Williamsport Home, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Williamsport, Pennsylvania.
- Location
- 1900 Ravine Road, Williamsport, Pennsylvania 17701
- CMS Provider Number
- 395678
- Inspections on file
- 26
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Williamsport Home, The during CMS and state inspections, most recent first.
The facility failed to maintain a clean and safe environment, with surveyors noting a persistent urine odor in a resident's room, litter and an overflowing garbage can at the main entrance, and maintenance issues in residents' rooms across multiple nursing units. These deficiencies were discussed with the Nursing Home Administrator and DON.
A resident with a left leg contracture and severe pain reported inadequate pain control despite receiving prescribed medications, including Tylenol and Oxycodone. The facility failed to manage the resident's pain effectively, as confirmed by interviews and clinical record reviews, which was inconsistent with professional standards of practice.
The facility failed to assess bed rail entrapment risks for several residents, particularly in zone six, and did not obtain informed consent for the use of grab bars. Residents were moved to new rooms and beds without reassessment, and consent was sometimes obtained after installation. These deficiencies were acknowledged by the facility's leadership.
The facility failed to ensure timely physician responses to pharmacist recommendations for three residents. Recommendations for medication adjustments were delayed, with responses taking over a month in some cases. The facility's policy lacked a specified time frame for physician responses, leading to untimely actions.
A facility failed to assess and implement interventions to maintain a resident's continence status. The resident, moderately impaired with a BIMS score of 10, was frequently incontinent and not on a toileting plan. Despite being on a check and change toileting program and a restorative ambulation program, there was no documentation of a bowel and bladder tracker or assessment for a scheduled toileting program after the annual MDS assessment. The resident was alert and able to make needs known, yet remained frequently incontinent.
The facility failed to properly store respiratory care equipment for two residents. A resident's nebulizer mouthpiece was left uncovered, and their prescribed medication was not administered as ordered. Another resident's oxygen tank was unsecured. These issues were brought to the attention of the Nursing Home Administrator and DON.
A resident experienced potential significant medication errors when Lorazepam was administered without a physician's order and Zofran was given without proper documentation. The resident, who had a diagnosis of Torsades de Pointes, did not have these medications in her readmission orders, and the administration of Zofran was concerning due to FDA warnings related to her condition.
The facility failed to secure the medication cart on the 300 Hall Nursing Unit. A surveyor observed the cart unlocked and unattended near the soiled utility room, with no licensed staff nearby. Several unlicensed staff were seen moving residents past the unsecured cart. An LPN returned to the cart after leaving it out of view and acknowledged the lapse. The issue was reviewed with the Nursing Home Administrator and DON.
The facility failed to assist a resident in obtaining routine dental care. A resident with her own teeth reported not seeing a dentist since admission, and clinical records confirmed no dental services were provided in the past 12 months, despite Medicaid coverage. The DON confirmed the lack of documentation for dental care or refusal, indicating a failure to provide routine prophylactic dental cleanings as covered under the State plan.
A resident was inaccurately documented as having PTSD in their clinical records and MDS, despite not having an official diagnosis from a medical professional. The resident reported trauma related to hearing sirens, but social services confirmed the absence of a formal PTSD diagnosis. The error was identified and discussed with facility leadership.
The facility was found deficient in maintaining hazardous area enclosures when the Laundry Room door was observed being held open by unapproved means. This issue was confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
The facility failed to maintain its automatic sprinkler system, with deficiencies including a ceiling penetration in the Activities Closet, lint-loaded sprinkler heads in the Laundry, and missing inspection data for the second quarter of 2024 and the three-year full flow trip test. These issues were confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility did not maintain illuminated exit signage in one area, affecting one of two floors. An observation revealed that the exit access corridor near a resident's room lacked proper signage. This issue was confirmed during an interview with the Facility Administrator and Facilities Manager.
The facility failed to maintain corridor openings according to NFPA 101 standards, as observed in the Library Room on the first floor. The gap between the doors exceeded the allowable one-eighth-inch, compromising the ability to resist smoke passage. This deficiency was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
A resident assessed as being at risk for pressure ulcers did not have a care plan developed until after discharge, despite the assessment indicating the need for one. This was confirmed in a phone interview with the Administrator and DON.
A facility failed to provide appropriate care for a resident's thoracic incision, leading to dehiscence and the need for a wound vac system. The facility did not notify the surgeon of initial signs of infection, nor did it implement recommended changes from a follow-up visit.
The facility failed to ensure an effective procedure for acquiring and dispensing medications, resulting in several residents not receiving their prescribed medications on time. For example, a resident did not receive Morphine ER 15 mg despite it being available in the facility's Omnicell, and another resident did not receive multiple medications due to unavailability from the pharmacy.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and orderly environment across multiple nursing units and the main entrance, as observed by surveyors. On the 300 Hall Nursing Unit, a persistent strong odor of urine was noted in a resident's room over several days. At the facility's main entrance, surveyors observed discarded medical face masks, a used tissue, an overflowing garbage can, and multiple cigarette butts littering the area. These observations were discussed with the Nursing Home Administrator and Director of Nursing. Further deficiencies were noted on the 400 and 500 Hall Nursing Units. In one resident's room on the 400 Hall, the paint was peeling, and the walls and closet frame were marred. On the 500 Hall, another resident's room had a marred closet frame, and a different resident had rolled towels on the windowsill to block cold air, indicating inadequate maintenance of the room's environment. These issues were also brought to the attention of the Nursing Home Administrator and Director of Nursing.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident 84, consistent with professional standards of practice. Resident 84, who suffers from a left leg contracture and is not a surgical candidate, was recommended for palliative care and pain management by orthopedics. Despite having physician orders for Tylenol and Oxycodone to manage varying levels of pain, Resident 84 reported that her pain, particularly in her legs, was not adequately controlled with the medication provided. She experienced mild pain without movement and severe pain with movement and care. The clinical record review revealed that Resident 84 received Tylenol and Oxycodone as needed according to her pain levels, but she still reported uncontrolled pain. Interviews with the resident and the Director of Nursing confirmed these findings. The facility's failure to manage Resident 84's pain effectively was noted as inconsistent with professional standards of practice, as required by the relevant state codes.
Failure to Assess Bed Rail Entrapment Risks and Obtain Consent
Penalty
Summary
The facility failed to adequately assess the risk of side rail entrapment for several residents, as well as to review the risks and benefits of side rail utilization with the residents or their representatives, and to obtain informed consent. Specifically, the facility did not assess zone six for potential entrapment for Residents 3, 9, 12, 38, 71, and 262. This oversight occurred despite the presence of bilateral grab bars on the beds of these residents, which were intended to promote independent bed mobility. For Resident 12, although an enabler bar assessment and consent were completed in November 2023, and an entrapment evaluation was conducted in December 2023, the facility did not assess the new bed and grab bars for potential entrapment risks when the resident moved to a different room in May 2024. Similarly, Resident 9's new bed was not assessed for zone six entrapment risks after a room change in May 2024. Resident 71, who had moved rooms and beds multiple times since August 2024, also lacked documentation of assessments for the appropriateness of grab rails, the resident's ability to use them, or the risk of entrapment, and there was no consent or education provided regarding the use of enabler bars. Resident 3 had a physician's order for grab bars dated October 2024, but the evaluation did not include an assessment of zone six. Resident 59's grab bars were applied before obtaining verbal consent from the responsible party, and the risk assessment was completed after the installation. For Resident 262, the entrapment zone measurement sheet was completed after the grab bars were installed, and zone six was not assessed. Similarly, Resident 38's entrapment risk assessment did not include zone six. These deficiencies were acknowledged by the facility's Nursing Home Director and Director of Nursing during interviews.
Delayed Physician Response to Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure a timely physician response to consultant pharmacist recommendations for three residents. The facility's policy on Monthly Medication Regimen Review, last reviewed in February 2025, requires urgent irregularities to be reported immediately to the Director of Nursing and the attending physician. However, the policy did not specify an appropriate time frame for physician responses to pharmacist recommendations. For Resident 57, a recommendation for a gradual dose reduction of Duloxetine was made on September 26, 2024, but the physician declined the recommendation only on November 15, 2024. Similarly, for Resident 64, a recommendation to reduce Omeprazole was made on August 29, 2024, and accepted on October 25, 2024, while another recommendation for a gradual dose reduction of Olanzapine was made on October 24, 2024, and accepted on November 27, 2024. Additionally, for Resident 21, a recommendation to decrease the dose of Omeprazole was made on September 26, 2024, but the physician accepted it only on November 5, 2024, which was one month and 10 days later. These delays in physician responses to pharmacist recommendations indicate a failure in the facility's policy to ensure timely action, as there was no specified time frame for responses. The concerns regarding the untimely responses were discussed with the Nursing Home Administrator and Director of Nursing on February 27, 2025.
Failure to Implement Continence Interventions for a Resident
Penalty
Summary
The facility failed to assess and implement interventions to maintain a resident's continence status, as identified in the clinical record review and staff interviews. Resident 9, who was moderately impaired with a BIMS score of 10, was frequently incontinent of bowel and bladder and not on a toileting plan. Despite being on a check and change toileting program and a restorative ambulation program, there was no documentation of a bowel and bladder tracker or assessment for a prompted or scheduled toileting program after the annual MDS assessment in January 2025. The resident had a physician's order to transfer and ambulate with assistance and was able to ambulate between five and 160 feet during the review period. Staff noted that Resident 9 was alert, verbal, and able to make needs known, yet remained frequently incontinent. The facility's failure to identify the potential to increase or maintain continence and to implement a structured toileting program contributed to the deficiency. This information was reviewed with the Director of Nursing.
Improper Storage of Respiratory Equipment for Two Residents
Penalty
Summary
The facility failed to store oxygen and respiratory care equipment according to professional standards for two residents. For Resident 28, observations on February 25 and 26, 2025, revealed a nebulizer machine on the resident's stand with the mouthpiece hanging uncovered. The resident was prescribed Ipratropium-Albuterol Solution to be inhaled via nebulizer every four hours as needed for shortness of breath, but the medication administration record showed it had not been administered since February 22, 2025. This discrepancy was discussed with the Nursing Home Administrator and Director of Nursing on February 26, 2025. For Resident 74, an observation on February 25, 2025, showed the resident in bed with supplemental oxygen from a free-standing oxygen cylinder tank that was not secured in a stand. The Nursing Home Administrator was informed of the safety concerns regarding the unsecured oxygen tank on the same day. These findings indicate a failure to adhere to proper storage and safety protocols for respiratory care equipment, as required by professional standards.
Medication Administration Errors for a Resident
Penalty
Summary
The facility failed to administer medication to a resident according to professional standards of practice, resulting in a potential significant medication error. Resident 262, who was initially admitted to the facility and later sent to the hospital, had her medications Lorazepam (Ativan) and Zofran discontinued while she was hospitalized. Upon readmission, these medications were not included in her new medication orders. However, a dose of Lorazepam was administered to her without a physician's order on February 9, 2025, and there was no documentation of anxiety or a physician's contact to justify this administration. Additionally, on February 10, 2025, Resident 262 complained of nausea, and a one-time dose of Zofran was administered after contacting the on-call provider. However, there was no evidence of a physician's order for this administration, nor was there documentation on the medication administration record. The administration of Zofran was particularly concerning given the resident's diagnosis of Torsades de Pointes, a condition that could be exacerbated by Zofran, as noted in the FDA warning. The Director of Nursing confirmed these deficiencies, acknowledging that the Lorazepam was accessible to staff even after being discontinued and that there was no documentation of the Zofran administration. The facility identified these issues as a resident concern, but the report does not mention any adverse reactions experienced by the resident due to these medication errors.
Medication Security Lapse on 300 Hall Nursing Unit
Penalty
Summary
The facility failed to ensure appropriate medication security on the 300 Hall Nursing Unit. On February 25, 2025, at 8:48 AM, a surveyor observed the medication cart on this unit unlocked and unattended near the soiled utility room. No licensed staff were present in the vicinity, and several unlicensed staff were seen pushing residents in wheelchairs past the unsecured cart. At 8:49 AM, a licensed practical nurse, identified as Employee 1, returned to the cart from down the hallway, having left it unsecured and out of their direct view. During an interview at 9:18 AM, Employee 1 acknowledged leaving the medication cart unsecured. The findings were reviewed with the Nursing Home Administrator and the Director of Nursing on February 26, 2025.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to assist a resident, identified as Resident 84, in obtaining routine dental care. During an interview and observation, Resident 84, who has her own teeth, reported that she had not seen a dentist since her admission to the facility. A review of her clinical records confirmed that there was no evidence of her receiving dental services over the past 12 months, despite her being covered by the state Medicaid benefit. An interview with the Director of Nursing further revealed that there was no documentation of Resident 84 receiving dental care or being offered and refusing such care. This indicates a failure by the facility to provide routine prophylactic dental cleanings as covered under the State plan.
Inaccurate Clinical Documentation of PTSD Diagnosis
Penalty
Summary
The facility failed to ensure accurate clinical documentation for a resident, identified as Resident 100, who was admitted to the facility with a list of active diagnoses that incorrectly included Post Traumatic Stress Syndrome (PTSD). The admission Minimum Data Set (MDS) dated January 28, 2025, also inaccurately listed PTSD as a diagnosis. During an interview, the resident expressed that hearing sirens was traumatizing due to past experiences but clarified that there was no official PTSD diagnosis from a psychologist or medical professional. Employee 2 from social services confirmed that while the resident had a history of trauma related to sirens, there was no formal PTSD diagnosis. A subsequent social service progress note confirmed with the resident's medical providers that PTSD was not a diagnosis and would be removed from the resident's records. This discrepancy was discussed with the Nursing Home Administrator and Director of Nursing.
Deficiency in Hazardous Area Enclosure
Penalty
Summary
The facility failed to maintain proper hazardous area enclosures, specifically in the Laundry Room, which was found to have its door held open by unapproved means. This deficiency was observed during a survey on February 13, 2025, at 11:34 a.m., affecting one of two floors in the facility. The issue was confirmed during an exit interview with the Facility Administrator and the Facilities Manager later that day.
Plan Of Correction
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Williamsport Home agrees with the allegations and citations listed on the statement of deficiencies. The Williamsport Home maintains that the alleged deficiencies do not, individually, and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Williamsport Home's written credible allegation of compliance. By submitting this plan of correction, The Williamsport Home does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Williamsport Home reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. 1. The Laundry Room door was addressed immediately so that the door would shut properly on February 13, 2025. 2. A full house audit of doors will be completed to ensure no doors are propped open by February 28, 2025. 3. The Nursing Home Administrator or designee will conduct training/education with all staff regarding the requirement of K321 by March 7, 2025. 4. An audit on doors will be conducted weekly x 2 and then monthly x 2 by the Maintenance Director or designee. The results of the audit will be taken to monthly QA by the Maintenance Director for review.
Failure to Maintain Automatic Sprinkler System
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in compliance with NFPA 25 standards, as evidenced by several deficiencies observed during a survey. On the first floor, a penetration in the ceiling assembly was noted in the Activities Closet, which could compromise the integrity of the fire protection system. Additionally, sprinkler head assemblies in the Laundry area were found to be 'loaded' with lint, indicating a lack of regular cleaning and maintenance. Furthermore, the facility did not have the required automatic sprinkler system testing and inspection data for the second quarter of 2024, nor did it have current data for the three-year full flow trip test inspection and testing. These deficiencies were confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
Plan Of Correction
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Williamsport Home agrees with the allegations and citations listed on the statement of deficiencies. The Williamsport Home maintains that the alleged deficiencies do not, individually, and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Williamsport Home's written credible allegation of compliance. By submitting this plan of correction, The Williamsport Home does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Williamsport Home reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. 1. a) The unsealed penetration will be sealed in Activities closet by February 26, 2025. b) The sprinkler head assemblies in the laundry area were cleaned on February 24, 2025. c) The facility cannot reactively correct the sprinkler testing for the second quarter of 2024. d) The facility cannot reactively correct the three-year full flow trip test inspection and data. 2. a) A full house audit will be conducted by the Maintenance Director or designee for any penetrations observed by February 28, 2025. Any penetrations identified will be sealed per Life Safety guidelines. b) A full house audit will be conducted by the Maintenance Director or designee for to ensure sprinkler heads are clear of any lint by February 28, 2025. Any areas identified will be cleaned. c) A quarterly schedule will be developed for 2025 to ensure quarterly sprinkler testing is completed. d) The three-year full flow trip test inspection will be scheduled by the end of the first quarter of 2025. 3. The Nursing Home Administrator or designee will conduct training/education with maintenance personnel regarding the requirement of K032 to include monitoring for penetrations, lint free sprinkler heads, quarterly sprinkler testing and three-year trip testing and data by March 7, 2025. 4. a) An audit on penetrations and linen covered sprinkler heads will be conducted weekly x 2 and then monthly x 2 by the Maintenance Director or designee. The results of the audit will be taken to monthly QA by the Maintenance Director for review. b) Maintenance Director or designee will complete an audit for any quarterly sprinkler testing quarterly x4. The results of the audit will be taken to monthly QA by the Maintenance Director for review. c) Maintenance Director or designee will complete an audit annually for the completion of the full flow-trip. The results of the audit will be taken to monthly QA by the Maintenance Director for review.
Exit Signage Deficiency
Penalty
Summary
The facility failed to maintain proper exit signage in accordance with NFPA 101 standards, specifically affecting one of the two floors. During an observation conducted on February 13, 2025, at 10:50 a.m., it was noted that the exit access corridor closest to Resident Room 1 lacked illuminated exit signage. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager later that day.
Plan Of Correction
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Williamsport Home agrees with the allegations and citations listed on the statement of deficiencies. The Williamsport Home maintains that the alleged deficiencies do not, individually, and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Williamsport Home's written credible allegation of compliance. By submitting this plan of correction, The Williamsport Home does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Williamsport Home reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. 1. The chevron was ordered on February 24, 2025, and will be placed in the corridor located closest to the Resident Room 1 by March 18, 2025. 2. A full house audit will be conducted by maintenance personnel on all exit signs to ensure that the exit access corridors have the proper illuminated exit signage by February 28, 2025. 3. The Nursing Home Administrator or designee will conduct training/education with maintenance personnel regarding the requirement of K0293 by March 7, 2025. 4. An audit on exit signs will be conducted weekly x 2 and then monthly x 2 by the Maintenance Director or designee. The results of the audit will be taken to monthly QA by the Maintenance Director for review.
Corridor Door Deficiency in Library Room
Penalty
Summary
The facility failed to maintain corridor openings in compliance with the National Fire Protection Association (NFPA) 101 standards. During an observation on February 13, 2025, it was noted that the distance between the doors of the Library Room on the first floor exceeded the allowable one-eighth-inch gap. This deficiency was identified as affecting one of the two floors in the facility. The issue was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day. The report highlights that the corridor doors did not meet the required specifications to resist the passage of smoke, as stipulated by the NFPA 101 and CMS regulations. This deficiency indicates a failure to adhere to fire safety standards, which are critical for ensuring the safety of residents and staff in the event of a fire.
Plan Of Correction
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Williamsport Home agrees with the allegations and citations listed on the statement of deficiencies. The Williamsport Home maintains that the alleged deficiencies do not, individually, and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Williamsport Home's written credible allegation of compliance. By submitting this plan of correction, The Williamsport Home does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Williamsport Home reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. 1. The Library Room doors will be fixed to not exceed a one-eighth-inch gap by March 7, 2025. 2. A full house audit will be conducted by maintenance personnel on all corridor doors to ensure door gaps do not exceed a one-eighth inch by February 28, 2025. 3. The Nursing Home Administrator or designee will conduct training/education with maintenance personnel regarding the requirement of K0363 by March 7, 2025. 4. An audit on corridor door openings will be conducted weekly x 2 and then monthly x 2 by the Maintenance Director or designee. The results of the audit will be taken to monthly QA by the Maintenance Director for review.
Failure to Implement Timely Care Plan for Pressure Ulcer Risk
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident at risk of developing pressure ulcers. The Minimum Data Set Assessment dated March 7, 2024, identified the resident as being at risk and indicated that a care plan would be developed. However, the facility did not create this care plan until April 3, 2024, which was two days after the resident had already been discharged. This deficiency was confirmed during a phone interview with the Administrator and Director of Nursing on May 8, 2024.
Failure to Provide Appropriate Surgical Incision Care
Penalty
Summary
The facility failed to provide the highest practicable care regarding surgical incision assessments and treatments for a resident (Resident CR1). Upon admission, Resident CR1 had a thoracic incision with 25 staples and black crusted drainage. A nursing note indicated redness and warmth around the incision, but there was no documented evidence that the surgeon was notified. The facility's policy did not specify the frequency of surgical incision assessments for signs of infection. Additionally, after a follow-up visit with the neurosurgeon, there was no documented evidence that the facility implemented the recommended changes, such as keeping the resident off the incision and using Allevyn foam every three days. Weekly skin assessments also failed to document the condition of the thoracic incision or any signs of infection or pressure-related injury. On March 18, 2024, the resident's thoracic incision was found to be open with a large amount of brown drainage. A neurosurgery consult revealed that the incision had dehisced due to ongoing pressure, necessitating the use of a wound vac system. The facility's failure to appropriately assess and implement physician-recommended treatment orders for the resident's incision was confirmed during a phone interview with the Administrator and Director of Nursing.
Failure to Ensure Effective Medication Acquisition and Dispensing
Penalty
Summary
The facility failed to ensure an effective procedure for acquiring and dispensing medications for five of six residents reviewed. The procedure for obtaining medications for new admissions was not followed, resulting in several residents not receiving their prescribed medications on time. For instance, Resident 1 did not receive Morphine ER 15 mg as ordered due to awaiting arrival, despite the medication being available in the facility's Omnicell. Similarly, Resident 2 did not receive multiple medications, including Colestipol and Advair, due to them not being available from the pharmacy, and there was no documented evidence that the 5 Step Order Process was completed to obtain these medications or check their availability in the Omnicell. Resident 3 also did not receive several medications, such as Advair and Flonase, due to unavailability from the pharmacy, with no evidence of the 5 Step Order Process being followed. Resident 4 did not receive Acyclovir as ordered, despite it being listed as available in the Omnicell. Lastly, Resident 6 did not receive a Lidocaine patch for pain relief 22 hours after admission due to awaiting its arrival from the pharmacy. Interviews with the Administrator and Director of Nursing confirmed these findings, indicating a systemic issue in the medication acquisition and dispensing process.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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