Aristacare At East Falls
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 3300 Henry Avenue, 7th Floor, Philadelphia, Pennsylvania 19129
- CMS Provider Number
- 396143
- Inspections on file
- 39
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Aristacare At East Falls during CMS and state inspections, most recent first.
A resident’s room lacked functional running water in both the sink and shower for approximately two weeks after the facility shut off the water due to a plumbing issue, leaving only the toilet operational. The maintenance director confirmed the inoperable fixtures, and facility records showed an external repair estimate that was not accepted, with no internal repair timeline established. The administrator acknowledged awareness of a water issue but not the lack of sink water, relied on hand sanitizer in the room, and did not view the absence of running water as an infection control concern or relocate the resident despite available beds. Staff interviews, including an RN, respiratory therapist, and CNA, emphasized that proper hand hygiene with soap and water is critical for infection prevention, consistent with CDC guidance that alcohol-based sanitizer alone is insufficient when hands are visibly soiled or after exposure to bodily fluids.
A resident with a history of brain injury, anxiety, and epilepsy was administered medications that had been discontinued by the hospital because the facility did not have the updated discharge medication list at admission. The nurse practitioner was unaware of the discontinuation orders and continued the previous medication regimen until the resident's family raised concerns, resulting in the resident receiving unnecessary medications.
Two residents identified as being at risk for falls did not have the required bilateral fall mats in place as specified in their care plans. Observations confirmed that one resident had no fall mats and another had only one mat instead of two, with staff interviews verifying these lapses.
Multiple resident rooms had non-functioning call bell systems, with some call bell boxes pulled from the wall and no illumination when pressed. Residents reported that their call bells had not worked for extended periods and, when provided, manual bells were ineffective as staff did not respond. The facility lacked an effective process for notifying maintenance of repairs, relying on verbal communication rather than a formal system.
The facility failed to provide timely incontinence care for dependent residents, including a resident with severe cognitive impairment who went without care for approximately 24 hours, and several residents who reported delays, inadequate responses to call bells, and resulting health issues such as a yeast infection. Multiple complaints from residents and families were not addressed.
A resident with significant medical needs did not receive prescribed Prevalon boots to prevent pressure ulcers, resulting in the development of a wound on the lower leg. Staff confirmed the resident was not wearing the boots, which allowed leg crossing and contributed to the injury.
A resident with limited range of motion and a history of intracranial hemorrhage and tracheostomy did not receive the prescribed contracture management interventions, as ordered rolled gauze was not placed in the right hand. Staff were unclear about the purpose of the gauze, with a nurse aide believing it was for wound care, while the Director of Rehabilitation confirmed it was for contracture management. This resulted in the resident not receiving appropriate services to prevent further decrease in range of motion.
A resident with a history of traumatic brain injury and PTSD was admitted, but their care plan did not address their history of trauma or identify possible triggers for re-traumatization. This lack of trauma-informed care was confirmed by the DON.
A resident with moderate cognitive impairment and a POA on file for financial and insurance matters was allowed to sign an insurance change form without involving the designated POA, despite facility staff being aware of the POA documentation.
Staff failed to use required PPE while providing care to two residents with tracheostomy, hemodialysis, feeding tube, and indwelling catheter, despite physician orders for enhanced barrier precautions. Additionally, hand sanitizing dispensers and restroom supplies were found empty, compromising infection prevention measures.
The facility did not provide an ongoing activity program to meet resident needs, as confirmed by multiple residents who reported no available activities and by the absence of activity staff and scheduled group activities, especially on weekends.
Surveyors found that medications and biologicals were not properly labeled or securely stored in two nurses' stations. Unlabeled insulin vials, an opened tuberculin vial without an open date, and intravenous medications were left unattended or in unlocked refrigerators. Both an LPN and the DON confirmed that medications were left unsecured and unattended, contrary to facility policy.
The facility did not provide appropriate care for pressure ulcers and failed to prevent new ulcers from developing, as evidenced by lapses in assessment, monitoring, and treatment for a resident at risk. Established protocols for pressure ulcer prevention and care were not consistently followed.
The facility did not maintain adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
Nursing staff did not demonstrate required competencies in caring for residents with a Posey Net Restraint Bed or in administering medications via gastrostomy tube. Documentation of training and competency assessments was lacking, and a nurse was observed administering medication through a feeding tube without verifying tube placement or using a stethoscope, contrary to protocol. The facility administrator confirmed the absence of competency records for these procedures.
A resident was subjected to physical restraints without a documented medical need, in violation of requirements that ensure restraints are only used for medical treatment.
A facility did not provide written notification to the State Long-Term Care Ombudsman when a resident was transferred to the hospital. The facility was unable to produce documentation of the required discharge notice, and the Administrator confirmed that no such notification could be found for the relevant period.
Two residents with physician orders for restorative nursing therapy and range of motion interventions did not have individualized, person-centered care plans developed to address these needs. Despite documented functional limitations and specific orders for exercises and orthotic use, the facility did not create or implement care plans as required by policy.
A resident who was fully dependent on staff for ADLs due to functional quadriplegia and severe cognitive impairment did not receive scheduled showers or hair washing as outlined in the care plan. Documentation showed only one shower was provided in a month, and staff did not perform hair washing as requested, resulting in poor hygiene and a scalp issue.
A resident with hemiplegia and hemiparesis did not consistently receive ordered restorative nursing therapy or use of a prescribed upper extremity splint. Documentation and staff interviews revealed that therapy was only provided on a limited number of days, and the restorative nursing program was not performed daily as ordered due to insufficient staffing, with the restorative aide often reassigned to direct care duties.
A resident with paraplegia, who was alert and independent in a wheelchair, left the facility without staff knowledge and traveled to a nearby gas station before returning on his own. Staff were unaware of the resident's absence and the resident was not informed of the facility's policy on leaving the premises, resulting in a failure to provide adequate supervision and prevent elopement.
A licensed nurse administered medication through a gastrostomy tube to a resident with respiratory failure and gastrostomy status without verifying tube placement as required by facility policy. The nurse did not use a stethoscope to confirm placement and did not have one available, contrary to established procedures for safe medication administration.
A resident with respiratory failure and hypoxia was given oxygen at 3L/min via nasal cannula without a physician's order, contrary to facility policy. Staff confirmed the resident had been on oxygen since decannulation and desaturation, but an order was only obtained later for a different flow rate.
The facility did not complete required annual performance reviews for five nurse aides, as confirmed by missing documentation and staff interviews.
A resident with severe cognitive impairment and ongoing behavioral symptoms was not provided with a timely psychiatric consultation as ordered by the physician. Despite repeated documentation of the need for psychiatric follow-up and the use of Seroquel for anxiety without an FDA-approved diagnosis, the resident was not seen by psychiatric services, as confirmed by the DON.
The facility did not address pharmacist-identified irregularities in medication orders for several residents, including missing order durations for PRN psychoactive medications and incomplete pain management orders. Pharmacy recommendations were documented over multiple months before being acted upon, contrary to facility policy requiring timely implementation.
A resident receiving tracheostomy care was observed as a staff member placed used, dirty gauze back onto a paper towel alongside clean treatment items, resulting in dirty gauze being placed on top of clean gauze and supplies. The staff member confirmed this practice during interview, which did not align with infection prevention and control protocols.
The facility did not ensure that the most recent survey results and complaint investigations were readily accessible to residents, families, or legal representatives. Residents reported being unaware of the availability of these documents, and a review of the binder at the reception area confirmed that several recent survey results were missing.
A resident with complex medical needs, including anoxic brain injury and total dependence on staff for care, did not have complete documentation in the e-TAR for required two-person assist and bi-weekly bathing tasks. Facility policy and physician orders required detailed and timely documentation, but several care and bathing events were not properly recorded, as confirmed by facility leadership.
The facility did not maintain an effective pest control program, as evidenced by a resident being returned from a hospital appointment due to a bedbug being found, with no documented follow-up, and a live bedbug later confirmed in a resident room by a pest control technician. The administrator confirmed these incidents and that they were not reported in the event reporting system.
Multiple residents with high risk factors, including immobility and severe cognitive impairment, did not receive physician-ordered interventions for pressure ulcer prevention and treatment. Required actions such as turning and repositioning, use of air mattresses, offloading devices, and specific wound care treatments were not consistently implemented or documented. As a result, residents developed new pressure ulcers and existing wounds worsened, with increases in wound size and severity.
The NHA and DON failed to ensure that residents received appropriate wound care and pressure ulcer prevention measures, including implementing physician and wound care practitioner recommendations, providing air mattresses, and ensuring regular turning and repositioning. As a result, several residents developed new pressure ulcers or experienced worsening of existing wounds, with care plans lacking necessary interventions and documentation. These failures led to actual harm and an Immediate Jeopardy situation.
A resident with acute and chronic respiratory failure and a tracheostomy was not permitted to return to the facility after hospitalization, despite being clinically ready and the facility having open beds. The facility required financial documentation from the resident or representative as a condition for readmission, contrary to its own bed-hold policy and state regulations. Hospital staff made multiple attempts to coordinate the resident's return, but the facility did not review the records or accept the resident back.
A newly hired wound care nurse lacked documented competency in wound care, leading to improper prevention and management of pressure ulcers. As a result, several residents developed new pressure ulcers, and others experienced worsening of existing wounds due to care not meeting professional standards. The nurse was unaware of the need to update orders, and the facility could not provide evidence of her wound care competency.
Staff did not follow Enhanced Barrier Precautions for two residents with physician orders, as required PPE was not worn during hygiene care and peg tube site cleaning. These lapses were confirmed with the DON at the time of observation.
A facility failed to create a comprehensive care plan for a resident with anxiety, despite the resident's medical history and incidents indicating a need for such measures. The resident, with conditions including anoxic brain damage and respiratory failure, experienced severe anxiety and was at risk for falls. The care plan lacked goals, objectives, or interventions related to anxiety, contributing to the deficiency.
A resident with a traumatic subdural hemorrhage and reduced mobility was admitted with an unstageable pressure ulcer. The facility failed to timely assess, monitor, and treat the ulcer, leading to its deterioration to a Stage 4 ulcer. There was no documented wound care plan or treatment initiated until two weeks after admission, and the resident was not seen by a wound specialist until two months later. Additionally, there was no evidence of turning and positioning interventions to prevent further deterioration.
The facility failed to maintain an effective infection control program, with staff not adhering to enhanced barrier precautions, such as wearing gowns when required. Infection control committee meetings were inadequately conducted, lacking necessary attendance and failing to address critical areas. The facility's policies were insufficient, with the Enhanced Barrier Precautions policy not tailored to resident needs, and there was no comprehensive water management plan.
The facility failed to provide necessary orientation and annual training for nine staff members, including RNs, LPNs, and nurse aides, on essential topics such as infection control and emergency preparedness. The lack of training records was confirmed by the Nursing Home Administrator.
The facility failed to maintain dining dignity for residents by serving meals on Styrofoam plates with plastic utensils due to insufficient dinnerware stock. A resident expressed difficulty using plastic utensils, and the Registered Dietician was unaware of the issue. The shortage of regular dinnerware has persisted since the COVID epidemic, with silver utensils delivered but plates still awaited.
The facility failed to develop comprehensive care plans for four residents, addressing critical areas such as substance use disorder, dialysis access, mental health needs, and enteral feeding. One resident's care plan lacked specific goals for substance abuse monitoring, while another's did not specify dialysis access sites or address mental health needs. Two residents with gastronomy tubes lacked detailed care plans for tube management, and one also lacked interventions for mental health issues.
A resident with heart failure and end-stage renal disease was repeatedly administered midodrine despite physician orders to hold the medication if systolic blood pressure exceeded 110. The facility's Medication Administration Records and Consultant Pharmacist Reports documented numerous instances of non-compliance over several weeks, yet the nursing staff continued to administer the medication incorrectly. The Nursing Home Administrator could not explain the repeated failure to adhere to the physician's orders.
The facility failed to provide proper care and assessments for IV therapy in three residents. One resident had a PICC line with no documented care, another had an undated dressing, and a third had a peeling dressing with no maintenance orders. Staff were unaware of care protocols.
The facility failed to ensure nursing staff had the necessary competencies for resident care, as seven personnel files lacked evidence of training in critical areas like tracheostomy and ventilator care. The Nursing Home Administrator confirmed the absence of skills evaluations for both regular and agency staff.
The facility failed to ensure timely completion and review of consultant pharmacist medication recommendations for several residents. A resident with multiple diagnoses had no available medication reviews, while two other residents had reports with unsigned and undated recommendations, lacking evidence of implementation. The Nursing Home Administrator and DON confirmed these deficiencies.
A resident in a persistent vegetative state was administered morphine sulfate without proper documentation or rationale. The medication was given multiple times, but the eMAR often lacked reasons for its use, and there were no documented signs of storming episodes or non-pharmacologic interventions. The Nursing Home Administrator could not explain the absence of documentation, indicating a failure to ensure the resident's drug regimen was free from unnecessary medications.
The facility failed to maintain an effective antibiotic stewardship program, as antibiotic use for two residents was not properly documented or reviewed. One resident received Cefpodoxime and Bactrim without proper clinical indication or review, while another received Levaquin without a documented review. The Infection Preventionist confirmed the lack of proper antibiotic tracking and reporting.
The facility did not offer influenza and pneumococcal vaccines to five residents, as required by its policies. There was no documentation in the residents' records indicating they were offered these vaccines or received education on their benefits and side effects. The Nursing Home Administrator confirmed the lack of documentation, highlighting a failure to adhere to vaccination policies.
The facility did not ensure that nurse aides received the required 12 hours of continuing education annually. A review of personnel files for three nurse aides showed no evidence of completed education hours, and the Nursing Home Administrator confirmed the absence of records during the survey.
The facility failed to update care plans for three residents, affecting their nutrition and mobility care. A resident with anemia and cerebral palsy had an outdated tube feeding plan despite weight fluctuations. Another resident with myasthenia gravis had an unupdated mobility care plan. A third resident with hydrocephalus had a tube feeding plan not revised to match current orders.
Failure to Maintain Functional Running Water for Resident Care and Hand Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to maintain functional running water in one resident room, which is necessary for hygiene and provision of care. Surveyors observed that the sink in the identified room was not functioning and had no running water, and the shower was non-functional with the faucet removed, leaving only the toilet operational. The Director of Maintenance stated that the water supply to this room had been shut off for approximately two weeks due to a plumbing issue and confirmed that both the sink and shower were inoperable, and that this was the only room affected on the unit. Facility documents showed that an outside contractor evaluated the issue and provided an estimate for repairs dated February 9, 2026, but the facility did not accept or proceed with the proposed work, and repairs were not completed by the time of the survey. The Nursing Home Administrator confirmed awareness of a water issue in the room for approximately two weeks but reported being unaware that the sink lacked running water. He stated that the facility declined the external repair estimate and planned to complete the repairs internally, without providing a definitive start date or timeline for completion. The Administrator also stated that hand sanitizer was available in the room as an interim infection control measure and did not identify the lack of running water as an infection control concern, and no alternative accommodations were implemented despite available beds and the ability to relocate the resident. Interviews with a licensed nurse, a respiratory therapist, and a nursing assistant confirmed that proper hand hygiene, including handwashing, is considered the top priority for infection prevention and is required before and after providing patient care, with hand sanitizer used only until staff are able to wash their hands. CDC guidance cited in the report states that handwashing with soap and water is essential for infection prevention and that alcohol-based sanitizer alone is not sufficient when hands are visibly soiled or after exposure to bodily fluids.
Failure to Prevent Significant Medication Error Due to Lack of Updated Medication List
Penalty
Summary
A deficiency occurred when a resident with diagnoses of anoxic brain damage, anxiety, and epilepsy was admitted to the facility without the hospital's updated medication discharge list. Despite the hospital's instructions to discontinue clonazepam, Keppra, Seroquel, and valproic acid, the facility continued to administer these medications according to previous physician orders. Specifically, clonazepam and Seroquel were administered on the day after admission, and Keppra and valproic acid were administered for several days following admission. The nurse practitioner was unaware of the hospital's instructions to discontinue these medications and only adjusted the orders after concerns were raised by the resident's family. The nurse practitioner also reported repeatedly reminding nursing staff to obtain the updated medication list from the hospital. During this period, the resident was noted to be lethargic while awaiting the correct medication list, indicating that the facility failed to ensure the resident was free from significant medication errors.
Failure to Implement Fall Prevention Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement required fall prevention interventions for two residents identified as being at risk for falls. One resident, admitted with chronic obstructive pulmonary disease, hemiplegia, hemiparesis, and cerebral infarction, had a care plan indicating a moderate fall risk due to confusion, deconditioning, and unawareness of safety needs. The care plan specified that fall mats should be placed on both sides of the bed following two documented falls. However, during two separate observations, the resident was found in bed without the required bilateral floor mats in place. A nurse aide confirmed the absence of the mats during these times. Another resident, admitted with amyotrophic lateral sclerosis and myasthenia gravis, also had a care plan intervention for bilateral fall mats due to fall risk. Observation revealed that only one fall mat was present on the right side of the bed, rather than on both sides as required. This was confirmed by an LPN. These failures to follow the specified safety interventions in the residents' care plans resulted in the deficiency.
Plan Of Correction
1. Identified residents were immediately provided with fall mats as care planned. 2. Residents with care plan for fall mats were audited to ensure the fall mats were properly in place. 3. Random audits will be conducted weekly x 4 and monthly x 3 for residents with an order for floor mats to ensure placement as indicated. 4. Results of the audits will be reported to QAPI committee for results, areas of improvement and/or continuation of audits.
Failure to Maintain Functional Resident Call Bell Systems
Penalty
Summary
The facility failed to ensure that resident call bell systems were functioning properly in six resident rooms, as required by federal regulations. Observations revealed that in multiple rooms, call bell boxes were pulled out of the wall and rendered ineffective, with no illumination outside the rooms when the call bell button was pressed. In several instances, residents were not provided with an alternative means of calling for assistance, such as a tap bell, as outlined in the facility's own policy. Interviews with residents confirmed that their call bells had not worked for weeks or months, and some were given manual bells that staff did not respond to. Further review of facility documentation and interviews with staff, including the Nursing Home Administrator, indicated that there was no effective process for informing maintenance of needed repairs. Maintenance requests were communicated verbally, and only recently had staff been trained to use a computerized system for reporting issues. Grievances from residents and families also documented ongoing problems with non-functioning call bells and inadequate alternative solutions.
Plan Of Correction
Corrective actions are currently in process. Maintenance/designee will complete an initial audit on all call bell systems on each wing. Maintenance will complete random audits weekly x4 and monthly x2 to ensure the call bell system is functioning properly. Findings will be reported to the QAPI committee.
Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for residents who were unable to carry out activities of daily living, specifically related to incontinence care. One resident with severe cognitive impairment and complete dependence on staff for all activities was not provided incontinence care for approximately 24 hours, as documented in the resident's bowel and bladder diary. The documentation showed a significant gap between care events, with the resident found wet with a bowel movement after this period. The care plan required staff to check and document incontinence status upon rising, after meals, at bedtime, and as needed, every shift, but this was not followed. Additionally, interviews with three alert and oriented residents who were dependent on staff for incontinence care revealed ongoing concerns about untimely care. One resident reported having to remain in a saturated brief until morning on multiple occasions, while another described poor call bell response and negative staff attitudes. A third resident stated they developed a yeast infection due to improper changing. Two residents and their family members reported making multiple complaints to the facility, but stated that no changes had occurred in response.
Plan Of Correction
1. Identified Residents had no negative outcome from not receiving ADL care. 2. Director of nursing or designee audited current residents to ensure ADL was provided for the past seven days. 3. Audits will be conducted by the Director of Nursing/designee of ten random residents who require ADL assistance to ensure they received care and will audit their documentation to ensure it reflects accordingly, weekly x 4 and then monthly x 3. Education will be provided to facility nursing staff regarding the Nursing Policy Activities of Daily Living (ADLs) and nursing assistant shift responsibilities. 4. Results of the audits will be reported to the QAPI committee.
Failure to Provide Pressure Ulcer Prevention as Ordered
Penalty
Summary
A resident with multiple complex medical conditions, including nontraumatic intracranial hemorrhage, dysphagia, tracheostomy status, acute and chronic respiratory failure, hypertension, and gastrostomy, was admitted to the facility. Physician orders directed that Prevalon boots be applied to the resident during both day and night shifts to offload pressure and reduce the risk of skin injuries. Despite these orders, nursing notes documented the development of an open area on the resident's right posterior lower leg above the ankle, with specific wound measurements provided. On subsequent observations, the resident was not wearing the prescribed Prevalon boots. Interviews with nurse aides confirmed that the resident was not using the boots, which allowed the resident to cross his legs, resulting in a wound at the site where the legs met. The aides also noted that a blister had formed and subsequently ruptured in the same area. The Director of Nursing was informed of these findings. The failure to ensure the resident consistently received care as ordered to prevent pressure ulcers constituted the deficiency.
Plan Of Correction
1. Identified resident had their pressure relieving devices immediately applied. 2. Audit of all residents with orders for pressure relieving devices to the heels to ensure device in place. 3. Random weekly x 4 then monthly x 3 audits by DON or designee of pressure wound prevention devices for the heels to ensure compliance with interventions/orders. CNA staff educated on pressure wound prevention devices for the heels. 4. Results of the audits will be reported to the QAPI committee.
Failure to Provide Contracture Management for Resident with Limited ROM
Penalty
Summary
A deficiency was identified when a resident with a history of nontraumatic intracranial hemorrhage and tracheostomy status, who was admitted to the facility with limited range of motion, did not receive appropriate treatment and services to prevent further decrease in range of motion. Physician orders specified that a clean rolled gauze should be placed in the resident's right hand for passive stretch and a carrot orthosis should be used on the left hand for contracture management. The resident's care plan also indicated the use of resting hand splints during the daytime for 6-8 hours. During an observation, it was noted that the rolled gauze was not in place on the resident's right hand as ordered. When questioned, a nurse aide stated that the gauze was for wound care and that the wound care nurse was responsible for placing it. However, the Director of Rehabilitation clarified that the gauze was intended for contracture management, not wound care. This miscommunication and lack of proper implementation of the physician's orders resulted in the resident not receiving the prescribed intervention to prevent further loss of range of motion.
Plan Of Correction
1. Resident R12 had gauze applied per physician orders. 2. Other Residents with splints were checked for proper appliance per physician orders. 3. Random audits will be conducted by DON or designee weekly x4 and monthly x3 to ensure proper application of splints/devices per orders. 4. Results of the audits will be reported to the QAPI committee.
Failure to Address PTSD and Trauma Triggers in Care Plan
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care in accordance with professional standards of practice for a resident with a diagnosis of post-traumatic stress disorder (PTSD). The resident was admitted with a history of traumatic subarachnoid hemorrhage, traumatic brain injury, and PTSD. Upon review, it was found that the resident's care plan, initiated after admission, did not address the resident's history of traumatic events or identify possible triggers that could cause re-traumatization. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan did not include interventions or considerations for the resident's PTSD and potential triggers.
Plan Of Correction
1. Resident R7 care plan was immediately updated to include PTSD. 2. Residents with a d/x of PTSD care plan will be reviewed/updated to include possible triggers. 3. Care plans for residents with a d/x of PTSD will be audited/implemented and interviewed for triggers. New admissions will be audited for PTSD d/x and triggers, 2x week for 2 weeks and then 1x week for 3 weeks. 4. Audits will be submitted to the QAPI committee for review.
Failure to Involve POA in Insurance Decision for Cognitively Impaired Resident
Penalty
Summary
Resident CL1, who was admitted with diagnoses including respiratory failure with hypoxia, COPD, tracheostomy, and dependence on renal dialysis, was assessed as having moderate cognitive impairment with a BIMS score of 8. The resident had a Power of Attorney (POA) document on file, granting the POA authority to make financial and insurance decisions. Despite this, the facility had the resident sign an insurance change form instead of obtaining the required signature or approval from the designated POA. This was confirmed by the Business Office Manager, Administrator, and Assistant Director of Nursing, who acknowledged that the POA was not involved in the insurance decision, even though the documentation was present in the clinical record.
Failure to Implement and Follow Infection Control Precautions
Penalty
Summary
A review of facility policy and clinical records revealed that residents with tracheostomies, hemodialysis, feeding tubes, and indwelling urinary catheters had physician orders and special instructions for enhanced barrier precautions, including the use of personal protective equipment (PPE) by staff. During a facility tour, it was observed that hand sanitizing dispensers near several resident rooms were empty, and a public restroom lacked soap and paper towels. These deficiencies in infection control supplies were confirmed by facility staff. Additionally, direct observations showed that a dialysis patient care technician provided bedside dialysis to a resident with a tracheostomy and hemodialysis without wearing the required PPE. Similarly, a licensed nurse was observed providing care to a resident with a feeding tube and indwelling urinary catheter, also without appropriate PPE. Both staff members acknowledged the failure to follow PPE protocols, and these lapses were confirmed by the Assistant Director of Nursing and Infection Preventionist.
Failure to Provide Ongoing Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the needs and preferences of all residents, as evidenced by observations, documentation review, and interviews. Three residents reported during a resident council meeting that there were no activity programs available, with one resident noting the absence of their preferred group activity, Bingo, and another stating the last activity attended was on July 4, 2025. Review of the activity calendar for July 2025 showed no group activities scheduled on weekends, only listing Independent Leisure. Facility observation confirmed the lack of activity programs and absence of activity staff. The administrator acknowledged that there was no activity staff and confirmed that activity programs were not provided according to the calendar for July 2025.
Failure to Properly Label and Secure Medications in Nurses' Stations
Penalty
Summary
Surveyors observed that medications and biologicals were not properly labeled or securely stored in two nurses' stations. At the west side nurse's station, the area was found unattended, and the medication refrigerator under the counter was unlocked. Inside the refrigerator, multiple vials of unopened Lantus and Lispro insulin were found without labels, as well as an opened vial of Purified Protein Derivative tuberculin that lacked an open date, despite instructions to discard after 30 days. An unopened vial of Influenza vaccine was also present. On the counter, there were bags of sodium chloride and a plastic bin containing intravenous fluids, including Meropenem and Ertapenem, labeled for a specific resident, left out in the open. These findings were confirmed by a licensed nurse present during the observation. At the east side nurse's station, similar issues were identified. A plastic bag labeled vancomycin contained multiple vials of the medication, and the medication refrigerator under the counter was also found unlocked with medications inside. The Director of Nursing confirmed that medications were left unattended on the counter and that the refrigerator was not locked. Facility policy requires all drugs and biologicals to be stored in a safe, secure, and orderly manner, with improperly labeled or discontinued drugs returned to the pharmacy or destroyed, and all storage compartments to be locked when not in use.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that the facility did not consistently follow established protocols for pressure ulcer prevention and care, resulting in inadequate interventions for affected residents.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices, which revealed that staffing levels and licensed nurse coverage were insufficient to meet regulatory requirements.
Failure to Ensure Staff Competency in Specialized Resident Care
Penalty
Summary
Nursing staff at the facility failed to demonstrate competency in caring for residents with specialized needs, specifically those using a Posey Net Restraint Bed and those requiring medication administration via gastrostomy tube. Review of personnel files and staff interviews revealed that there was no documentation of training or competency assessments for staff responsible for residents with a Posey Net Bed, despite manufacturer recommendations requiring proper training. The Director of Nursing confirmed that no records existed to show that the relevant staff had received appropriate education or demonstrated competency in the use of the Posey Net Restraint Bed. Additionally, during a medication administration observation, a nurse administered medication through a gastrostomy tube without verifying tube placement or using a stethoscope, as required by facility protocol. The nurse admitted to not having a stethoscope available and could not provide evidence of competency in this procedure. The facility administrator also confirmed the absence of competency records for medication administration via gastrostomy tube, and noted that the staff educator had left the facility several months prior, leaving a gap in staff development and competency verification.
Use of Physical Restraints Without Medical Necessity
Penalty
Summary
A deficiency was identified regarding the use of physical restraints on residents. The report notes that residents were not consistently free from the use of physical restraints, except when required for medical treatment. This indicates that physical restraints were used in situations where they were not medically necessary, contrary to regulatory requirements.
Failure to Notify Ombudsman of Facility-Initiated Transfer
Penalty
Summary
The facility failed to provide written notification to the Office of the State Long-Term Care Ombudsman regarding a facility-initiated transfer of a resident to the hospital. Review of the clinical record for one resident revealed that the resident was discharged, but the facility could not produce documentation showing that a copy of the discharge notice was sent to the Ombudsman. During an interview, the Administrator confirmed that there was no proof of discharge notification for the relevant time period, and the facility was unable to locate any such documentation for that month.
Failure to Develop and Implement Comprehensive Care Plans for Restorative Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents requiring restorative therapy and range of motion interventions. For one resident with hemiplegia and hemiparesis following cerebrovascular disease, physician orders indicated the need for restorative nursing therapy (RNP) for upper extremity range of motion exercises, but no corresponding care plan was developed. For another resident, physician orders included RNP for both lower extremity assistive range of motion (AROM) exercises, right upper extremity T-Bar orthosis/splint application for contracture management, and active assistive range of motion (AAROM) for both upper extremities. Despite these orders and documented functional limitations in range of motion, there was no person-centered care plan addressing these needs. Facility policy requires that individualized care plans with measurable objectives and timetables be developed for each resident to address their medical, nursing, mental, and psychological needs. The policies also specify that rehabilitative nursing care should be reinforced through the care plan and performed daily for residents requiring such services. The lack of care plans for the identified residents represents a failure to comply with these requirements, as observed through clinical record review and direct observation.
Failure to Provide Scheduled Showers and Hair Washing for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who was totally dependent on staff for activities of daily living due to functional quadriplegia and severe cognitive impairment, did not receive showers as scheduled. The resident's care plan specified that hair should be washed during showers at least once a week, and the resident was scheduled for showers twice weekly. However, documentation showed that the resident only received one shower during the month reviewed, and there was no evidence that hair washing was performed according to the care plan. The resident's representative reported that the resident's hair was not being washed as requested, resulting in the hair becoming filthy and an open area developing on the back of the head, which was attributed to tightly braided hair. Staff interviews and review of clinical records confirmed the lack of documented showers and hair washing. The DON also confirmed the absence of documentation supporting that the resident received hair washing as outlined in the care plan.
Failure to Provide Consistent Rehabilitative Nursing Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide consistent rehabilitative nursing care as required for a resident with hemiplegia and hemiparesis following a cerebrovascular event. The resident had physician orders for restorative nursing therapy for the upper extremities and the application of a right upper extremity splint for up to six hours daily, with skin checks before and after application. However, documentation showed that therapy was only conducted on 7 out of the last 30 days in July, and observation revealed the resident was not using the prescribed splint at the time of review. The resident, who is nonverbal, indicated through gestures that she does not like the splint and does not always receive therapy. Interviews with staff confirmed that the restorative nursing program (RNP) was not being performed daily or consistently as ordered. The restorative aide explained that when there is insufficient staffing, the RNP aide is reassigned to work as a nursing assistant, resulting in missed restorative care sessions. This failure to provide ordered rehabilitative care was attributed to staffing shortages, as confirmed by staff interviews and documentation review.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident from leaving the premises without staff knowledge. A resident with a thoracic spinal cord injury and paraplegia, who was alert, oriented, and independent in activities of daily living using a wheelchair, left the facility on his own at approximately 11:30 p.m. Staff were unaware of the resident's departure and only became aware when the resident returned to the building. The resident reported that he went to a gas station two blocks away and returned on his own, stating that staff did not find him. Facility documentation and interviews revealed that the resident was not aware of the facility's policy regarding leaving the premises. The facility's elopement policy requires staff to promptly report and attempt to prevent residents from leaving, as well as to investigate and report all cases of missing residents. In this incident, staff did not detect the resident's absence in real time, and the resident was not educated on the policy prior to the event, contributing to the failure to prevent the elopement.
Failure to Verify Feeding Tube Placement Prior to Medication Administration
Penalty
Summary
A deficiency was identified when a licensed nurse failed to check for proper placement of a gastrostomy tube prior to administering medication to a resident with a history of acute and chronic respiratory failure and gastrostomy status. The facility's policy and competency guidelines require staff to verify tube placement and patency before administering medications through a feeding tube, specifically by injecting air and listening for a 'whooshing' sound with a stethoscope. During direct observation, the nurse administered medication via gravity using a large syringe without performing the required placement check and did not have a stethoscope available during the procedure. Upon interview, the nurse stated she pushed air into the tube but did not use a stethoscope, claiming she could hear without it. However, inspection of the medication cart confirmed that no stethoscope was present, and the nurse acknowledged this. The facility's policies were reviewed and clearly outlined the steps for confirming tube placement, which were not followed during this medication administration event.
Oxygen Administered Without Physician Order
Penalty
Summary
A resident with a history of acute and chronic respiratory failure with hypoxia was observed receiving oxygen via nasal cannula at 3 liters per minute while in bed and awake. Review of the clinical record revealed that there was no physician's order for oxygen administration at the time of observation. Staff interviews confirmed that the resident had been on oxygen since being decannulated and experiencing desaturation, but no physician's order had been obtained for the oxygen therapy provided. Further interviews with the respiratory therapist confirmed that the resident was placed on 3 liters of oxygen without a physician's order, and that the physician was only later asked to write an order, which was for 2 liters per minute. The facility's policy requires verification of a physician's order prior to oxygen administration, but this protocol was not followed for this resident.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete a performance review for each nurse aide at least once every 12 months, as required. Documentation review, personnel file review, and staff interviews revealed that five nurse aides did not have records of annual performance evaluations. When requested, the Nursing Home Administrator and DON were unable to provide annual training or evaluation records for these employees. The facility Administrator confirmed the absence of performance evaluations for all five nurse aides reviewed.
Failure to Provide Timely Behavioral Health Services and Psychiatric Consultation
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a BIMS score of 0, exhibited ongoing behavioral symptoms such as yelling out, yelling at staff, and refusing interventions like wearing a helmet or being repositioned. The clinical record shows that as-needed medications were administered, but their effectiveness was limited to about three hours. Despite these persistent behaviors, the resident was not provided with a timely psychiatric consultation as ordered by the physician. Instead, the resident was started on Seroquel, an antipsychotic medication, for anxiety, even though there was no documented diagnosis of schizophrenia, psychosis, bipolar disorder, or major depressive disorder, which are the FDA-approved indications for this medication. Physician progress notes repeatedly documented the need for psychiatric follow-up, but there was no evidence that the resident was actually seen by psychiatric services. The DON confirmed in an interview that the psychiatric consultation had not occurred and could not provide a date for when it would take place. The failure to provide timely behavioral health care and services, specifically the lack of psychiatric evaluation as ordered, led to the deficiency cited in the report.
Delayed Response to Pharmacist Recommendations on Medication Orders
Penalty
Summary
The facility failed to act upon irregularities identified by the consulting pharmacist in a timely manner for four residents. According to the facility's policy, pharmacist recommendations must be implemented within seven days. For multiple residents, pharmacy reviews repeatedly noted issues such as missing order durations for PRN psychoactive medications, lack of documented rationale for continued use beyond 14 days, and missing indications for PRN pain medications. These recommendations were documented over several months but were not addressed within the required timeframe. Specifically, one resident with anxiety had pharmacy recommendations regarding the duration and documentation for Clonazepam orders that were not addressed for nearly three months. Another resident with pain management needs had repeated recommendations to clarify PRN pain medication orders for moderate pain, which were not acted upon over a four-month period. Additional residents with orders for Lorazepam, Doxazosin, Valproic Acid, and Alprazolam also had pharmacy-identified irregularities, such as missing order durations and diagnoses, that were not corrected until weeks or months after the initial recommendations. These delays in addressing pharmacist recommendations were confirmed through review of clinical records, pharmacy reviews, and facility policy.
Failure to Maintain Infection Control During Tracheostomy Care
Penalty
Summary
During an observation of tracheostomy care for Resident R54, Employee E8 prepared the necessary materials by placing a paper towel on the bed and arranging both clean gauze and other supplies on top of it. While performing suctioning and cleaning the stoma, Employee E8 used gauze from the paper towel, then placed the used, dirty gauze back onto the same paper towel alongside the remaining clean items. The employee continued to pick up additional gauze from the paper towel, resulting in dirty gauze being placed on top of clean gauze and supplies. An interview with Employee E8 at the time of the observation confirmed that dirty gauze was placed on top of clean treatment items during the respiratory care procedure. This practice was found to be inconsistent with the facility's infection prevention and control program, as it failed to prevent the potential development and transmission of communicable diseases during tracheostomy care.
Failure to Provide Accessible Survey Results to Residents and Families
Penalty
Summary
The facility failed to make the most recent survey results, including surveys, certifications, complaint investigations from the preceding three years, and any current plans of correction, readily accessible to residents, family members, and legal representatives. During a resident council meeting, several residents stated they were not aware of the availability of survey results. Observation of the reception area revealed that while a binder containing state survey inspection results was present, it did not include the most recent recertification results or complaint survey results from multiple specified dates. This finding was confirmed by regional facility staff.
Incomplete Medical Record Documentation for Dependent Resident
Penalty
Summary
The facility failed to maintain medical records according to accepted professional standards for one resident. Review of the facility's policy indicated that all services provided to a resident, as well as any changes in their medical or mental condition, must be documented in the resident's medical record. Documentation should include care-specific details such as the name and title of the individual providing care, the resident's response to treatment, any refusals, notifications made, and the signature and title of the documenting staff. For one resident with significant medical needs, including anoxic brain injury, contractures, reduced mobility, tracheostomy, and epilepsy, the care plan required two-person assistance for activities of daily living and total dependence on staff for personal and oral hygiene. Despite physician orders for two-person assist for care and bi-weekly bathing with skin evaluations, the electronic treatment administration record (e-TAR) showed incomplete documentation for paired care on several specified dates and incomplete bathing tasks on other dates. These findings were confirmed with the facility's administrator and assistant director of nursing, indicating that the required documentation for care and bathing was not consistently completed as per policy and physician orders.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, which states that the building should be kept free of insects and rodents. A grievance report documented that a resident was returned to the facility from a hospital appointment after a bedbug was found on the resident, resulting in the cancellation of the appointment. Review of pest control logs and reports from the pest control company showed no evidence of follow-up on this incident. Additionally, pest control company records indicated that a live bedbug was found in a resident room, confirmed by a pest control technician after the nurse stored the specimen. The facility administrator confirmed awareness of both incidents and acknowledged that the event was not reported in the event reporting system.
Failure to Provide Physician-Ordered Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide pressure ulcer care and prevention in accordance with physician orders, facility policy, and professional standards of practice, resulting in the development and worsening of pressure ulcers among multiple residents. Clinical records and observations revealed that residents at high risk for pressure injuries, including those with severe cognitive impairment, immobility, incontinence, and complex medical conditions such as anoxic brain damage and tracheostomy status, did not consistently receive prescribed interventions such as turning and repositioning, use of air mattresses, offloading devices, and specific wound care treatments. Documentation was often incomplete or missing, and there was a lack of clarity regarding which wound care treatments were actually administered. For several residents, physician and wound care practitioner orders for specialized mattresses, offloading of heels, and specific wound dressings (such as calcium alginate, Medi honey, Dakin's solution, and Vashe moistened gauze) were not implemented as directed. In some cases, the treatment administration records did not reflect the provision of ordered equipment or wound care, and staff interviews confirmed uncertainty about which treatments were provided. Observations further confirmed that residents were not on air mattresses or receiving heel offloading as ordered, and nurse aide documentation showed minimal evidence of required interventions being performed. As a result of these failures, residents developed new pressure ulcers and existing wounds deteriorated, with documented increases in wound size, depth, and severity, including progression to Stage 4 pressure injuries and the development of additional wounds. The lack of timely and appropriate wound care, failure to follow prevention protocols, and inadequate documentation led to actual harm for multiple residents, as evidenced by the worsening of their pressure ulcers and the development of new wounds.
Failure to Prevent and Manage Pressure Ulcers Resulting in Immediate Jeopardy
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to ensure that the facility provided treatment and services consistent with professional standards of practice to prevent and manage pressure ulcers. Multiple residents developed new pressure ulcers or experienced worsening of existing wounds due to the facility's failure to implement physician and wound care practitioner recommendations, such as providing wound care, using air mattresses, and ensuring regular turning and repositioning. Facility documentation lacked evidence that these interventions were provided as ordered, and observations confirmed that required equipment, such as air mattresses and heel boots, were not in use for affected residents. Residents with significant medical needs, including those dependent on tracheostomy/ventilator and at high risk for pressure ulcers, did not have comprehensive care plans addressing necessary interventions like offloading, air mattresses, or turning and repositioning. The facility also failed to update or implement wound care orders as recommended by the wound care practitioner, resulting in the deterioration of wounds for several residents. In some cases, wounds progressed in size and severity, with documentation showing increases in wound dimensions, the development of drainage, slough, eschar, and wound odor. Interviews with the DON and Administrator confirmed that the facility did not follow professional standards or its own wound care guidelines. The DON acknowledged that staff failed to document and provide required interventions, and that care plans were incomplete for residents at high risk of pressure injuries. The facility's non-compliance with physician orders and lack of appropriate wound care led to actual harm for multiple residents and resulted in an Immediate Jeopardy situation.
Failure to Permit Resident Return After Hospitalization Due to Financial Documentation Requirement
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, despite the resident being clinically ready for readmission and having an anticipated return documented in the Minimum Data Set (MDS). The resident, who had acute and chronic respiratory failure and a tracheostomy, was initially admitted to the hospital for abnormal lab results and subsequently diagnosed with sepsis. The resident's payor source was documented as Medicaid pending, and the facility's policy indicated that Medicaid pending residents are to be treated as Medicaid approved for the 15-day bed hold period, after which the non-Medicaid process applies. During the resident's hospitalization, there was no evidence in the clinical record that the facility inquired about the resident's discharge plan or return status. Hospital case management staff reported that they repeatedly contacted the facility to arrange the resident's return after completion of antibiotic treatment, but the facility required financial statements from the resident or representative as a condition for readmission. Text message communications and interviews with facility staff confirmed that financial information was made a prerequisite for the resident's return, even though the transfer to the hospital was for medical reasons. Despite the hospital faxing clinical records multiple times and the facility having open beds available, the facility did not review the records or accept the resident back. The administrator and facility liaison both confirmed that financial information was required prior to readmission. This action was not in accordance with the facility's own bed-hold policy and state regulations, resulting in the resident not being permitted to return to the facility after hospitalization.
Failure to Ensure Wound Care Nurse Competency Resulting in Pressure Ulcer Development and Deterioration
Penalty
Summary
The facility failed to ensure that nursing staff, specifically a newly hired wound care nurse, possessed the appropriate competencies and skill sets necessary for the care of residents with wounds. Clinical record reviews showed that the facility did not provide treatment and services consistent with professional standards of practice to prevent the development of pressure ulcers, resulting in new pressure ulcers for several residents. Additionally, the facility did not provide adequate treatment and services to promote healing and prevent infection, leading to the worsening or deterioration of existing pressure ulcers in multiple residents. During an interview, the DON confirmed that the wound care nurse was responsible for wound rounds and implementing physician recommendations but was unaware of the need to change orders. The facility was unable to provide documentation of wound care competency for the nurse prior to the survey.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not implementing Enhanced Barrier Precautions for two residents as ordered by their physicians. For one resident, a physician's order for Enhanced Barrier Precautions was in place, but during hygiene care, both a licensed nurse and a nurse aide did not wear the required personal protective equipment (PPE). In a separate instance, another resident with a physician's order for Enhanced Barrier Precautions had their peg tube site cleaned by a licensed nurse who also did not wear the required PPE. These deficiencies were confirmed at the time of observation with the Director of Nursing. Both residents had active physician orders for Enhanced Barrier Precautions, which are intended to reduce the transmission of multi-drug-resistant organisms through the use of targeted PPE during high-contact care activities. The failure to use PPE occurred during direct care activities for both residents.
Failure to Address Anxiety in Resident Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive and individualized care plan for a resident with anxiety, as required by regulations. The care plan did not include goals, objectives, or interventions related to the resident's anxiety, despite the resident's medical history and recent incidents indicating a need for such measures. The resident, identified as having anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, gastrostomy status, end-stage renal disease, and cognitive communication disorder, experienced severe anxiety and was at risk for falls. A fall incident report revealed that the resident removed their tracheostomy tube and became hypoxic due to confusion and agitation. Nursing progress notes documented the resident's severe anxiety and risk for falls, noting behaviors such as pulling at hand mitts and kicking legs over the side of the bed. Despite these observations, the resident's care plan lacked specific strategies to address the anxiety, which contributed to the deficiency identified by the surveyors.
Plan Of Correction
1. R1 care plan has been updated to include goals, objectives and interventions related to anxiety. 2. Director of Nursing/Designee will audit residents with a current diagnosis of anxiety to ensure interventions are present in care plan. 3. NHA/Designee will complete care plan education to the Interdisciplinary Team. Random weekly audits x 4 and monthly x 3 will be completed. 4. QAPI committee will review trends and make recommendations for further audits.
Failure to Timely Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to timely assess, monitor, and provide treatment consistent with professional standards to a resident's sacral pressure ulcer, resulting in actual harm. The resident was admitted with a traumatic subdural hemorrhage, left hemiplegia/hemiparesis, muscle weakness, and reduced mobility, and was identified as having an unstageable pressure ulcer upon admission. However, there was no documented evidence of a wound care plan or treatment initiated until two weeks after admission. The resident's pressure ulcer was not properly assessed or monitored, as evidenced by the lack of documentation of the ulcer's size or description in the initial nursing admission assessment. The first documented wound observation was not conducted until two weeks after admission, and the resident was not seen by a wound specialist until two months later. During this time, the pressure ulcer deteriorated from an unstageable condition to a Stage 4 ulcer, with significant increases in size and depth. Additionally, there was no documented evidence of turning and positioning interventions to prevent further deterioration of the pressure ulcer. The facility's failure to implement a timely and effective wound care plan, along with the lack of consistent monitoring and assessment, contributed to the worsening of the resident's condition, resulting in actual harm.
Inadequate Infection Control Program and Policy Implementation
Penalty
Summary
The facility failed to maintain an effective infection control program, particularly in implementing enhanced barrier precautions for residents. Observations revealed that staff members did not adhere to the required use of personal protective equipment (PPE) when providing care to residents who required enhanced barrier precautions. For instance, a respiratory therapist and a nurse aide were observed providing care to residents with only masks and gloves, omitting the use of gowns, which are necessary for residents at high risk of colonization with multidrug-resistant organisms (MDROs). The infection control committee meetings were inadequately conducted, lacking the necessary attendance and failing to address critical areas of infection control. The minutes from these meetings did not include data on needed improvements or surveillance measures such as hand hygiene, PPE usage, and environmental disinfecting. Additionally, there were no infection tracking or surveillance logs completed for several months, indicating a significant gap in the facility's infection surveillance and reporting processes. Furthermore, the facility's policies were found to be insufficient and not tailored to the specific needs of the resident population. The Enhanced Barrier Precautions policy was merely copied from the CDC website without being incorporated into a facility-specific policy. Additionally, the facility lacked a comprehensive water management plan, which is crucial for preventing water-borne illnesses. The absence of access to the Pennsylvania Patient Safety Reporting System (PA-PSRS) further hindered the facility's ability to report healthcare-associated infections as required by state regulations.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to maintain an effective training program for its staff, as required by regulations. Upon review of personnel files, facility documentation, and staff interviews, it was found that nine out of thirteen staff members reviewed did not receive the necessary orientation or annual training. Specifically, Employees E22, E10, E23, and E24, who were hired in August 2024, did not receive any orientation training upon hire. This training should have included essential topics such as communication, residents' rights, dementia management, quality assurance, infection control, compliance and ethics, behavioral health, accident prevention, restorative nursing techniques, emergency preparedness, fire prevention, and safety cultural competency. Additionally, Employees E28, E29, E30, E31, and E32, who were hired between 2018 and 2022, did not receive any annual training on the same critical topics. The facility's assessment, last reviewed in September 2024, indicated that it evaluates educational needs annually and lists required competencies, but there was no specific indication of the trainings required to meet the resident population's needs. During an interview, the Nursing Home Administrator confirmed that there were no training records available for the employees in question at the time of the survey.
Deficiency in Dining Services Dignity
Penalty
Summary
The facility failed to maintain or enhance the dignity and respect of residents during dining services on one nursing unit. Observations on two consecutive days revealed that lunch trays were delivered to residents' rooms on Styrofoam plates with plastic utensils. This practice was inconsistent, as some residents, like one interviewed resident, expressed a preference for regular dinnerware, finding plastic utensils difficult to use. The inconsistency in dining ware was not known to the Registered Dietician, who was unaware that disposable items were being used. Further investigation revealed that the facility had not adjusted its stock of dinnerware to accommodate an increased number of residents receiving lunch. An employee confirmed that there were insufficient dishes and utensils, a situation persisting since the COVID epidemic. Although silver utensils had been ordered and delivered, the facility was still awaiting the arrival of additional plates. This deficiency was noted under the regulations concerning management and resident rights.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for four residents, addressing critical areas such as substance use disorder, pain management, dialysis access, mental health needs, and enteral feeding. For one resident, there was an incident involving possible substance abuse, where a visitor was suspected of administering illicit drugs. Although a care plan was initiated to monitor the resident's drug regimen and supervise visits, it lacked specific goals or interventions. Another resident, who required dialysis due to end-stage renal disease, had a care plan that did not specify the dialysis access sites or the one used for treatments. Additionally, the care plan did not address the resident's mental health needs, despite diagnoses of anxiety, depression, and a psychotic disorder. There were no non-pharmacologic interventions included to manage these conditions. Two other residents with gastronomy tubes lacked care plans detailing the size, type, or management of their tubes. One of these residents also had mental health diagnoses, but their care plan did not include interventions for these issues. The facility's failure to develop these comprehensive care plans was confirmed during interviews with the Nursing Home Administrator and Director of Nursing.
Failure to Follow Physician Orders for Blood Pressure Medication
Penalty
Summary
The facility failed to adhere to physician orders regarding the administration of blood pressure medication for a resident diagnosed with heart failure and end-stage renal disease. The resident was prescribed midodrine to be administered twice daily, with specific instructions to hold the medication if the systolic blood pressure (SBP) exceeded 110. However, the medication was repeatedly administered despite the resident's SBP being above the specified threshold on numerous occasions between July and September 2024. The Medication Administration Records revealed multiple instances where midodrine was given to the resident even when their SBP was significantly higher than 110, with readings as high as 165. This pattern of non-compliance with the physician's orders was noted over several weeks, indicating a systemic issue in following medication protocols. The facility's Consultant Pharmacist Reports also highlighted these medication errors, emphasizing that the physician's hold order was not consistently followed. Despite these errors being documented and communicated in the Consultant Pharmacist Reports, the nursing staff continued to administer the medication incorrectly. The Nursing Home Administrator was unable to provide an explanation for the repeated failure to comply with the physician's orders when questioned by surveyors. This deficiency was identified as a violation of the nursing services regulation, specifically 28 Pa Code 211.12(d)(5).
Deficiencies in IV Therapy Management
Penalty
Summary
The facility failed to provide care and assessments consistent with professional standards of practice related to intravenous therapy for three residents. For Resident R43, there was a lack of documentation regarding the care of a PICC line, despite a physician's order for weekly dressing changes. An observation revealed that the PICC line dressing was not dated, and this was confirmed by a licensed nurse. Resident R44 also had issues with the care of their PICC line. The Medication Administration Record showed no documentation of PICC line care, and an observation found the dressing undated. A licensed nurse confirmed these findings during an interview. For Resident R150, the PICC line dressing was dated two weeks prior and was peeling away from the skin. The licensed nurse was unaware of any medications or fluids administered through the PICC line and was unsure of the dressing change frequency. There were no physician orders for the care and maintenance of the PICC line, and no notes related to its removal, despite an order to remove it.
Lack of Competency Training for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skills to meet the specific needs of residents. A review of personnel files and staff interviews revealed that seven out of thirteen personnel files lacked evidence of skill competency training for critical care areas such as tracheostomy care, ventilator care, airway suctioning, oxygen administration, emergency airway management, intravenous therapy, and the use of physical restraints. Employees E22, E10, E23, and E24, who were hired as registered nurses, licensed practical nurses, and nurse aides, respectively, did not have documented evaluations or training in these areas. Additionally, the facility was unable to provide training and competency evaluations for agency staff, including Employees E4, E25, and E26, who were also involved in direct resident care. The Nursing Home Administrator confirmed that the necessary skills competencies evaluations and trainings were not available for review during the survey. This deficiency highlights a significant gap in ensuring that staff are adequately prepared to handle the complex medical needs of residents, particularly those requiring specialized care such as tracheostomy and ventilator management.
Failure to Complete and Review Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure that consultant pharmacist medication reviews were completed and that recommendations were reviewed by the physician in a timely manner for three of eight residents reviewed. Resident R38, who was admitted with diagnoses including end stage renal disease, respiratory failure, anxiety disorder, tracheostomy, and ventilator dependence, had no consultant pharmacist medication reviews available for review at the time of the survey. This indicates a lack of adherence to the requirement for monthly drug regimen reviews by a licensed pharmacist. For Resident R26, multiple consultant pharmacist medication reports were reviewed, revealing that recommendations made by the pharmacist were not signed, dated, or indicated as implemented. Similarly, Resident R7's medication reports showed that recommendations were not dated when reviewed, nor was there any indication of implementation. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that the required medication reviews were not completed, signed, and dated for several residents, including R38, R26, and R7, as per the facility's policies and procedures.
Failure to Document Rationale for Morphine Administration
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically morphine sulfate, which was administered without proper documentation or rationale. Resident R45, who was in a persistent vegetative state and had multiple diagnoses including hypertension, seizures, anoxic brain damage, and ventilator dependence, was given morphine sulfate solution 20 mg per mL, 0.5 mL every four hours as needed for storming. The medication was administered on several occasions throughout September 2024, but the electronic Medication Administration Records (eMAR) often lacked documented rationale for its use. Further review of Resident R45's progress notes revealed no documented signs or symptoms of storming episodes, nor any non-pharmacologic interventions trialed. During an interview, the Nursing Home Administrator was unable to explain the absence of documented signs or symptoms of neurostorming or the continued need for morphine. This lack of documentation and monitoring indicates a failure to ensure the resident's drug regimen was free from unnecessary medications.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program, as evidenced by the lack of proper documentation and review of antibiotic use for two residents. For Resident R26, there was a physician's order for Cefpodoxime to treat a urinary tract infection, and another order for Bactrim for prophylaxis. However, there was no clinical indication documented for the initiation of Bactrim, nor was there any evidence that the use of Cefpodoxime was reviewed within 48 hours as required by the facility's policy. Additionally, no infection report was completed for the use of Cefpodoxime. Similarly, for Resident R38, a physician's order was given for Levaquin to treat leukocytosis and pneumonia, but the facility documentation lacked a completion date for the infection report and did not confirm if the antibiotic was reviewed within 48 hours. Furthermore, there were no infection tracking or surveillance logs that included the infections and antibiotic usage for Residents R26 and R38. The Infection Preventionist confirmed that the antibiotic tracking and reporting data was not properly completed for these residents.
Failure to Offer Vaccinations and Provide Education
Penalty
Summary
The facility failed to offer influenza and pneumococcal vaccines to five residents, as determined through clinical record reviews and staff interviews. The facility's policies stated that all residents should be offered these vaccines and receive education on their benefits and potential side effects. However, there was no documentation in the clinical records of Residents R43, R38, R2, R44, and R12 indicating that they were offered the pneumococcal vaccine. Additionally, Resident R12's record also lacked evidence of being offered the influenza vaccine. Further review revealed that there was no documentation showing that these residents or their responsible parties received any education regarding the vaccines' benefits and potential side effects. The Nursing Home Administrator confirmed the absence of such documentation, indicating a lapse in following the facility's vaccination policies. This deficiency was noted under the regulation 28 Pa Code 201.18(b)(1) Management.
Deficiency in Nurse Aide Continuing Education
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of continuing education per year, as mandated by regulations. This deficiency was identified during a review of personnel files and interviews with staff. Specifically, the personnel files of three nurse aides, Employees E28, E31, and E32, showed no evidence of completing the necessary continuing education hours. Employee E28 was hired on August 28, 2018, Employee E31 on June 10, 2021, and Employee E32 on August 10, 2022. During an interview, the Nursing Home Administrator confirmed that there were no continuing education records available for these employees at the time of the survey.
Failure to Update Care Plans for Nutrition and Mobility
Penalty
Summary
The facility failed to revise the care plans for nutrition, mobility, and skin integrity for three residents, leading to deficiencies in their care. Resident R1, who was admitted with conditions including anemia, cerebral palsy, anxiety disorder, and respiratory failure, had a care plan for tube feeding that was not updated to reflect the resident's nutritional requirements despite fluctuations in weight. The Director of Nursing confirmed the lack of revision in the care plan related to nutritional care. Resident R12, diagnosed with myasthenia gravis and a left-hand contracture, had a care plan for limited mobility and range of motion that was not updated to reflect the resident's current mobility care requirements. Similarly, Resident R39, with diagnoses including hydrocephalus, anemia, and severe protein-calorie malnutrition, had a care plan for tube feeding that was not revised to align with the current tube feeding orders. A licensed nurse confirmed the findings regarding the lack of updates in the care plan for tube feeding orders.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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