Failure to Follow Dietary Orders Leads to Resident's Death
Summary
The facility administration failed to ensure dietary orders were followed, resulting in a resident's death due to choking. The resident, who had a medical history including cerebrovascular accident (CVA), dysphagia, and dementia, was on a prescribed pureed diet with thin consistency. However, the resident was found with a deli sandwich, which was not in accordance with her dietary orders, leading to her choking and subsequent death despite attempts to perform the Heimlich maneuver. The Director of Nursing (DON) was aware of the incident but did not follow up with an investigation or speak with the night CNAs involved. The DON reported that she left messages for the CNAs, who were as-needed employees, but did not receive a response. Additionally, there was no documentation to verify that staff education regarding dietary orders had been provided, and the DON acknowledged the lack of investigative information related to the resident's death. The Administrator was not fully informed of the situation at the time of the incident and only learned about the circumstances later. The Administrator acknowledged that there should have been in-servicing of the staff and that the DON should have communicated the details of the incident to him. The CNAs involved claimed that the resident took the sandwich from another resident, and the Administrator reported that education for staff on following dietary orders had since started.
Removal Plan
- The Administration failed to effectively and efficiently oversee the wound care program. The Administration also failed to provide oversight to ensure dietary orders were being followed.
- The Administrator was re-educated and the DON will be re-educated by the Regional Nurse on Wound Treatment Management Policy, Skin Assessment Policy, Pressure Injury Prevention Policy, Notification of Change of Condition Policy, and Comprehensive Care Plan Policy. They were also educated on the Therapeutic Diet Orders Policy.
- The Administrator was re-educated on his job description by the Regional Director of operations and the DON will be re-educated on her job description by the Regional Nurse Consultant.
- The administrator and DON will report with each other to get updates regarding the process of the plan, identified concerns and non-compliance regarding choking incidents, and initiate the process to begin further investigation of the event. No such event has been noted at this time.
- Nurse implemented immediate notification form regarding sentinel events which has been placed on green paper and posted at each nurse's station, the time clock and given to each department.
- The Regional Nurse Consultant and/or Regional Director of Operations will visit the assessment daily to ensure compliance and identify any areas of concern with not accurately performing and documenting skin assessment, not providing care to prevent pressure ulcer, not following the care plan related to completing skin assessment and providing treatment, as ordered, and not ensuring the diet order for a resident on pureed diet. No concerns noted at this time.
- The DON will receive a 1:1 counseling from the Nurse regarding communicating with the administrator unexpected deaths, to notify the administrator immediately so an investigation can be initiated.
Penalty
Resources
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Facility leadership, including the NHA and DON, did not ensure that physicians or other advanced practice providers were notified when multiple residents’ capillary blood glucose (CBG) levels were outside the parameters ordered by their physicians. Despite job descriptions assigning the NHA overall operational responsibility and the DON overall clinical leadership and regulatory compliance responsibility, the facility failed to implement effective management to ensure timely provider notification of these changes in condition. During interviews, the NHA and DON acknowledged that administration had not effectively managed this process, resulting in an Immediate Jeopardy situation for numerous residents.
Facility leadership failed to ensure effective systems and enforcement of policies for accurate resident identification during medication administration. The NHA and DON were responsible for developing, maintaining, and monitoring nursing and operational policies, including a medication administration policy requiring use of resident photos in the MAR and adherence to the five rights of medication administration. Despite this, multiple residents lacked photos in the EHR, and an agency RN relied only on calling out a resident’s name without verifying identity against the MAR photo or another reliable identifier. As a result, morphine sulfate and levothyroxine intended for one resident were given to another, who developed bradycardia and required ED transfer and naloxone administration. Surveyors cited this as Immediate Jeopardy due to the breakdown of medication administration safeguards.
Administration failed to ensure a DON was employed, did not maintain required RN coverage, and did not provide sufficient staffing, despite being responsible for recruiting competent leadership and ensuring adequate licensed and non-licensed staff. After the last DON left, there was no RN on staff, including most weekends, and there was no documented evidence that DONs from sister facilities who were said to be helping were actually present. A CMA/MT had been assessing pain and administering PRN narcotic pain medications, which leadership confirmed was outside that role’s scope of practice. A resident reported long delays in call light response, another reported that staff left the halls during mealtimes, and an LPN stated residents needed more attention than staff could provide. These failures resulted in Immediate Jeopardy under nursing services and were cited under F727, F658, and F725.
The facility failed to ensure that a resident with a physician’s order for full code status received timely and continuous CPR when found unresponsive, as nursing staff did not accurately verify the resident’s code status and did not maintain resuscitation efforts until EMS arrival, and facility leadership did not initially recognize or investigate this as deficient practice or provide staff re-education on CPR and code status verification. In addition, when no Treatment Nurse was on duty, multiple residents with Stage III and Stage IV pressure ulcers did not receive ordered wound care because LPNs were not clearly informed they were responsible for performing wound treatments on their assigned residents, despite the expectation by the DON and RN Supervisor that floor nurses would assume this role.
Facility administration, including the NHA and DON, did not effectively manage operations to ensure compliance with elopement-prevention regulations and facility policies. Although their job descriptions required them to direct care and nursing services in accordance with local, state, and federal standards, they failed to implement and oversee measures to prevent residents identified as elopement risks from leaving the building unsupervised. As a result, a known elopement-risk resident exited the facility without supervision, creating an Immediate Jeopardy situation for multiple residents documented as elopement risks.
The Administrator failed to provide effective oversight of social services and referral processes, resulting in multiple physician-ordered consultations and diagnostic tests not being timely scheduled or properly documented in the EMR for several residents with dysphagia, neurologic conditions, and G-tubes. An LVN documented that social services was notified of orders for Modified Barium Swallow and Barium Swallow studies, but the Social Services Director (SSD) and assistant did not ensure appointments were scheduled or that refusals, barriers, or follow-up efforts were entered into the medical record, instead relying on paper folders and a temporary communication board that was not part of the permanent record. One resident with a history of stroke and dysphagia had ENT and MBS orders that were not fully acted upon or documented, another resident reportedly refused an MBS without any EMR note of the refusal, and another resident’s swallow study was delayed while the SSD attempted but did not document contact with the responsible party and hospital. The facility’s own policies required Social Services to coordinate referrals and document them in the medical record, and the Administrator, as the SSD’s direct supervisor, did not identify or correct these documentation and follow-through failures.
Failure to Ensure Provider Notification of Abnormal Blood Glucose Levels
Penalty
Summary
The deficiency involves the failure of the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to effectively manage the facility to ensure provider notification of residents’ changes in condition, specifically related to capillary blood glucose (CBG) levels. Review of the NHA’s job description showed that the NHA is responsible for overall leadership, management, and operation of the facility, including ensuring high-quality care and regulatory compliance. Review of the DON’s job description showed that the DON is responsible for overall clinical leadership and management of nursing services, including ensuring resident-centered care and compliance with Pennsylvania Department of Health and CMS regulations. Surveyors determined that the facility failed to ensure that physicians or other advanced practice providers were notified when residents’ CBG levels were outside the parameters set in the physicians’ orders. This failure affected 12 of 21 residents reviewed (R2, R4, R16, R33, R37, R46, R47, R56, R70, R80, R97, and R116). During an interview, the NHA and current DON confirmed that facility administration did not effectively manage the facility to ensure provider notification of changes in condition. This failure resulted in an Immediate Jeopardy situation for those residents, and was cited under 28 Pa. Code 201.14(a), 201.18(b)(1)(3)(e)(1), and 211.12(d)(1)(2)(3)(5).
Plan Of Correction
Nursing Home Administrator (NHA) and the Director of Nursing (DON) will effectively manage the facility to ensure provider notification of resident changes in condition by ongoing auditing and staff education on the requirement to notify the physician of abnormal blood sugar results to prevent a negative outcome to occurs Weekly reports by both the Administrator and the DON will be presented to the Greenery Center for Rehab and Nursing governing body to ensure the delivery of high-quality short-term rehabilitation and long-term care services while maintaining compliance with all federal, state (Pennsylvania), and local regulations. The Nursing Supervisor will be educated by the DON/Designee on the importance of notifying a physician of abnormal blood sugar results This education will be ongoing for licensed nursing staff. The DON/Designee will complete weekly ongoing audit of 90% abnormal blood sugar results and physician notification to prevent any negative outcome from occurring.
Failure of Administrative Oversight Leads to Wrong-Resident Opioid Administration
Penalty
Summary
The deficiency involves the failure of the Nursing Home Administrator (NHA) and Director of Nursing (DON) to administer and oversee the facility in a manner that ensured effective systems for accurate resident identification prior to medication administration. The NHA’s job description required development, maintenance, and interpretation of policies and procedures, consultation with department directors to correct problem areas, and ensuring residents receive necessary services to attain and maintain their highest practicable functional status. The DON’s job description required planning, organizing, implementing, and evaluating nursing services, maintaining and updating nursing policies and procedures, and ensuring staff education and compliance with those policies. Despite these responsibilities, the facility did not ensure that established identification protocols were consistently implemented and enforced. The facility’s “Medication Administration” policy required licensed nurses to follow professional standards of practice and the five rights of medication administration, including verification of the right resident. The policy specifically required staff to use the resident’s photograph in the Medication Administration Record (MAR) as part of the identification process and to remain with the resident until medications were taken. The “Resident Admission Procedure” policy required staff to obtain and upload resident photographs to the electronic health record to support accurate identification. However, multiple residents did not have photographs available in the electronic health record until surveyor inquiry, demonstrating that the facility did not consistently implement its identification process or ensure an alternative reliable method for resident identification was consistently used. As cited under F760, an agency RN (Employee 1) administered morphine sulfate and levothyroxine that were ordered for one resident (Resident 50) to another resident (Resident 51). Although Resident 51 had a photograph available in the electronic health record, Employee 1 did not use the photograph or another reliable identifier to confirm identity. Instead, Employee 1 called out Resident 50’s name, and Resident 51 responded verbally, after which Employee 1 proceeded with medication administration without further verification. Resident 51 subsequently experienced bradycardia and required transfer to the emergency department, where naloxone was administered to reverse the opioid effects. The surveyors determined that the NHA and DON failed to ensure effective systems were implemented, monitored, and enforced to support staff compliance with facility policy and professional standards for resident identification prior to medication administration, resulting in Immediate Jeopardy.
Plan Of Correction
1. Facility cannot retroactively correct the deficient practice identified by the complaint survey on 4/9/2026. 2. Administrator and Director of Nursing audited all charts for resident identification and provided education to licensed nurses as part of the IJ abatement plan and continue to follow approved abatement plan enforcement actions. 3. Administrator and Director of Nursing will be educated by the Chief Nursing Officer, Corporate Operations Officer and Regional Director of Operations on job descriptions, expectations, and implementation of enforcement of effective systems to support accurate resident identification prior to medication administration. Corporate leadership will review current policies for resident identification and compliance monitoring. 4. DON/designee will audit nurses administering medications to ensure the 5 rights of medication pass are followed and all residents have accurate resident identification prior to medications administration is identified in 3 resident med passes, 3 X week for 4 weeks. Results from audits will be sent to the QA committee as part of the compliance program to ensure 100% correct resident identification for medication passes. 5. April 25, 2026
Failure of Administration to Ensure DON, RN Coverage, Scope Compliance, and Adequate Staffing
Penalty
Summary
The deficiency involves the Administrator’s failure to ensure appropriate nursing leadership, RN coverage, and staffing, as required by the Administrator job description and federal regulations. The Administrator’s job description states they are responsible for directing day-to-day facility functions in accordance with applicable regulations, recruiting competent department directors, and ensuring adequate trained licensed and non-licensed personnel are on duty at all times. Despite this, the facility had no Director of Nursing (DON) after the last DON’s final day on 03/13/26, which was confirmed by both the Administrator and the Regional Director of Operations (RDO). The RDO reported that DONs from sister facilities were helping, but there was no documented evidence of their presence. The Assistant Director of Nursing (ADON) confirmed the facility had not had an RN on staff since the former DON left on 03/13/26 and that, even when the former DON was present, there was no RN coverage for most weekends. Surveyors determined that Administration was aware there was no qualified DON overseeing resident care since 03/13/26 and that there was not an RN in the building for a minimum of 8 hours a day, 7 days a week. The facility also failed to ensure that staff worked within their scope of practice and that staffing levels were sufficient to meet residents’ needs. Clinical record review for one resident (R2) showed that a Certified Medication Aide/Medication Technician (CMA/MT1) assessed pain levels, administered PRN narcotic pain medications, and reassessed pain, and CMA/MT1 confirmed she had been performing these assessments and administering PRN narcotics throughout her employment. The Vice President of Clinical Operations stated that it was not within a CMA/MT’s scope of practice to assess pain or administer PRN pain medications. A local police narrative documented that the Administrator told an officer that one resident needed constant care and that it was very difficult to provide that level of care due to lack of staffing. One resident reported that call lights took 30–45 minutes to be answered, another resident reported that during mealtimes all staff went to the dining room leaving no staff on the halls, and an LPN stated residents needed more attention than staff could provide. The survey identified these failures under F727 (nursing services and RN/DON requirements), F658 (services within scope of practice), and F725 (sufficient staffing), and Immediate Jeopardy was cited under §483.35 Nursing Services related to facility administration.
Failure to Ensure CPR per Code Status and Wound Care Coverage in Absence of Treatment Nurse
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a way that ensured effective and efficient use of resources to maintain residents’ highest practicable physical well-being, specifically in relation to CPR and code status verification. One resident with a physician’s order for full code status was found unresponsive, pulseless, and not breathing. Licensed nursing staff did not accurately determine this resident’s code status and failed to initiate and continuously provide CPR in accordance with the physician’s full code order until EMS arrived. When the hospice nurse arrived, no life-saving measures were in progress, and the resident was later pronounced deceased. The DON stated she had not identified this incident as deficient practice at the time it occurred and did not realize the magnitude of the problem until it was brought to her attention during the survey. The DON also acknowledged that the facility did not provide additional education to nursing staff on verifying code status and continuing CPR until EMS assumed responsibility. The facility’s administration, including the Administrator and DON, did not have an adequate system in place to identify this deficient practice, determine its root cause, or ensure that nursing staff were trained and competent in verifying residents’ code status and implementing CPR according to orders. The Administrator indicated that when it was discovered that the LPN had not properly determined the resident’s code status and had not continued CPR until EMS arrival, administrative staff should have reviewed the incident to determine the root cause and re-educated nursing staff on the CPR policy and procedure. However, this did not occur prior to the surveyors’ identification of the issue. As a result, the surveyors determined that an Immediate Jeopardy situation existed related to the failure to ensure CPR was initiated and continued for a resident with full code status. A second deficiency involved the facility’s failure to have an adequate system to ensure that licensed nursing staff were made aware of their responsibilities for wound care in the absence of a Treatment Nurse. Multiple residents with pressure ulcers did not receive wound care as ordered by their physicians on days when no Treatment Nurse was assigned. The Treatment Nurse stated that weekend nurses should perform wound care when a Treatment Nurse is not present. Several LPNs reported they did not provide ordered wound care to residents with Stage III and Stage IV pressure ulcers because they were not aware they were responsible for completing wound care on their assigned residents. The DON indicated that on specific dates without a Treatment Nurse, it was the RN Supervisor’s responsibility to remind floor nurses to complete wound care, and a communication sheet instructed the RN Supervisor to remind nurses to perform wound care and sign the Treatment Administration Record. The RN Supervisor stated it was an understood responsibility that floor nurses were responsible for wound care in the absence of a Treatment Nurse, but the interviewed LPNs’ statements showed they had not been effectively informed of this responsibility, resulting in missed wound treatments as ordered. Overall, the facility’s administrative systems did not ensure that critical clinical responsibilities—verifying and acting on residents’ code status with appropriate CPR, and providing ordered wound care in the absence of a Treatment Nurse—were clearly assigned, communicated, and carried out by nursing staff. The DON’s and Administrator’s own interviews confirmed that they had not identified the CPR incident as deficient practice at the time, had not conducted a root cause review, and had not re-educated staff on CPR procedures, and that the process for ensuring wound care coverage on days without a Treatment Nurse relied on informal understandings rather than a consistently implemented system, leading to missed treatments for residents with pressure ulcers.
Removal Plan
- In-service nurses on checking a resident's Code Status in the EMAR and proper procedures for CPR.
- Review all active residents' EMAR to ensure Code Status is posted.
- Identify residents with DNR status.
- In-service all nurses on each shift on checking Code Status in the EMAR and proper procedures for CPR.
- Update the policy and procedure for Review of Resident Deaths.
- Implement a Death Review form for the DON and/or Quality Nurse to complete and immediately initiate changes as needed.
- Require all resident deaths be reviewed by the DON/designee.
- Require unexpected/high-risk deaths be reviewed by the DON/designee.
- Require cases be presented to QAPI at the next scheduled meeting.
- Consult on the death review policy/procedure, how to complete the Death Review form, actions for discrepancies, training nurses to look up code status in the EMAR, and proper CPR procedure.
- QAPI Team to verify the DON is reviewing completed Death Review forms and following through on discrepancies.
- QAPI to monitor Death Review forms.
- QAPI to review all Death Review forms.
Failure of Administration to Prevent Elopement of High-Risk Residents
Penalty
Summary
Facility administration, specifically the Nursing Home Administrator (NHA) and the Director of Nursing (DON), failed to effectively manage operations to protect residents identified as elopement risks from exiting the building unsupervised. The NHA job description required leading, guiding, and directing facility operations in accordance with local, state, and federal regulations and facility policies to provide appropriate care. The DON job description required planning, organizing, developing, and directing the overall operations of the nursing service department in accordance with applicable standards, regulations, and facility policies, as directed by the Administrator and Medical Director, to provide appropriate care and services to residents. Despite these defined responsibilities, the NHA and the previously employed DON did not ensure that federal and state guidelines and regulations related to elopement prevention were followed. As a result, a resident who was a known elopement risk exited the building without supervision. This failure created an Immediate Jeopardy situation for 10 of 94 residents who were documented as elopement risks. During an interview, the NHA and current DON confirmed that facility administration failed to effectively manage the facility to protect residents from elopement. The deficiency was cited under 28 Pa. Code 201.14(a) Responsibility of licensee, 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management, and 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.
Failure of Administrative Oversight for Physician-Ordered Consults and Diagnostic Tests
Penalty
Summary
The deficiency involves the Administrator’s failure to provide effective oversight and necessary resources to ensure that physician-ordered consultations and diagnostic tests were scheduled, carried out, and documented in the electronic medical record (EMR) for multiple residents. The Administrator was the direct supervisor of the Social Services Director (SSD) and was responsible, per the job description, for directing day-to-day operations, ensuring policies and procedures were implemented, and reviewing the competence of the workforce. Despite this, the Administrator was not aware that the SSD was not consistently scheduling ordered appointments or documenting referral activities in the EMR, and allowed the SSD to maintain paper records in a personal folder and use a temporary communication board that was not part of the permanent medical record. For one resident with COPD, dysphagia, and altered mental status, a physician ordered a Modified Barium Swallow (MBS) to rule out silent aspiration. Nursing documented that the SSD was notified of the order, and the expectation was that the SSD would schedule the test and document follow-up. However, there was no documentation in the EMR that the MBS was scheduled, completed, or refused, and the SSD later stated that the resident had refused the MBS and that the responsible party had also refused, but she had not documented this in the resident’s medical record. For another resident with seizures, dystonia, traumatic brain injury, and a gastrostomy, a physician ordered a Barium Swallow consult. Nursing notes indicated that the Social Services Assistant or SSD was notified, but the SSD acknowledged that although she contacted the resident’s sister and the hospital, she did not document her attempts to schedule the MBS or her contacts with the responsible party in the EMR, nor did she follow up with the speech therapist after being unable to schedule the test. A third resident with hemiplegia, hemiparesis following cerebral infarction, dysphagia, aphasia, and a gastrostomy had physician orders for an ENT consult to assist with vocal cord mobility and an MBS to rule out silent aspiration and determine if oral diet was possible. The SSD stated that an in-house ENT consult had been scheduled but not documented in the EMR and that the MBS had not been scheduled because they were waiting for the ENT consult and insurance authorization. The SSD did not document any attempts to obtain authorization, schedule the MBS, or notify the speech therapist or primary physician of delays. The SSD described a referral process in which orders were left under her office door when she was absent and acknowledged that she did not routinely document referral attempts or follow-up in the EMR, instead keeping papers in a folder and using a communication section of the EMR that was automatically cleared and not part of the permanent record. The facility’s policy required Social Services to collaborate with nursing to arrange ordered services and to document referrals in the resident’s medical record, but this was not done. The Administrator confirmed that he was aware the SSD was documenting on paper and in a non-permanent communication board, and that he expected physician orders to be followed and referrals documented, but he had not ensured that this occurred, resulting in ordered consultations and tests for several residents not being timely scheduled or properly documented. The surveyors also observed one resident with a gastrostomy lying in bed with an enteral feeding pump at bedside not connected to the gastrostomy tube, and this resident was verbally nonresponsive. While this observation did not directly reference a missed order, it occurred in the context of broader concerns about the facility’s management of residents requiring specialized nutritional support and diagnostic evaluation for swallowing. Across the reviewed cases, there was no evidence in the EMR of timely scheduling, follow-up, or clear documentation of refusals or barriers to completing ordered tests and consultations. The SSD herself stated that if something was not documented, it was considered not done, and acknowledged that she should have documented her attempts and follow-up in the EMR so they would be part of the medical record. The Administrator’s lack of effective oversight and failure to ensure adherence to the facility’s referral and documentation policies contributed to these gaps in care coordination and recordkeeping for multiple residents. The facility’s written policy on Social Services referrals required that referrals for medical services be based on physician evaluation, that Social Services collaborate with nursing and other disciplines to arrange ordered services, and that Social Services document the referral in the resident’s medical record. The Administrator’s job description required development and maintenance of policies and procedures, routine inspections to ensure implementation, consultation with department directors to correct problem areas, and review of staff competence. Despite these requirements, the Administrator did not detect or correct the SSD’s practice of using non-medical-record systems (paper folders and a temporary communication board) for tracking referrals, did not ensure that physician orders for MBS and ENT consults were carried out, and did not ensure that all referral-related activities were documented in the EMR. This lack of administrative oversight and failure to enforce established policies led to physician-ordered consultations and tests for several residents not being timely scheduled or properly documented in the medical record.
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