F0835

D

Failure of Administration to Control Environmental Hazard on Dementia Unit

Ebensburg, Pennsylvania Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility administration, specifically the Nursing Home Administrator (NHA) and Director of Nursing (DON), failing to effectively use facility resources to promote resident safety and maintain residents’ highest practicable physical well-being. Review of the NHA’s job description, dated September 23, 2025, showed that the NHA is responsible for leading, directing, and managing overall operations in accordance with applicable federal, state, and local regulations, and for organizing and directing resources to ensure quality care for each resident at all times. The DON’s job description, also dated September 23, 2025, indicated responsibility for organizing, developing, managing, and directing the Nursing Service Department in compliance with regulatory standards, and working directly with the Administrator and Medical Director to ensure the highest degree of quality care, including following all health, sanitary, and infection control policies and established nursing standards of practice.

Based on review of employee job descriptions, observations, and staff interviews, surveyors determined that the NHA and DON did not fulfill these essential duties because they failed to ensure that water-absorbing beads were secured. This failure occurred on the dementia unit and resulted in the residents’ environment not being kept free of accident hazards, as required under 42 CFR 483.25(d)(1)(2) (F689 – Free of Accident Hazards/Supervision/Devices). The unsecured water-absorbing beads placed residents on the dementia unit at risk for serious harm and created an Immediate Jeopardy situation. The deficiency was also cited under 28 Pa. Code 201.14(a) Responsibility of Licensee, 28 Pa. Code 201.18(e)(1) Management, and 28 Pa. Code 211.12(d)(1)(5) Nursing Services.