injury and laceration. The incident was witnessed by Resident R1's roommate, who heard a noise and called for help. Licensed Practical Nurse Employee E4 responded to the call and found the resident with the lift on top of her, noting blood on the resident's forehead. Interviews with staff and the resident confirmed that the transfer was conducted by a single aide, contrary to facility policy. The investigation revealed that the legs of the Hoyer lift were not properly positioned, contributing to the accident. The resident was transported to the hospital for evaluation and treatment of the head injury, which was closed using surgical glue. The incident was identified as actual harm due to the failure to follow established safety protocols for mechanical lift transfers.
Failure to Notify Ombudsman of Discharges
Penalty
Summary
The facility failed to provide appropriate discharge notices to the state office of the long-term care ombudsman for facility-initiated transfers and discharges over a seven-month period from January 2024 to July 2024. This deficiency was identified through a clinical record review and confirmed during an interview with the Executive Director, employee E1, on September 19, 2024. The review revealed that the required notifications were not sent in a timely manner, as mandated by the regulations, which is a violation of 28 Pa. Code 201.18(b)(3) Management.
Failure to Honor Resident's Dialysis Schedule Preference
Penalty
Summary
The facility did not ensure that Resident R22's rights were exercised regarding their scheduled dialysis appointments. Resident R22, who is diagnosed with End Stage Renal Disease and Chronic Obstructive Pulmonary Disease, expressed a preference for early morning dialysis sessions, which was changed to a later time by the facility. The Director of Nursing stated that the change was made because the resident needed an escort and claimed that the resident agreed to the change. However, there was no documented evidence to support this mutual agreement.
Failure to Adhere to Midline Catheter Care Standards
Penalty
Summary
The facility failed to provide adequate treatment and care for a midline catheter in accordance with professional standards of practice for Resident R113. The facility's policy required that central venous access device and midline dressing changes be done at established intervals and immediately if the integrity of the dressing is compromised. Transparent semi-permeable membrane dressings were to be changed every 7 days and as needed. However, an observation on April 2, 2024, revealed that Resident R113's midline dressing, last changed on March 29, 2024, had not been changed from March 13, 2024, to March 29, 2024, despite a physician's order to change the PICC line dressing weekly. This was confirmed by the Director of Nursing on April 5, 2024. The clinical record review for Resident R113 showed that the resident was admitted to the facility on an unspecified date and had a physician's order dated March 29, 2024, to change the PICC line dressing weekly. The treatment administration record (TAR) for March 2024 indicated that the order was signed off by staff on March 29, 2024, but the dressing was not changed between March 13, 2024, and March 29, 2024. This lapse in care was confirmed by the Director of Nursing, indicating a failure to adhere to the facility's policy and professional standards of practice for midline catheter care.
Improper Oxygen Therapy Administration
Penalty
Summary
The facility did not ensure the proper administration of oxygen therapy in accordance with professional standards of practice for two residents. Resident R18, diagnosed with chronic obstructive pulmonary disease, high blood pressure, heart disease, and stage 3 kidney disease, was observed with oxygen tubing dated February 17, 2024, which was confirmed by a licensed nurse. This observation was made on April 2, 2024. Additionally, Resident R22, diagnosed with end-stage renal disease and chronic obstructive pulmonary disease, had an order for 3 liters of oxygen. On the same day, it was observed that Resident R22's oxygen condenser was not clean, with a thick gray coating of dust covering the filter, as confirmed by an LPN.
Failure to Provide Dialysis Treatment and Medication as Ordered
Penalty
Summary
The facility failed to ensure that Resident R22, who was diagnosed with End Stage Renal Disease and required hemodialysis, received dialysis treatment and medication as ordered. The resident missed a scheduled dialysis session on March 15, 2024, because there was no escort available. Additionally, on March 22, 2024, the resident did not receive medications scheduled for 10:00 a.m. and 2:00 p.m. because they were at dialysis. These deficiencies were confirmed by the Director of Nursing on April 4, 2024, at 10:00 a.m. The facility's policy on coordinating dialysis care and services was not followed, leading to a lapse in the resident's treatment and medication administration.
Failure to Provide Adequate Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of three residents, as evidenced by issues with medication administration and availability. For Resident R32, there was an error in the delivery of medications, resulting in a double dose of Aspirin 81 mg and Nifedipine 60 mg being delivered. This was observed during a medication administration session on April 2, 2024. Resident R35, who was diagnosed with benign prostate hyperplasia, high blood pressure, and an overactive bladder, did not receive the prescribed medication Mirabegron 25 mg for four consecutive days starting from December 7, 2023, due to the medication not being available. This was confirmed by a nursing note and an interview with the Director of Nursing on April 4, 2024. Resident R97 also experienced issues with medication availability. The resident had a physician's order for Guaifenesin 600 mg to be administered every 12 hours, but the medication was not available during a medication administration session on April 3, 2024. These deficiencies indicate a failure to adhere to the facility's policy on medication administration, which requires immediate notification to the pharmacy and nursing supervisors when medications are not delivered. The facility's failure to ensure the timely acquisition, receipt, and administration of medications compromised the pharmaceutical services provided to these residents.
Failure to Address Pharmacist's Recommendations in a Timely Manner
Penalty
Summary
The facility failed to develop and maintain policies and procedures for the monthly drug regimen review that included specific time frames for the different steps in the medication regimen review process. This deficiency was identified through the review of facility policies, clinical records, and staff interviews. The facility's policy did not specify a timeframe for the physician and facility response to the pharmacy consultant's recommendations. As a result, there were delays in addressing the pharmacist's recommendations for Resident R55, including a recommendation to evaluate the dose of Seroquel and to add a stop date for Buspar, which were not addressed until several weeks later. Resident R55's Medication Regimen Review report dated November 29, 2023, included a recommendation to evaluate the current dose of Seroquel and to add a stop date for Buspar. These recommendations were not addressed until January 18, 2024. Additionally, a recommendation from the February 28, 2024, report to discontinue an as-needed medication that had not been administered since December 1 was not addressed until March 14, 2024. These delays in addressing the pharmacist's recommendations indicate a failure to act on irregularities in a timely manner, as required by the facility's policies and procedures.
Failure to Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to offer and/or provide the pneumococcal immunization to two residents, identified as Resident R18 and R33, as required by their policy. The review of the clinical records for these residents revealed no evidence that they received the pneumococcal vaccine or that it was offered to them. Both residents were of an age that made them eligible for the vaccine, and there were no documented contraindications to immunization. The Director of Nursing confirmed the absence of documented evidence that the vaccine was offered or administered to these residents.
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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