Fair Acres Geriatric Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lima, Pennsylvania.
- Location
- 340 N. Middletown Road, Lima, Pennsylvania 19037
- CMS Provider Number
- 395780
- Inspections on file
- 24
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Fair Acres Geriatric Center during CMS and state inspections, most recent first.
Surveyors found that residents were not educated on filing grievances and that grievance forms or boxes were not available or accessible on five nursing units. Staff interviews confirmed the absence of standardized grievance materials, and the DON stated there was no formal grievance policy. Resident council minutes showed no education on the grievance process.
The facility failed to maintain and inspect its emergency generator, lacking documentation for a 3-year, 4-hour load test, an annual 90-minute load bank test, and an annual fuel quality test. This deficiency was confirmed during an exit interview with the Maintenance Director.
The facility failed to maintain and inspect the fire alarm system, as the annual inspection report noted that the kitchen's duct detector was missing and untested. The facility lacked documentation of remediation, confirmed by the Maintenance Director.
The facility failed to maintain and inspect its sprinkler system, as it could not provide documentation of a dry sprinkler full flow test within the past three years and had a missing sprinkler escutcheon above the ice machine on the fifth floor. These issues were confirmed during an exit interview with the Maintenance Director.
The facility failed to maintain the door to a hazardous area on the first floor, as observed when the Clean Utility Room entry door was missing a strike plate. This deficiency was confirmed by the Maintenance Director.
The facility failed to maintain smoke barrier doors in compliance with NFPA 101 standards. Observations revealed that doors on the first floor did not close smoke tight and had missing hardware, while a door on the second floor was obstructed by a bariatric chair. These deficiencies were confirmed during an exit interview with the Maintenance Director.
The facility failed to prevent the unauthorized use of electrical devices, as observed in a designated smoking room and Resident Room 118. A fan was powered by a surge protector in the smoking room, and a light duty extension cord was used for resident electronics in Room 118. Additionally, an oscillating fan was plugged into a power outlet multiplier in the same room. These actions were confirmed by the Maintenance Director, indicating non-compliance with NFPA 101 standards.
The facility failed to maintain proper oxygen storage and cylinder identification. On one floor, the Clean Utility Room lacked required precautionary signage for oxygen storage. Additionally, on another floor, full and empty oxygen cylinders were mixed, and on the ground floor, cylinders were not labeled. These deficiencies were confirmed during an exit interview with the Maintenance Director.
The facility failed to maintain portable fire extinguishers on two floors. A fire extinguisher was blocked by a laundry cart, and others were improperly mounted, affecting access. These issues were confirmed by the Maintenance Director.
The facility did not maintain the fire resistance rating of vertical openings on the tenth floor. An observation revealed that the rated access ceiling door in the Electrical Closet next to room 1020 failed to self-close and latch, as confirmed by the Maintenance Director.
A facility failed to maintain corridor doors to resist smoke passage and positively latch, as observed in resident room 211. The door did not latch properly, compromising safety standards. This was confirmed by the Maintenance Director during an exit interview.
The facility failed to maintain smoke barrier walls free of unsealed penetrations, as observed on the eleventh floor above the smoke doors by room 1108. An unsealed penetration around electrical conduits was noted, which was confirmed by the Maintenance Director.
The facility did not maintain its HVAC system properly on one floor, as three portable air conditioning units were vented above the drop ceiling into the interstitial space, creating a plenum. This was confirmed by the Maintenance Director.
The facility failed to maintain the fire protection rating for linen chutes, with deficiencies observed on multiple floors. Chute doors in soiled utility rooms on the second, third, fourth, seventh, eighth, and tenth floors were found to be non-compliant, either failing to latch or being propped open. These issues were confirmed by the Maintenance Director, affecting six out of fifteen levels in the facility.
The facility failed to maintain electrical wiring protection on the tenth floor, where a junction box above the smoke doors at a resident's room was missing its cover plate, exposing the wiring. This was confirmed by the Maintenance Director.
A resident's drug regimen review at Fair Acres Geriatric Center revealed that the attending physician did not address several medication recommendations made by a pharmacist. These included discontinuing certain supplements and adjusting medication timing. The facility's Director of Nursing confirmed the absence of documented physician responses, indicating non-compliance with drug regimen review requirements.
Failure to Provide Grievance Education and Accessible Grievance Materials
Penalty
Summary
The facility failed to provide evidence that residents were educated on the process of filing grievances and did not ensure that grievance forms or boxes were available and accessible on the nursing units across five floors. Observations on multiple floors revealed the absence of grievance forms and drop boxes, and staff interviews confirmed that these resources were not present. Instead, staff reported that residents could either call a posted phone number, write complaints on plain paper, or use blank envelopes to submit grievances, but no standardized forms or accessible boxes were available on the units. In the main lobby, a complaint box was observed, but no grievance forms were available for residents to use. Review of facility documentation, including resident council minutes, showed no evidence of education or discussion regarding the grievance process. Additionally, the Director of Nursing confirmed that the facility did not have a formal grievance policy in place. The facility's policy on resident rights referenced staff training but did not address resident education or the availability of grievance materials. These findings demonstrate a lack of compliance with requirements to honor residents' rights to voice grievances without discrimination or reprisal.
Failure to Maintain and Inspect Emergency Generator
Penalty
Summary
The facility failed to maintain and inspect its emergency generator as required by NFPA standards. During a document review on February 3, 2025, it was discovered that the facility could not provide documentation of a 3-year, 4-hour load test of the emergency generator. This test is crucial to ensure the generator's capability to supply service within 10 seconds, as stipulated by NFPA 101 and NFPA 110. Further investigation revealed additional deficiencies in the facility's maintenance and testing procedures. The facility was unable to provide documentation for an annual 90-minute load bank test and an annual fuel quality test. These tests are essential to verify the reliability and efficiency of the emergency power system, which is critical for the safety and well-being of the residents. An exit interview with the Maintenance Director on February 4, 2025, confirmed the lack of documentation for these required tests and inspections. The absence of these records indicates a failure to adhere to the necessary maintenance protocols, potentially compromising the facility's ability to provide essential power in emergencies.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. Documentation will be provided by outside contractor for 3-year, 4-hour load test of emergency generator. Submission of Load test paper documentation will be checked quarterly to ensure all proper documentation is maintained. Documentation provided by outside contractor for 3-year, 4-hour load test of emergency generator. Documentation provided by outside contractor for Annual load bank test of. Documentation provided by outside contractor, Ferguson & McCann for fuel quality test. All paperwork needed for these items will be reviewed monthly by maintenance designee to ensure this issue does not reoccur.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain and inspect the fire alarm system as required, affecting the entire component. During a document review on February 3, 2025, it was discovered that the annual fire alarm inspection report dated May 2, 2024, indicated that the duct detector for the kitchen could not be found and was not tested. The facility was unable to provide documentation showing that this deficiency had been addressed. This was confirmed during an exit interview with the Maintenance Director on February 4, 2025.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0345 Johnson Controls Fire Protection was contacted and will provide information on the functionality of the duct detector. Annual fire alarm report will be reviewed by Maintenance designee to ensure this issue does not reoccur.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain and inspect its sprinkler system as required, affecting the entire component. During a document review on February 3, 2025, it was found that the facility could not provide documentation that a dry sprinkler full flow test had been conducted within the past three years. Additionally, an observation on February 4, 2025, revealed a missing sprinkler escutcheon above the ice machine on the fifth floor. These deficiencies were confirmed during an exit interview with the Maintenance Director on February 4, 2025.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0353 - 1 Sprinkler Company will be contracted to perform inspection. Area will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0353 - 2 Escutcheon was replaced. Area will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated.
Deficiency in Door Maintenance to Hazardous Area
Penalty
Summary
The facility failed to maintain the integrity of doors to hazardous areas, specifically on the first floor. During an observation on February 3, 2025, at 10:35 a.m., it was noted that the entry door to the Clean Utility Room was missing a strike plate. This deficiency was confirmed during an exit interview with the Maintenance Director on February 4, 2025, at 1:00 p.m. The absence of the strike plate compromises the door's ability to function as a proper barrier in accordance with fire safety regulations.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal Law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any court proceedings. New strike plate was installed and will be monitored monthly for one quarter by a maintenance department designee to ensure condition is not replicated.
Failure to Maintain Smoke Barrier Doors
Penalty
Summary
The facility failed to maintain smoke doors in compliance with NFPA 101 standards, affecting multiple areas across different floors. On February 3, 2025, observations revealed that the double doors to the Day Room on the first floor, next to rooms 129 and 118, did not close smoke tight when tested. Additionally, on the same day, the double smoke barrier doors next to the elevator on the first floor were found to have missing hardware on the push bar. These deficiencies were confirmed during an exit interview with the Maintenance Director on February 4, 2025. Further observations on February 4, 2025, indicated that on the second floor, next to room 208, one of the double smoke doors was obstructed by a bariatric chair, preventing it from closing smoke tight. This condition was also confirmed during the exit interview with the Maintenance Director. These findings demonstrate a failure to ensure that smoke barrier doors were maintained to resist the passage of smoke, as required by the NFPA 101 standards.
Plan Of Correction
Plan of Correction: Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0374 A & B A. New door coordinator for double doors next to room 129 will be installed. Door will be monitored monthly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. B. New door coordinator for double doors next to room 118 will be installed. Door will be monitored monthly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0374 Missing Hardware on push bar was installed on door. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. 2/19/2025 Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. Chair was removed from area blocking fire doors. Door was checked to ensure smoke tight closure. Fire and Safety or designee will monitor area weekly for 1 quarter to ensure this issue does not reoccur.
Unauthorized Use of Electrical Devices in Facility
Penalty
Summary
The facility was found to have failed in prohibiting the improper and unauthorized use of electrical devices, as observed during a survey. On February 3, 2025, between 9:00 a.m. and 12:30 p.m., it was noted that a fan in the designated smoking room was powered using a surge protector, which is not compliant with the regulations. Additionally, in Resident Room 118, a brown light duty extension cord was used to power resident electronics, which is against the guidelines that prohibit the use of extension cords as a substitute for fixed wiring. Further observations on February 4, 2025, at 10:20 a.m., revealed another instance of non-compliance in Resident Room 118, where an oscillating fan was plugged into a power outlet multiplier. These findings were confirmed during an exit interview with the Maintenance Director on February 4, 2025, at 1:00 p.m. The use of these unauthorized electrical devices indicates a failure to adhere to the standards set by NFPA 101 and related codes, which are designed to ensure safety in the facility.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0920 a & b a. Fan power source was relocated to wall outlet. Smoking room will be monitored weekly for one quarter by maintenance designee to ensure this condition is not replicated. b. Extension cord was removed. Room 118 will be monitored weekly for one quarter by maintenance designee to ensure this condition is not replicated. Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0920 Fan was plugged into wall outlet. Fire and Safety or designee will monitor room weekly for 1 quarter.
Deficiencies in Oxygen Storage and Cylinder Identification
Penalty
Summary
The facility failed to maintain proper oxygen storage requirements, as evidenced by observations and interviews conducted during the survey. On the first level, the Clean Utility Room lacked the necessary precautionary signage for oxygen storage, which should include the wording: "CAUTION: OXIDIZING GAS(ES) STORED WITHIN, NO SMOKING." This deficiency was confirmed during an exit interview with the Maintenance Director. Additionally, the facility did not properly store and identify medical gas cylinders on one of the three floors. On the second floor, full and empty oxygen cylinders were mixed in both racks, and on the ground floor, the cylinders were not labeled to distinguish between full and empty. These issues were also confirmed during the exit interview with the Maintenance Director.
Plan Of Correction
Plan of Correction: Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. New signage was installed. First level clean utility room will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0923 a & b A. New signage will be installed on second floor inside oxygen storage to ensure there is no mixing of full versus empty cylinders. Area will be monitored weekly for 1 quarter by a maintenance department designee to ensure this condition is not replicated. B. New signage on ground floor will be installed to label/designate full versus empty cylinders. Area will be monitored weekly for 1 quarter by a maintenance department designee to ensure this condition is not replicated.
Deficiencies in Fire Extinguisher Maintenance
Penalty
Summary
The facility failed to maintain portable fire extinguishers in accordance with NFPA 10 standards on two of fifteen floors. On February 3, 2025, a fire extinguisher in a corridor was obstructed by an unattended soiled laundry cart, as observed at 10:25 a.m. This was confirmed during an exit interview with the Maintenance Director on February 4, 2025. Further deficiencies were noted on February 4, 2025, between 9:40 a.m. and 10:30 a.m. On the thirteenth floor, next to stair tower #2, a fire extinguisher was improperly hung by its hose due to a missing mounting bracket. Additionally, on the tenth floor, fire extinguishers were mounted directly below handrails, impeding direct access. These issues were also confirmed in an exit interview with the Maintenance Director.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0355 Laundry cart was moved. Staff was in-serviced on the importance of not blocking fire extinguishers with laundry cart. Area will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0355 a New extinguisher and bracket was installed. Area will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. b Extinguishers will be remounted above handrail. Area will be monitored weekly for one quarter and by Fire & Safety Supervisor or designee for 1 quarter to ensure this condition is not replicated.
Failure to Maintain Fire Resistance Rating on Tenth Floor
Penalty
Summary
The facility failed to maintain the fire resistance rating of vertical openings, specifically affecting the tenth floor. During an observation on February 4, 2025, at 10:40 a.m., it was noted that the rated access ceiling door in the Electrical Closet next to room 1020 did not self-close and latch as required. This deficiency was confirmed during an exit interview with the Maintenance Director at 1:00 p.m. on the same day.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. Spring will be reset on ceiling door to ensure latching and ability to close. Ceiling door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated.
Corridor Door Fails to Latch, Compromising Smoke Resistance
Penalty
Summary
The facility failed to ensure that corridor doors were maintained to resist the passage of smoke and positively latch, as required by regulations. During an observation on February 4, 2025, at 10:50 a.m., it was noted that the door to resident room 211 on the second floor did not positively latch in the frame. This deficiency was identified as one of over three hundred corridor doors within the facility. The issue was confirmed during an exit interview with the Maintenance Director on the same day at 1:00 p.m. The report highlights that the door's inability to latch properly compromises its function to resist smoke passage, which is a critical safety requirement in long-term care facilities. The deficiency was observed and documented by surveyors, indicating a lapse in the facility's maintenance of safety standards for corridor doors.
Plan Of Correction
Exit Date: 02/04/25 0363 Scope/ Severity: E NFPA 101 STANDARD Corridor - Doors: Name - BLDG. 8 Component - 05 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. Observations: Based on observation and interview, it was determined the facility failed to ensure that corridor doors were maintained to resist the passage of smoke and positively latch on one of over three hundred corridor doors within the facility. Findings include: Observation on February 4, 2025, at 10:50 a.m., revealed, on the second floor, resident room 211, failed to positively latch in the frame. Exit interview with the Maintenance Director on February 4, 2025, at 1:00 p.m., confirmed the door did not latch. Plan of Correction: Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0363 Door was repaired to latch in the frame. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated.
Unsealed Penetration in Smoke Barrier Wall
Penalty
Summary
The facility failed to maintain smoke barrier walls free of unsealed penetrations, which is a requirement for ensuring a 1/2-hour fire resistance rating. During an observation on February 4, 2025, at 10:00 a.m., it was noted that on the eleventh floor, above the smoke doors by room 1108, there was an unsealed penetration around electrical conduits. This deficiency was confirmed during an exit interview with the Maintenance Director on the same day at 1:00 p.m.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0372 Penetration will be sealed with UL Rated Fire Stop. Fire safety supervisor or designee will monitor area weekly for 1 Quarter to ensure this condition is not replicated.
HVAC System Deficiency Due to Improper Venting
Penalty
Summary
The facility failed to maintain the heating, ventilating, and air conditioning (HVAC) system on one of its fifteen floors. During an observation on the ground floor inside the office therapy department, it was found that three portable air conditioning units were vented above the drop ceiling into the interstitial space, creating a plenum. This observation was confirmed during an exit interview with the Maintenance Director.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0521 Temporary AC units were removed from the building. Maintenance Department or designee will monitor are weekly for one quarter to ensure this issue does not reoccur.
Fire Protection Deficiencies in Linen Chutes
Penalty
Summary
The facility failed to maintain the fire protection rating for linen chutes, as evidenced by several deficiencies observed during a survey. On multiple floors, including the second, third, fourth, seventh, eighth, and tenth, the rubbish and laundry chute doors in the soiled utility rooms were found to be non-compliant. Specifically, the chute doors on the second and third floors failed to positively latch, while the chute door on the fourth floor was propped open by a lining cart. Additionally, the chute doors on the seventh, eighth, and tenth floors failed to close and latch properly. These deficiencies were confirmed during an exit interview with the Maintenance Director, who acknowledged the issues with the chute doors. The failure to maintain the fire protection rating for these chutes affects six out of fifteen levels in the facility, indicating a significant lapse in maintaining fire safety standards as required by NFPA 101. The report does not mention any corrective actions or plans to address these deficiencies.
Plan Of Correction
Plan of Correction: Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0541-a Door was repaired to positive latch. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0541-b Door was repaired to positive latch. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0541-c Linen chute door was closed and Facility staff will be educated about the hazards of propping doors open. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0541-d Door will be repaired to positive latch. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0541-e Door will be repaired to positive latch. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0541-f Door will be repaired to positive latch. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated.
Electrical Wiring Protection Deficiency
Penalty
Summary
The facility failed to maintain the protection of electrical wiring, as observed on the tenth floor. Specifically, a junction box located above the double smoke doors at resident room 1008 was missing its cover plate, which exposed the inner wiring. This deficiency was identified during an observation conducted on February 4, 2025, at 10:15 a.m. The Maintenance Director confirmed the missing cover plate during an exit interview later that day at 1:00 p.m.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0911 Junction box cover was replaced. Facilities Director or designee will monitor weekly for 1 Quarter to ensure this issue does not reoccur.
Failure to Act on Pharmacist's Recommendations
Penalty
Summary
Fair Acres Geriatric Center was found to be non-compliant with the requirements for drug regimen review as per 42 CFR 483.45(c). The facility failed to ensure that medication irregularities identified by a licensed pharmacist were acted upon by a physician for one of the residents reviewed. Specifically, the pharmacist's recommendations to discontinue certain medications and adjust the timing of another were not addressed by the attending physician. These recommendations included discontinuing D-Mannose due to ongoing urinary tract infections and potential effects on blood sugar, Melatonin due to concurrent use with Trazadone for insomnia, Glucosamine-Chondroitin due to uncontrolled pain, and PreserVision AREDS 2 due to duplication with another multivitamin. Additionally, a recommendation was made to change the timing of Omeprazole to optimize its effectiveness. The clinical record of the resident in question did not contain any documentation from the attending physician acknowledging or addressing these recommendations. During an interview, the Director of Nursing confirmed the absence of documented evidence of a physician's response to the pharmacist's recommendations. This lack of action and documentation constitutes a failure to comply with the federal and state regulations regarding drug regimen reviews and the necessary follow-up actions by the attending physician.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court finding. All residents receiving a Drug Regimen Review have the potential to be affected. Resident R134 was seen by the physician following the pharmacy recommendation that was reviewed by the physician on 10/9/24 on 10/21/24, 11/21/24, 12/20/2024, and 1/22/25. Resident R134 had drug regimen reviews completed on 11/6/24, 12/6/24, and 1/8/24 which did not have any additional recommendations for the physician. Medication Regimen Review Policy and Procedure was reviewed. The physicians were re-educated on the Medication Regimen Review Policy and Procedure. DON, or designee, will audit for documented evidence of a response to Drug Regimen Reviews. Audits will occur monthly x3. If trends are identified, corrective action, including a Root Cause Analysis, will be reported to the QA Committee.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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