Failure to Honor Resident's DNR Status and Inadequate QAPI Response
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address all causal factors related to four staff members providing Cardiopulmonary Resuscitation (CPR) to a resident with an Advanced Directive for Do Not Resuscitate (DNR). The QAPI committee also failed to notify the Governing Body of the adverse event. The incident involved a resident whose end-of-life wishes were not honored, as licensed staff did not review the resident's chart for code status prior to initiating CPR. Additionally, the resident's nurse was not in the facility at the time of the code and could not immediately locate the appropriate paperwork to identify the resident's DNR status when she returned. All licensed staff performing CPR on the resident did not have current CPR certification at the time of the incident. The facility did not develop or implement an action plan to prevent recurrence of such events. The incident occurred when a Certified Nursing Assistant (CNA) noticed the resident's breathing was shallow and their color had changed. The CNA called for help, and a Registered Nurse (RN) and a CPR Instructor responded. The RN began chest compressions, and the CPR Instructor called a Code Blue. The resident's nurse returned to the facility during the code but was unable to verify the resident's DNR status. The resident expired after CPR was performed. The QAPI committee's documentation did not include a performance improvement plan or any corrective actions to address the incident. Interviews with staff revealed that the nurses involved in the incident assumed the code status had been checked and proceeded with CPR. The Director of Nursing (DON) confirmed that the facility's policy on CPR and Advance Directives was not followed. The Administrator acknowledged that the incident was discussed in a QAPI meeting, but no performance improvement plan was developed. The Regional President of the facility's management company was not notified of the adverse event until much later and expressed concern that the facility did not honor the resident's end-of-life wishes. The incident was not reported to the State Agency as required.
Removal Plan
- Clinical operations (Clin-Ops) nurse will in-service the Executive Director (ED), Director of Nursing (DNS) and Quality Assurance and Performance Improvement (QAPI) committee on new policy A.3a. titled, Accident/Incident & Adverse Events.
- ED and DNS will in-service 100% of licensed staff on Accident/Incident & Adverse Event Documentation and Investigation. No licensed staff member will be allowed to work until completion of in-service.
- System to be followed per policy, Notification and Documentation in the Resident's Medical Record: a. The Licensed Nurse shall place the resident on the 24-Hour Report, document the incident, and notify the supervisor and Director of Nursing for follow through prior to the end of shift in which the accident/incident or adverse event occurs.
- The Licensed Nurse may complete a Nurses' Note and update the Resident Care Plan.
- The Nurse's Notes could contain the following documentation.
- The Executive Director/Director of Nursing will notify the State Department of Health in accordance with reporting guidelines in the event the accident/incident is reportable.
- The Executive Director/Director of Nursing will monitor, track, and trend the accident/incident and adverse event through utilization of the electronic medical record quality assurance reports. These reports will be reviewed through the weekly Risk Review Meeting attended by the Interdisciplinary team (IDT). The event log will be reviewed in the Quality Assurance Performance Improvement (QAPI) meeting.
- Through investigation and root cause analysis, performance improvement plans will be implemented to correct all causal factors of the adverse event.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility QAPI committee failed to correct repeated quality deficiencies and did not ensure that plans to improve care and services effectively addressed them. A prior survey had cited the facility and included QAPI-related plans of correction, but the current survey found multiple repeat deficiencies, including F604, F609, F628, F700, F880, F883, and PA1020. The NHA confirmed the facility had multiple repeat deficiencies and had not corrected the quality issues.
QAPI minutes showed an ongoing PIP for pressure ulcers, but the facility did not document clear interventions, data analysis, or a plan showing how it would reach its stated goals. The minutes contained inconsistent pressure ulcer entries, blank or incomplete PIP sections, and separate short-stay and long-stay references without explanation. The DON confirmed the facility had no documented analysis of the PIP and no laid-out plan for how the project would be carried out.
The facility’s QAPI committee failed to resolve repeated deficiencies involving medication storage and labeling, food served at improper temperatures and not palatable, and staff not wearing hair coverings in the kitchen. Prior POCs called for audits and reporting to QAPI, but surveyors again cited the same issues under F761, F804, and F812 on the current survey.
A facility’s QAPI committee failed to correct recurring deficiencies involving a clean, homelike environment, pressure ulcer prevention, drug regimen reviews, safe food storage/preparation/service, and infection control. Prior plans of correction relied on audits and reporting to QAPI, but the same deficient practices were again cited in the current survey under F584, F686, F756, F812, and F880.
Failure to Address Ongoing Rodent Infestation in QAPI: The facility did not use its QAPI process to address a known rodent problem. Rodent feces and traps were observed in resident rooms, dining and food areas, clean dish and linen areas, and other parts of the building. Interviews confirmed the infestation was ongoing, recommended structural repairs had not been made, the issue was not discussed in the QAPI meeting, and no education had been provided to residents or staff.
QAPI failed to track and monitor a black debris issue in the 300-hall shower room. An observation found black debris in the shower’s inner bottom corners, and records showed the QAPI plan only listed environmental rounds monitored by the Administrator and Maintenance without further comments. The Maintenance Supervisor said he knew about the issue, had cleaned it, but did not document weekly rounds or findings, and the Administrator also said he did not document the weekly monitoring.
QAPI Committee Failed to Correct Repeat Deficiencies
Penalty
Summary
The facility QAPI committee failed to correct repeated quality deficiencies and did not ensure that plans to improve the delivery of care and services effectively addressed those deficiencies. A prior State Survey and Certification survey ending August 22, 2025, cited the facility and included plans of correction with quality assurance systems intended to maintain compliance with nursing home regulations. However, the current survey ending August 7, 2026, found repeated deficiencies from the prior survey, including F604, F609, F628, F700, F880, F883, and PA1020. During an interview on 8/6/26 at 3:00 p.m., the Nursing Home Administrator confirmed that the facility had multiple repeat deficiencies from the previous survey and that the facility failed to correct the quality deficiencies and ensure that plans to improve care and services effectively addressed them.
QAPI PIP for Pressure Ulcers Lacked Documented Interventions and Analysis
Penalty
Summary
The facility failed to provide evidence of a required Performance Improvement Project (PIP) focused on pressure ulcers, despite multiple QAPI meeting minutes showing the topic was discussed over time. The minutes reviewed showed changing pressure ulcer goals and data entries, including a goal to reduce pressure ulcers to at or below 2%, later a goal of zero new facility-acquired pressure ulcers, and later a PIP listing pressure ulcers at 10.6% with national and state comparisons of 5.7% and 6.1%. However, the minutes did not include identified interventions, analysis of current facility practices, resident data explaining the increase, or documentation showing how the facility planned to reach the stated goals. The 6/26/26 QAPI minutes also contained inconsistent pressure ulcer entries, including a section for new or worsening pressure ulcers, another section for pressure ulcer trends, and a separate current PIP for short-stay residents with current data listed as 0%. The facility did not explain why pressure ulcers were being separated into short-stay and long-stay residents, and the current PIP section was at times blank or lacked supporting detail. During interview, the DON and administrator stated there had been staff turnover and the person taking minutes had not entered the data, and the DON confirmed the facility had no documented analysis of the PIP project and no laid-out plan showing what the facility was going to do or how it was going to do it.
QAPI Failed to Resolve Repeated Medication, Food Service, and Kitchen Compliance Deficiencies
Penalty
Summary
The facility’s QAPI committee failed to correct recurring quality deficiencies identified in prior surveys and did not ensure that plans of correction effectively addressed repeated problems in the delivery of care and services. The report states that a prior State Survey and Certification survey ending June 26, 2026, had cited deficiencies involving medication storage and labeling, food being served at improper temperatures and not being palatable, food items not being dated as required, and staff not wearing hair coverings in the kitchen, with plans of correction that included audits and reporting results to the QAPI committee. On the current survey ending July 30, 2026, surveyors again found repeated deficiencies related to medication storage and labeling under F761, food not being palatable and not at appropriate temperatures under F804, and failure to wear hair coverings in the kitchen under F812. The report states that the facility’s QAPI committee failed to successfully implement the prior plans to ensure ongoing compliance with medication labeling/storage, food temperature and palatability, and the wearing of appropriate hair coverings in the kitchen.
QAPI Committee Failed to Correct Repeated Deficiencies
Penalty
Summary
The facility’s QAPI committee failed to correct recurring deficient practices identified in prior surveys and complaint investigations. The report states that previous plans of correction for deficiencies involving a clean, homelike environment, pressure ulcer development/prevention, drug regime reviews, food storage/preparation/service, and infection control included quality assurance systems and audits to be reported to the QAPI committee, but the current survey found those same areas remained deficient. The current survey ending July 23, 2026 cited repeated deficiencies under F584, F686, F756, F812, and F880, showing that the committee was ineffective in correcting the cited practices. The report also notes that the facility’s prior survey ending August 14, 2025 and complaint surveys ending March 19, 2026 and April 28, 2026 had already identified these issues and that the facility’s plans of correction relied on audits and QAPI review. Despite those plans, the current survey again found deficiencies related to the clean/homelike environment, pressure ulcer development/prevention, drug regime reviews, food store/prepare/serve safely, and infection control. The cited regulatory references included 28 Pa. Code 201.14(a) Responsibility of licensee and 28 Pa. Code 201.18(e)(1) Management.
Failure to Address Ongoing Rodent Infestation in QAPI
Penalty
Summary
The facility failed to establish a system to address, monitor, and take action on a known rodent problem through its QAPI process. The QAPI committee notes from 7/14/26 did not document any plan for the rodent infestation, monitoring of the identified issue, infection concerns related to the infestation, or the structural repairs recommended by the pest control service. The meeting was documented as attended by the owner, administrator, DON, and IP, but the rodent problem was not addressed in the notes. During observation on 7/15/26, rodent feces were seen in resident rooms, the dining room, food storage, food preparation areas, clean dishes, the kitchen floor, medical supply storage areas, and sanitary linen areas. Bait boxes, glue traps, and snap traps were also observed in resident rooms, on a resident's dresser and bed, in closets, hallways, the dining room, food storage areas, and the basement. R4 stated she had recently trapped three rodents in her room and had purchased her own traps. Interviews with the administrator, owner, exterminator, DON, and IP confirmed the facility had an ongoing rodent problem, that recommended structural repairs had not been made, that the issue was not addressed at the QAPI meeting, and that no education had been provided to residents or staff to reduce or control the infestation.
QAPI Committee Failed to Track and Monitor Shower Room Deficiency
Penalty
Summary
The facility’s QAPI committee failed to take actions aimed at performance improvement and, after implementing those actions, failed to measure success and track performance to ensure improvements were realized and sustained. During an observation on 07/21/2026 at 3:05 PM, black debris was seen in the inner bottom corners of the 300-hall shower room, with white paste that was open and black debris underneath. Record review showed the facility’s QAPI plan for Environmental Rounds listed monitoring by the Administrator and Maintenance, but there were no additional comments addressing the environment or shower rooms. The Maintenance Supervisor stated he was aware of the black debris in the 300-hall shower room, said it had been cleaned with a chemical and wire brush, and said caulking had been applied, but he could not recall when the debris was removed and had no invoices or receipts. He also stated he did not document weekly rounds or findings. The Administrator stated he and the Maintenance Supervisor rounded weekly as part of the QAPI plan after the shower had been identified with black debris during the annual survey exit on 05/21/2026, but he did not document the rounds and had no documentation showing monitoring of the shower.
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