York South Skilled Nursing And Rehabilitation Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in York, Pennsylvania.
- Location
- 200 Pauline Drive, York, Pennsylvania 17402
- CMS Provider Number
- 395309
- Inspections on file
- 32
- Latest survey
- June 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at York South Skilled Nursing And Rehabilitation Ctr during CMS and state inspections, most recent first.
A resident with diabetes and atrial fibrillation, whose POLST called for limited additional interventions and antibiotics if life could be prolonged, was incorrectly identified by an on-call provider as being on comfort care. This led to a lack of escalation in care when the resident developed fever and UTI symptoms. Despite no documentation supporting comfort care status, appropriate interventions were delayed, resulting in further decline and death.
A resident with a Foley catheter and multiple diagnoses, including dementia and obstructive uropathy, did not have documented catheter care as required by facility policy. Although physician orders addressed catheter management, there was no specific order or nurse aide task for catheter care, and the DON confirmed the lack of documentation. The resident was treated for a UTI during this period.
The facility failed to document weights for two residents as per physician orders and did not arrange transportation for a resident's dialysis appointment, resulting in a missed treatment. The DON confirmed the lack of documentation and transportation arrangements.
A facility failed to provide routine medications to a resident due to unavailability from the contracted pharmacy and lack of emergency supply. The resident, with conditions such as diabetes, hypertension, and insomnia, missed evening doses of Midodrine, insulin, and Trazadone. The DON confirmed the deficiency, which violated the facility's pharmaceutical service policy.
The facility failed to provide and document wound care treatments for four residents with various medical conditions, including malnutrition, CHF, peripheral vascular disease, and diabetes. Treatments were not completed or documented on multiple occasions, as confirmed by the DON.
A CNA at the facility was found to have performed tasks beyond their scope of practice, including passing medications and checking blood sugar levels, under the direction of an LPN. This involved two residents who confirmed receiving medications and blood sugar checks from the CNA. Witness statements from other staff and residents corroborated these actions, although no adverse outcomes were reported.
The facility failed to maintain a safe and clean environment in three resident shower rooms, with issues such as black and pink substances on floors, a cracked shower gurney mat, non-functioning ceiling vents, and a loose sink. Observations were made in the presence of the Director of Housekeeping, and the Nursing Home Administrator was informed of these deficiencies.
The facility failed to report abuse allegations within the required 24-hour timeframe for two residents. One resident with dementia was verbally abused by a nurse aide, and another resident with morbid obesity was verbally abused by a respiratory therapist. Both incidents were reported to authorities well after the required timeframe.
The facility failed to create comprehensive care plans for four residents, including those admitted to hospice care and those with specific medical interventions like catheters and supplemental oxygen. The absence of these care plans was confirmed by the DON, violating facility policy and state regulations.
The facility failed to monitor and document the pH levels of the sanitizer sink and did not store and serve food and beverages according to professional standards. Observations revealed missing documentation for pH levels and improperly labeled and dated food items in the kitchen and nourishment pantries. The Food Service Director confirmed these oversights, indicating a lapse in adherence to facility policies.
The facility failed to implement enhanced barrier precautions for two residents, one with severe ulcers and another with an indwelling catheter. Required signage was missing, and staff did not follow gowning protocols during wound care, as confirmed by the DON.
A facility failed to inform a resident of charges for services not covered under Medicare or Medicaid. The resident, admitted for short-term rehabilitation with conditions like hypertension and heart failure, was not given the SNF-ABN form detailing costs after Medicare A services ended. This left the resident unaware of their financial responsibility for services until discharge.
The facility failed to review and revise care plans for three residents. One resident's care plan included discontinued interventions, another's care plan included discontinued geri-sleeves, and a third resident's care plan was incomplete and not updated with specific information. The DON confirmed these deficiencies.
A resident with Alzheimer's and pleural effusion was not provided necessary grooming assistance, resulting in significant facial hair despite her care plan indicating a need for help with daily hygiene. Observations confirmed the deficiency, highlighting a lapse in care plan implementation.
A resident with pressure ulcers did not receive proper wound care, as an employee reused a paper measuring tape on multiple wounds and failed to change gloves or perform hand hygiene between treatments. The resident had stage 4 pressure ulcers and a non-pressure full thickness ulcer, and the Director of Nursing confirmed the breach in protocol.
A resident with a history of peripheral vascular disease and hypertension was diagnosed with a UTI and prescribed Keflex. Despite treatment, the resident continued to experience burning during urination, but the facility failed to follow up on these symptoms until nearly a month later. The DON confirmed that additional follow-up should have occurred sooner.
A facility failed to provide proper respiratory care for a resident with ALS and COPD, as the Trilogy mask was improperly stored and not cleaned according to standards. Observations showed the mask on the floor and later on a nightstand with a substance in its fold. Staff interviews confirmed the mask should be stored in a plastic bag and cleaned weekly, indicating a lapse in equipment maintenance.
The facility did not complete a required annual performance review for a nurse aide, Employee 2, who was hired over a year ago. The facility's policy mandates annual performance appraisals, which were not conducted for this employee, as confirmed by the NHA during an interview.
A facility failed to educate a resident with type 2 diabetes and hypertension on the influenza vaccination. The resident refused the vaccine for the 2023-2024 season, but there was no documentation of the refusal or evidence of education and a vaccine information statement being provided. The DON confirmed the lack of documentation and education during an interview.
Failure to Follow Resident's Plan of Care and POLST Directives
Penalty
Summary
The facility failed to provide care and services consistent with a resident's comprehensive plan of care, resulting in a decline in health status. The resident had diagnoses including diabetes mellitus type II and atrial fibrillation, and had a POLST indicating limited additional interventions, use of IV fluids and cardiac monitoring as indicated, and use of antibiotics if life could be prolonged. Despite these directives, clinical documentation and staff interviews revealed that the contracted on-call provider incorrectly identified the resident as being on comfort care measures, which led to a lack of escalation in care when the resident developed a fever and symptoms suggestive of a urinary tract infection (UTI). Progress notes showed that the resident experienced a fever and foul-smelling urine, and although the on-call provider was notified, documentation stated that only comfort care measures were to be provided, with no escalation of care. This was not consistent with the resident's POLST or physician orders, which did not indicate comfort care status at that time. The resident continued to decline, exhibiting lethargy, poor oral intake, and eventually was found to have a confirmed UTI and acute kidney injury. Orders for antibiotics and IV fluids were eventually given, but only after a significant delay and further deterioration in the resident's condition. Interviews with facility staff, including the DON, confirmed that there was no documentation or order placing the resident on comfort care during the period in question. The failure to follow the resident's established plan of care and advanced directives resulted in delayed and insufficient medical intervention, contributing to the resident's decline and subsequent death.
Failure to Provide and Document Catheter Care for Incontinent Resident
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident who was incontinent of bladder and had an indwelling Foley catheter. Facility policy required catheter care to be performed twice daily and as needed, with documentation of care provided, urine output if ordered, and any abnormal findings. Review of the resident's clinical record showed diagnoses including obstructive uropathy, congestive heart failure, and dementia. The resident had a Foley catheter placed for urinary retention, and the care plan included interventions for skin care and use of a moisture barrier after each incontinent episode. Physician orders included instructions for catheter management, but there was no specific order or nurse aide task for catheter care. Further review of the clinical record did not reveal documentation that catheter care was being provided as required by facility policy. The resident was treated with antibiotics for a urinary tract infection during the review period. During an interview, the DON was unable to locate documentation indicating that catheter care was completed, and stated that she would expect such care to be performed and documented according to policy.
Failure to Document Weights and Arrange Transportation for Dialysis
Penalty
Summary
The facility failed to ensure that its residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered plan of care. For Resident 1, who had diagnoses including Alzheimer's disease and acute pancreatitis, there was a physician's order to monitor daily weight and notify cardiology or the primary care physician if there was a significant weight increase. However, there were no documented weights for Resident 1 on specified dates, indicating a failure to adhere to the physician's orders. Similarly, Resident 3, diagnosed with end-stage renal disease and a history of falling, had a physician's order to be weighed on specific days before dialysis. The facility did not document weights on the required dates, and Resident 3 missed a scheduled dialysis appointment due to transportation issues. The Director of Nursing confirmed the lack of documentation for the ordered daily weights and the missed dialysis appointment, as well as the absence of notification to the physician about the missed treatment.
Failure to Provide Routine Medications
Penalty
Summary
The facility failed to provide routine drugs and pharmaceutical services to meet the needs of its residents, specifically for one resident. The facility's policy, titled Provider Pharmacy Requirements, dated 2007, mandates regular and reliable pharmaceutical services, including accurate dispensing of prescriptions and providing routine and emergency pharmacy services. However, a review of a resident's clinical record revealed that on a specific date, the resident missed their evening medications, including Midodrine, long-acting insulin, and Trazadone, because the medications were not available from the pharmacy. An interview with the Director of Nursing confirmed that the resident did not receive the medications as they were not available from the facility's contracted pharmacy, nor were they available in the facility's emergency medication supply. The resident's diagnoses included diabetes mellitus Type II, hypertension, and insomnia, which necessitated the timely administration of these medications. The failure to provide these medications was a direct violation of the facility's policy and state regulations regarding pharmacy and nursing services.
Failure to Document and Complete Wound Care Treatments
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for four residents with wound care orders. Resident 15, diagnosed with severe protein-calorie malnutrition and congestive heart failure, had multiple wound care orders documented in the July 2024 Treatment Administration Record (TAR). However, there was no evidence that the treatments were completed on several dates, including July 15, 17, 18, 19, 20, 22, and 24, 2024. Resident 17, with diagnoses of peripheral vascular disease and congestive heart failure, also had wound care orders documented in the July 2024 TAR. The treatments for wounds on the buttocks and left buttocks were not completed on July 27 and 28, 2024, during the night shift. Additionally, nursing progress notes indicated that treatments were not completed on July 9 and 28, 2024, due to time constraints. Resident 18, diagnosed with malignant neoplasm of the colon and sarcopenia, had an order for Calazime skin protectant application every shift, but there was no evidence of treatment completion on July 10 and 19, 2024, during the evening shifts. Resident 19, with peripheral vascular disease and diabetes mellitus, had missing documentation for treatments on July 1 and 17, 2024. The Director of Nursing confirmed the lack of additional information regarding the missing documentation of wound treatments.
Unqualified Staff Performing Out-of-Scope Tasks
Penalty
Summary
The facility failed to ensure that services provided to residents were conducted by staff with the appropriate skills, experience, and qualifications. Employee 3, a Certified Nursing Assistant (CNA), was found to have assisted Employee 4, a Licensed Practical Nurse (LPN), in tasks beyond the CNA's scope of practice. These tasks included passing medications, obtaining blood sugar readings using a glucometer, and turning off alarming IV pumps. Witness statements from other staff members and residents confirmed that Employee 3 was involved in these activities, which are not within the scope of practice for a CNA. Residents 20 and 21 were directly affected by these actions, as they received medications and had their blood sugar levels checked by Employee 3. Resident 20 confirmed receiving medications and having blood sugar checks conducted by Employee 3, while Resident 21 reported that Employee 3 administered medications and checked blood sugar levels on weekends. Another resident, Resident 22, witnessed Employee 3 giving medications to a roommate. Despite these actions, the facility's investigation revealed no adverse outcomes from Employee 3's actions. However, the facility acknowledged that Employee 3 acted outside of his scope of practice, leading to his termination and the barring of Employee 4 from returning to the facility.
Deficiency in Maintaining Safe and Clean Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and home-like environment in three of four resident shower rooms located on the first and second floor nursing units. During observations conducted on June 26, 2024, in the presence of the Director of Housekeeping, it was noted that the second floor men's shower room had a black substance on the floor at the base of the wall in two of the three showers. Similarly, the second floor women's shower room had a pink and black substance on the floor at the base of the wall on all three sides of the shower, a cracked blue mat on the shower gurney with exposed foam, and a non-functioning ceiling vent in front of the shower on the right. In the first floor shower room, a black substance was observed on the floor at the base of the wall on two sides, the sink was found to be separated from the wall and loose, and the ceiling vent on the right was not functioning. Interviews with the Director of Housekeeping revealed that shower rooms are cleaned every other day and as needed, and a request had been submitted to Maintenance to replace the silicone in the women's shower room on the second floor about a week prior. The Nursing Home Administrator was informed of these issues, and it was revealed that work orders for maintenance would be submitted and housekeeping contacted.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or mistreatment within the required 24-hour timeframe to the appropriate authorities, as per their policy. In the case of Resident 40, who had diagnoses including dementia and anxiety, a physical therapist reported that a nurse aide verbally abused the resident by making derogatory comments. The facility substantiated the verbal abuse but did not report the incident to the Area Agency on Aging until 24 days later, which was beyond the required reporting timeframe. Similarly, for Resident 61, who had diagnoses including morbid obesity and muscle weakness, an incident occurred where a respiratory therapist made derogatory remarks to the resident. The facility's investigation confirmed verbal abuse, and the therapist was barred from returning to the facility. However, the incident was not reported to the local authorities until six days after it occurred, again failing to meet the 24-hour reporting requirement. These failures were acknowledged by the Nursing Home Administrator during an interview.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for four residents, as required by their policy. Resident 38, diagnosed with dementia and hypertension, was admitted to hospice care and had an external urinary catheter placed, yet no care plans were developed to address these needs. Similarly, Resident 67, with peripheral vascular disease and gastro-esophageal reflux disease, was admitted to hospice care without a corresponding care plan. Interviews with the Director of Nursing confirmed the absence of these necessary care plans. Resident 68, diagnosed with chronic obstructive pulmonary disease and neuromuscular dysfunction of the bladder, was observed using supplemental oxygen and a urinary catheter, but their care plan lacked guidance for these interventions. Resident 82, with Alzheimer's disease and peripheral vascular disease, had an active physician order for catheter care, yet no care plan was developed to address the use of the catheter. The Director of Nursing acknowledged the lack of care plans for these residents, which is a violation of the facility's policy and state nursing service regulations.
Deficiencies in Food Safety and Sanitization Monitoring
Penalty
Summary
The facility failed to properly monitor and document the pH levels of the sanitizer sink used for manual ware-washing, as well as to store and serve food and beverages according to professional standards. The facility's policy required the use of quaternary test strips to measure the concentration of the sanitizer, which should range between 200-400 parts per million. However, observations revealed that there was no documentation of pH levels for May and June 2024, and the facility did not have the necessary pH test strips. Employee 4, the Food Service Director, confirmed that the contracted chemical supply company had not delivered the pH strips, and the facility was supposed to document the pH of the solution three times a day. Additionally, the facility did not adhere to its policies regarding the labeling and dating of food and beverages. In the kitchen area, a thawed chocolate nutritional supplement was not date-marked with a pull date from the freezer. In the second-floor nourishment pantry, several items in the freezer were not marked with a resident identifier, and pre-packaged hot dogs in the refrigerator were not date-marked. Similarly, in the Arcadia unit nourishment pantry, an open container of nectar thick cranberry juice and thawed nutritional shakes were not date-marked. Employee 4 acknowledged these oversights, indicating that the items should have been properly labeled and dated according to the facility's policies.
Infection Control Deficiencies in Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain proper infection control practices for two residents, leading to deficiencies in the implementation of enhanced barrier precautions. Resident 78, who had diagnoses including congestive heart failure and peripheral vascular disease, was found to have multiple severe ulcers. Despite the facility's policy requiring enhanced barrier precautions for residents with chronic wounds, no sign was posted on Resident 78's door, and during a wound dressing change, an employee did not wear a gown as required. The Director of Nursing confirmed these lapses in protocol. Similarly, Resident 82, diagnosed with Alzheimer's disease and peripheral vascular disease, had an indwelling catheter and was supposed to be under enhanced barrier precautions. However, no sign was posted on their door until observed by surveyors, despite the precautions being in place since the catheter was inserted. The Director of Nursing acknowledged that the signage should have been posted earlier, indicating a failure to adhere to the facility's infection control policies.
Failure to Inform Resident of Non-Covered Service Charges
Penalty
Summary
The facility failed to periodically inform a resident of charges for services not covered under Medicare or Medicaid. Resident 239, who was admitted for short-term rehabilitation with diagnoses including hypertension and heart failure, was not provided with the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) form. This form should have detailed the estimated cost of the facility's inpatient skilled nursing services starting from January 31, 2024, after the termination of Medicare A services on January 30, 2024. Consequently, Resident 239 was unaware of their financial responsibility for services from January 31, 2024, until their discharge on February 14, 2024. An interview with the Nursing Home Administrator revealed that the facility was aware of the failure to issue the SNF-ABN form to residents and began taking steps towards compliance in February 2024.
Care Plan Review and Revision Deficiencies
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised appropriately for three residents. Resident 32's care plan included interventions for a palm protector and a cam boot, which were no longer in use. The palm protector was discontinued, and the cam boot was removed from the care plan, but these changes were not reflected in the care plan. Observations confirmed that the resident was not wearing these items, and the Director of Nursing (DON) confirmed that they should have been removed from the care plan. Resident 62's care plan included the use of geri-sleeves to prevent skin tears, but these were discontinued and not removed from the care plan. The resident's physician orders did not include the use of geri-sleeves, and the DON confirmed that they should have been removed from the care plan. The care plan also included interventions for skin tears, which were documented in the physician orders. Resident 70's care plan was incomplete, as it was entered as a template and not updated with specific information for the resident. The care plan included interventions for assistance with activities of daily living, but the specific details were not filled in. The DON acknowledged that the care plan should have been revised and updated with resident-specific information.
Failure to Assist Resident with Grooming Needs
Penalty
Summary
The facility failed to provide adequate grooming care for a resident, identified as Resident 72, who was unable to perform activities of daily living (ADLs) due to medical conditions including Alzheimer's disease and pleural effusion. The facility's policy on ADLs, revised in May 2023, mandates that residents who cannot perform ADLs independently should receive necessary assistance to maintain personal hygiene. However, observations on two consecutive days revealed that Resident 72 had significant facial hair, which she expressed a desire to have removed but was unable to do so herself. The resident's care plan, which noted an ADL self-care deficit due to weakness related to pleural effusion, included an intervention to assist with daily hygiene and grooming. Despite this, the resident was observed with unaddressed facial hair, indicating a lapse in the implementation of her care plan. Interviews with the resident and the Director of Nursing confirmed the oversight, as the resident had not been shaved as required by her care plan.
Failure to Ensure Proper Wound Care and Hygiene
Penalty
Summary
The facility failed to provide appropriate treatment and services to promote healing and prevent infection for a resident with pressure injuries. The resident, who had diagnoses including congestive heart failure and peripheral vascular disease, was observed to have a stage 4 pressure ulcer on the sacrum, a stage 4 pressure ulcer on the right heel, and a non-pressure full thickness ulcer on the lower right leg. During a wound treatment change, an employee used the same paper measuring tape for all wounds without changing it between measurements, which is against proper protocol. Additionally, the employee did not change gloves or perform hand hygiene between handling different wounds and dressing changes. This was observed during the application of a dressing to the right lower leg wound, the removal of the sacral dressing, the cleansing of the sacral wound, and the application of a new dressing to the sacral wound. The Director of Nursing confirmed that disposable items should not be reused on multiple wounds and that proper hand hygiene and glove changes should occur between wound treatments.
Failure to Follow Up on UTI Symptoms in Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who was incontinent of bladder, leading to a deficiency in preventing urinary tract infections (UTIs). The resident, who had diagnoses including peripheral vascular disease and hypertension, was diagnosed with a UTI on April 30, 2024. The resident was prescribed Keflex, an antibiotic, to be taken three times a day for seven days, with the last dose administered on May 8, 2024. Despite the treatment, a progress note on May 8, 2024, indicated that the resident continued to experience burning during urination, a symptom of UTI. The facility's interdisciplinary plan of care for the resident included an intervention to report signs and symptoms of UTI, such as burning during urination. However, there was no documented follow-up on the resident's continued symptoms until a urine culture was ordered on June 6, 2024. During an interview, the Director of Nursing confirmed that there was no follow-up on the progress note from May 8, 2024, and acknowledged that additional follow-up should have been completed before June 6, 2024.
Failure in Respiratory Care Equipment Maintenance
Penalty
Summary
The facility failed to provide respiratory care and oxygen services consistent with professional standards of practice for a resident diagnosed with amyotrophic lateral sclerosis (ALS), chronic obstructive pulmonary disease (COPD), and other conditions. The facility's policy on Bi-level Positive Airway Pressure (Bi-PAP) and Continuous Positive Airway Pressure (CPAP) devices, including the Trilogy device, lacked information on cleaning and storage of equipment. This omission contributed to improper handling and storage of the Trilogy mask used by the resident. Observations revealed that the Trilogy mask was found on the floor and later on the nightstand with a light tan substance in its fold, indicating inadequate cleaning and storage. Interviews with the resident and staff confirmed that the resident required assistance with the mask, and the mask should have been stored in a plastic bag and cleaned weekly. The Nursing Home Administrator also confirmed the mask should be stored properly and cleaned as needed, highlighting a failure in adhering to the facility's standards for respiratory care equipment maintenance.
Failure to Conduct Annual Performance Review for Nurse Aide
Penalty
Summary
The facility failed to complete a performance review for one of the five nurse aides reviewed, specifically Employee 2, within the required 12-month period. According to the facility's policy, titled HR616 Performance Appraisal, managers are required to meet with their employees at least annually to conduct a performance appraisal or have a performance-based conversation. This policy also states that in-service education will be provided based on the outcomes of these reviews. Employee 2 was hired on December 10, 2022, and as of June 26, 2024, no yearly performance evaluation had been conducted for this employee. During a staff interview, the Nursing Home Administrator confirmed that Employee 2 did not have a performance evaluation conducted, acknowledging that employees should have performance reviews conducted yearly.
Failure to Educate Resident on Influenza Vaccination
Penalty
Summary
The facility failed to ensure that a resident was educated on the influenza vaccination. A review of the clinical record for a resident with diagnoses of type 2 diabetes mellitus and hypertension revealed that the resident was admitted to the facility and subsequently refused the influenza vaccination for the 2023-2024 season. However, there was no documentation of the resident's declination of the vaccine or evidence that the resident was provided with education and a vaccine information statement regarding the influenza vaccination. During a staff interview, the Director of Nursing confirmed the lack of documentation and education provided to the resident.
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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