Aventura At Terrace View
Inspection history, citations, penalties and survey trends for this long-term care facility in Peckville, Pennsylvania.
- Location
- 260 Terrace Drive, Peckville, Pennsylvania 18452
- CMS Provider Number
- 395414
- Inspections on file
- 53
- Latest survey
- April 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Aventura At Terrace View during CMS and state inspections, most recent first.
Two residents with severe cognitive impairments and histories of falls experienced multiple falls resulting in injuries due to the facility's failure to implement effective fall prevention and supervision practices. Despite being on 1:1 supervision, one resident was left unattended, leading to repeated falls and serious injuries. The facility did not revise or enhance fall prevention measures following these incidents.
A facility failed to provide a discharged resident's medical records within two working days as requested by the resident's representative. Despite having an electronic health record system, the facility did not fulfill the request for electronic records and did not provide a written fee schedule. The Medical Records Director was unaware of the federal requirement for timely record provision, and the Nursing Home Administrator confirmed the failure to provide the requested records.
A facility failed to prevent and manage pressure ulcers for a resident with dementia and peripheral insufficiency. Despite being at risk for skin breakdown, the resident did not consistently receive incontinence care or barrier cream application. On one occasion, a nurse noted an open area in the intergluteal cleft, and further observations revealed additional pressure ulcers. The facility did not timely implement interventions such as a low air loss mattress, and no thorough investigation was conducted to identify causes and interventions.
A facility failed to manage psychotropic medications for a resident with dementia, anxiety, and a history of falls. The resident's Geodon dosage was increased without documented evaluations or non-pharmacological interventions, and there was no rationale for concurrent use with Ativan. The resident experienced multiple falls, and the DON confirmed the lack of documentation supporting medication changes.
A resident at risk for pressure ulcers developed a severe pressure sore due to the facility's failure to provide consistent care and services. Despite being identified as at risk, the resident did not receive timely incontinence care, barrier cream application, or regular repositioning. The wound deteriorated into a stage 4 pressure ulcer, requiring hospitalization and surgical intervention. Observations showed the resident was not repositioned as needed, and staff documentation was incomplete or inaccurate.
The facility failed to maintain proper food storage and sanitation practices, leading to potential food contamination risks. Observations included improperly labeled cooked meats, a compromised walk-in freezer, and structural deficiencies in the dietary department, increasing the risk of foodborne illness.
The facility failed to update its facility-wide assessment to reflect the needs of residents with dementia and behavioral health issues, particularly in the D1 Dementia/Memory Care Unit and C1 Male Behavioral Health Unit. The assessment lacked strategies for caring for these residents and did not include their activity or psychosocial needs. Additionally, the facility did not have a plan to recruit and retain direct care staff, relying heavily on agency staff without initiatives to reduce this dependency.
The facility failed to resolve grievances in a timely manner, as evidenced by unresolved complaints about call bell response times and missing personal items. A resident's grievance about missing clothing was not addressed promptly, leading to dissatisfaction. The facility's grievance handling was confirmed to be inadequate by the Nursing Home Administrator.
The facility failed to refund residents' personal funds held in trust accounts within 30 days of discharge or death, affecting 42 residents. The total amount not refunded was $72,312.54, with individual balances ranging from $9.00 to $10,949.30. The Nursing Home Administrator confirmed the deficiency, which violated resident rights and management regulations.
The facility failed to maintain a surety bond that met or exceeded the balance of residents' personal funds from October 2024 to January 2025, with the bond set at $150,000 while the account balance often exceeded this amount. Additionally, the bond's obligee was incorrectly listed as The Pennsylvania Department of Health instead of the residents, as confirmed by interviews with facility staff.
A facility failed to maintain a clean and sanitary environment for a resident requiring a PEG tube for enteral feeding. Observations over several days showed dried tube feed solution on the pump, pole, stand, wall, and floor, contrary to the facility's policy. The resident had diagnoses of dysphagia and severe protein calorie malnutrition, necessitating a clean environment to prevent complications.
The facility failed to make grievance procedures readily available on two of five nursing units, as confirmed by observations and resident interviews. Five residents reported not knowing how to file a grievance without assistance. The Nursing Home Administrator and DON confirmed the lack of posted procedures, violating resident rights.
A resident with multiple sclerosis reported that a nurse aide took him to cash a check and offered to hold $2,000 for safekeeping, which was never returned. The aide admitted to accepting the money but did not return it due to fear. The incident was reported to law enforcement, and the aide was charged with theft.
A resident with end-stage renal disease and mental health conditions was observed wearing protective mittens, a form of physical restraint, even when calm and not agitated. The facility's policy requires restraints to be used only when medically necessary and for the shortest duration possible. However, the resident was repeatedly observed with mittens in place despite being calm, indicating a failure to adhere to the policy. The Nursing Home Administrator and DON confirmed this oversight.
The facility did not follow its abuse prohibition procedures by failing to screen five employees before hiring them. The policy requires contacting references and obtaining information from former employers to assess for any past history of abuse or misconduct. The HR Director confirmed the oversight, stating she was unaware of the requirement.
Two residents in an LTC facility did not receive necessary personal hygiene services. One resident with cerebral palsy was observed with unkempt hair and food-stained clothing, despite scheduled bed baths. Another resident with dementia had inadequate skin care, with sloughing skin and dirty nails. Facility staff confirmed the failure to meet hygiene needs.
The facility failed to provide a varied and resident-centered activity program, as reported by residents and confirmed by activity calendars. A resident with physical limitations was not offered her preferred activity, and participation records inaccurately reflected her involvement in unsuitable activities. The Activity Director and NHA acknowledged the absence of a budget for activities, leading to a lack of structured engagement for residents.
A resident with spastic quadriplegic cerebral palsy and contractures did not receive timely podiatry services, resulting in excessively long toenails with dried blood and debris. Despite being cognitively intact, the resident reported not receiving foot care, and the DON confirmed the lack of routine podiatry services, indicating a failure to adhere to the facility's Foot Care Policy.
A facility failed to implement individualized pain management for a resident with alcoholic cirrhosis, as non-pharmacological interventions were not consistently attempted before administering Oxycodone. The resident received the medication 23 times in February and 74 times in March, with most doses given without prior non-pharmacological attempts. This was confirmed by the Nursing Home Administrator and DON.
A nurse aide continued to work for 127.25 hours with an expired registration, which the facility failed to notice until later. The Nursing Home Administrator confirmed the oversight and acknowledged the error.
The facility did not ensure that nurse aides received the required 12 hours of in-service training or annual performance reviews for five employees. A review of records showed that these employees did not complete the mandated training for 2024, and there was no documentation of performance reviews. The Director of Nursing and the Nursing Home Administrator confirmed the lack of documentation during a survey.
A resident reported broken and missing dentures in December, but the facility failed to provide timely dental services, resulting in the resident being without dentures for several months. Despite notifying social services, there was no follow-up until a dental appointment in late January, leaving the resident to cope by cutting food into smaller pieces and seeking staff assistance.
The facility failed to implement an effective compliance and ethics program, resulting in a lack of required training for six employees and an incident of theft involving a nurse aide and a resident with multiple sclerosis. The facility could not provide a copy of its Code of Conduct or related policies, and employee files showed no evidence of ethics or compliance training. The resident reported the theft, and the nurse aide was arrested and charged.
The facility failed to provide proper oxygen administration and care for two residents. One resident received oxygen without physician orders, while another had undated oxygen tubing that was reused after being on the floor. These actions were inconsistent with professional standards and facility policy.
The facility failed to serve food at palatable temperatures on the First Floor D Unit. During a lunch meal service, trays were delayed, resulting in food being served 45 minutes after arrival. A test tray revealed the chicken patty, potatoes, and corn were within the Danger Zone, and the ice cream was melted, confirming the food was not served at appetizing temperatures.
The facility did not ensure the Department of Health's survey results were accessible to residents and visitors on two units. Residents were unaware of the location of the survey results, and observations showed the results were either behind a restricted area or not posted at all. The NHA acknowledged the facility's responsibility to make these results accessible.
A resident with severe cognitive impairment and total dependence for transfers was injured when a nurse aide transferred the resident alone, contrary to the care plan requiring two staff for transfers. This resulted in a deep leg laceration, significant bleeding, and subsequent complications, including a closed degloving injury that required emergency medical intervention.
The facility did not consistently provide nourishing evening snacks when the interval between dinner and breakfast exceeded 14 hours, as required by policy. Two residents reported not being offered nighttime snacks regularly, and an audit showed that 40 out of 111 residents experienced the same issue. The NHA confirmed ongoing concerns about the lack of consistent snack provision.
The facility did not ensure that agency staff received required training on corrective measures outlined in the plan of correction, with only a small portion of agency staff completing the necessary education. The DON confirmed there was no monitoring system or documentation to track training completion, resulting in a breakdown of the QAPI program.
The facility did not consistently follow procedures for documenting controlled substance counts, as evidenced by a missing nurse signature on a narcotic count sheet for one medication cart. This failure was confirmed by the administrator and reflects a lapse in maintaining accurate controlled drug records.
The facility failed to provide drinking water consistent with resident needs and preferences on the D-female dementia unit. Observations revealed several rooms without water cups or with outdated and empty cups. Staff interviews confirmed that night shift nursing staff did not adhere to the protocol of replacing and dating water cups, and water was not passed that morning. A resident's daughter expressed concern about her mother's inconsistent access to fresh water.
The facility did not provide nourishing evening snacks to residents when more than 14 hours elapsed between dinner and breakfast, as required by policy. Residents reported that snacks were not routinely offered, and the Nursing Home Administrator could not explain the lapse.
A resident with dementia and dysphagia did not receive the prescribed assistive dining devices, such as a spouted sip cup, and was instead provided with a straw, which they could not use. The facility's inventory of adaptive dining equipment was insufficient to meet the needs of all residents requiring such devices, as confirmed by the corporate dietary manager.
The facility failed to prevent resident abuse, dementia care, and unnecessary psychoactive medication use. A resident was mishandled by staff, and the incident was not identified as abuse by the QAPI committee. The resident, with cognitive impairments, did not receive care aligned with their plan, leading to repeated unsafe situations. Additionally, the facility did not ensure proper documentation for psychoactive medication use.
The facility failed to implement timely infection control measures, resulting in the spread of gastrointestinal symptoms among 15 residents. Symptoms began on January 2, but interventions were not initiated until January 6. The Infection Preventionist was new to the role and not on duty during the critical period, leading to a delay in response.
A resident at Aventura at Terrace View, admitted with overactive bladder and muscle weakness, had a grievance filed on their behalf due to inadequate incontinence care. The grievance, filed in early October, was not resolved until mid-December, with the resolution noted as "resident deceased." The facility failed to demonstrate timely and adequate efforts to address the grievance, as confirmed by interviews with the NHA and DON.
A facility failed to investigate an injury of unknown origin and an allegation of abuse involving a resident with severe cognitive impairment. The resident was allegedly restrained inappropriately by a nurse aide, leading to an altercation between staff. The facility did not suspend the involved employee immediately or conduct a thorough investigation, highlighting systemic deficiencies in safeguarding residents. Additionally, a bruise on the resident's hip was not investigated, compromising the facility's ability to address potential abuse or neglect.
A facility failed to implement a comprehensive care plan for a resident at risk for skin breakdown due to decreased mobility. Despite the resident's severe cognitive impairment and need for assistance, the care plan lacked specific interventions for pressure sore prevention, leading to skin issues. The deficiency was confirmed by the DON, who acknowledged the absence of tailored preventative measures.
A medication administration error occurred when an LPN administered medications intended for another resident to a severely cognitively impaired resident, leading to increased fatigue. The error was due to the LPN relying on names and photos on the doorway instead of verifying the resident's identity.
The facility failed to provide restorative nursing services as planned for two residents, resulting in a lack of consistent ambulation support. Despite care plans outlining specific goals for mobility, the restorative nursing program was not implemented on multiple days, as confirmed by facility staff.
A facility failed to provide individualized incontinence care for a resident with overactive bladder and muscle weakness. The resident's care plan required hourly checks and changes, but there was no documentation to confirm this was done. The DON confirmed the lack of evidence for the care provided.
A resident with vascular dementia and severe cognitive impairment did not receive an individualized care plan to manage aggressive and wandering behaviors. Despite a physician's order for 1:1 supervision, the facility failed to consistently implement this intervention, leading to multiple aggressive incidents and an elopement. The facility's dementia program was not effectively applied to this resident.
A facility failed to ensure accurate accounting of narcotic medications for a resident and accurate controlled medication records on a medication cart. Doses of Oxycodone were signed out but not recorded on the Medication Administration Record. Additionally, multiple instances of nurses failing to sign off on narcotic counts were noted, indicating procedural inconsistencies. The DON confirmed these issues.
A facility failed to ensure proper documentation for the use of psychotropic medications for a resident with vascular dementia and mood disturbances. The resident was prescribed Ativan, Seroquel, and Trazodone without adequate justification in the clinical record. The DON confirmed the lack of resident-specific details to support the medication use.
A resident with irritable bowel syndrome was mistakenly given Doxycycline instead of Dicyclomine due to a pharmacy packaging error. The resident experienced nausea and vomiting after the incorrect medication was administered. The error was identified when the resident refused a subsequent dose, and it was confirmed that the medication was mislabeled.
A resident with severe cognitive impairment and a history of wandering eloped from the facility through an unsecured window. Despite being identified as a high risk for wandering, the resident was not adequately supervised and was last seen at 11:45 PM. The resident was found by police approximately one mile away, wet and cold, after exiting through a window that was not secured. The facility failed to promptly identify the resident's absence and ensure a safe environment, leading to immediate jeopardy.
A facility failed to effectively monitor a resident's whereabouts, resulting in an elopement incident. This lack of supervision placed 29 residents at risk for elopement in immediate jeopardy. The deficiency was cited under F689, indicating that the NHA and DON did not fulfill their duties to ensure resident safety and regulatory compliance.
A resident with dementia and atrial fibrillation, requiring two staff for bed mobility, fell due to insufficient staffing, resulting in head lacerations. The resident, on Warfarin, was hospitalized, received staples, and had a CT scan with contrast, leading to rapid atrial fibrillation with RVR, possibly from an allergic reaction. The resident's condition worsened, and she passed away in the PCU.
A facility failed to provide adequate care for two residents, resulting in one resident developing Stage 4 pressure ulcers and hospitalization due to infection and osteomyelitis. The facility did not conduct thorough assessments or document detailed evaluations of the resident's pressure ulcers, leading to worsening conditions. Another resident, at risk for pressure ulcers, developed a Stage 2 ulcer due to inadequate preventive measures. The Director of Nursing confirmed the lack of effective monitoring and evaluation of the residents' conditions.
A resident with severe cognitive impairment and a history of falls suffered a serious injury due to the facility's failure to implement individualized safety measures and consistent staff supervision. The resident's care plan was not adequately followed, leading to an unwitnessed fall resulting in a head laceration and traumatic subarachnoid hemorrhage. The facility's investigation was insufficient, lacking additional staff witness statements and evidence of implemented fall prevention interventions.
Failure to Prevent Falls Results in Resident Injuries
Penalty
Summary
The facility failed to implement effective interventions to prevent falls for two residents, resulting in serious injuries. Resident 4, who had a history of dementia, anoxic brain damage, and repeated falls, was found on the floor with a hematoma after being left unattended by staff. Despite being on 1:1 supervision, the resident experienced multiple falls, including one where the assigned aide left her unsupervised to assist another resident. The facility did not revise or enhance fall prevention measures following these incidents. Resident 3, who had severe cognitive impairment and a history of falls, also experienced multiple falls resulting in injuries. The resident was found on the floor with a skin tear after sliding from her wheelchair, and later sustained a forehead and nasal laceration after falling forward from her wheelchair. The facility failed to provide consistent supervision and did not implement effective interventions to prevent further falls with injury for this resident. The facility's lack of effective fall prevention and supervision practices led to repeated falls and actual harm to both residents. There was no documented evidence of revised or enhanced interventions to address the ongoing fall risks and behavioral symptoms of the residents involved.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide a copy of a discharged resident's clinical record within two working days as requested by the legal representative of Resident 18. The resident was admitted to the facility on November 19, 2024, and discharged on December 27, 2024. A formal written request for an electronic copy of the resident's complete medical record in Adobe Acrobat (.pdf) format on a CD was submitted by the resident's representative on January 14, 2025. However, as of the survey ending April 23, 2025, the requested records had not been provided. The facility's policy required written consent for the release of information and assigned responsibility for medical record services to the medical records practitioner. Despite this, the Medical Records Director confirmed that the signed authorization was received in February 2025 but was not acted upon. The Director was unaware of the federal requirement to provide records within two working days and admitted that the facility did not provide electronic records despite having the capability to do so. The resident's representative was verbally informed of a paper-based fee structure but was not provided a written fee schedule. Interviews with the Medical Records Director and the Director of Nursing revealed a lack of awareness and capability in fulfilling electronic record requests, despite the facility's use of an electronic health record system. The Nursing Home Administrator confirmed the facility's failure to provide the requested records. The facility was unable to provide documentation of a written fee schedule or evidence of efforts to fulfill the electronic record request.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to consistently provide care and services to prevent the development of pressure ulcers and to promote healing of existing wounds for a resident. The resident, who was admitted with a history of dementia and peripheral insufficiency, was identified as being at risk for skin breakdown due to incontinence and the need for extensive assistance with activities of daily living. Despite this, there was no documented evidence that incontinence care was consistently provided with each episode or that a barrier cream was applied as required by the resident's needs and consistent with professional standards of practice. On April 11, 2025, a nurse noted the presence of an open area in the intergluteal cleft of the resident, which was moist with light yellow slough and no observable drainage. The resident was incontinent of bowel and bladder and occasionally refused incontinence care, repositioning, and showers. Despite the resident's condition, the facility did not timely implement interventions such as the use of a low air loss mattress, which was not placed on the resident's bed until April 13, 2025. Further observations revealed additional pressure ulcers on the resident's right buttock, which were not present during a skin assessment conducted the previous day. The facility failed to conduct a thorough investigation into the development of these pressure areas to identify possible causes and corresponding interventions. The Director of Nursing confirmed that an investigation was not completed, and interventions were not timely implemented to prevent the development of pressure areas for this resident.
Inadequate Management of Psychotropic Medications
Penalty
Summary
The facility failed to manage and monitor medication regimens effectively for Resident 4, who was admitted with diagnoses including dementia with mood disturbances, anxiety, and a history of falling. The resident was severely cognitively impaired, as indicated by a BIMS score of 4. The care plan identified potential for distressed mood and behavioral symptoms, with interventions including medication per physician order and gradual dose reduction. However, a physician's order increased the dosage of Geodon, an antipsychotic medication, without documented behavioral evaluations, psychiatric reassessments, or non-pharmacological interventions. Additionally, there was no resident-specific rationale for the concurrent use of Geodon and Ativan, an antianxiety medication, nor was there documentation of gradual dose reduction or interdisciplinary team discussion. The deficiency was further evidenced by the resident experiencing three falls with injury, requiring emergency room visits, and the lack of documentation supporting the medication changes. An observation noted the resident sleeping in the activity room, while other residents participated in activities. The Director of Nursing confirmed the absence of resident-specific documentation to justify the increase in antipsychotic medication or the continued use of both psychoactive medications for Resident 4.
Failure to Prevent and Treat Pressure Ulcer
Penalty
Summary
The facility failed to consistently provide care and services to prevent the development and promote healing of a pressure sore for Resident 93, resulting in harm. Resident 93, who was moderately cognitively impaired and at risk for pressure ulcers, was admitted with conditions including radiculopathy, hypotension, and peripheral vascular disease. Despite being identified as at risk for pressure ulcers, the facility did not consistently implement the necessary interventions to prevent skin breakdown, such as incontinence care and the application of barrier cream. On February 26, 2025, Resident 93 was found to have an open area on the coccyx, which was not properly documented or treated in a timely manner. The facility's documentation revealed a lack of consistent implementation of a two-hour check and change protocol to prevent further skin alterations. Additionally, the facility failed to document turning and repositioning of the resident as per physician's orders, and staff were signing off on these tasks without completing them. This lack of proper care and documentation led to the deterioration of the wound into an unstageable deep tissue injury. Despite recommendations from a wound consultant to offload pressure and turn the resident every 1-2 hours, these interventions were not consistently implemented. Observations over several days showed the resident lying on his back without being repositioned, leading to further deterioration of the wound into a stage 4 pressure ulcer. The resident was eventually transported to the hospital for progressive wound deterioration and required surgical intervention. The facility's failure to develop and implement planned measures to prevent and promote healing of the pressure ulcer was confirmed by the Nursing Home Administrator and Director of Nursing.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness in the dietary department. During an initial tour of the dietary department, several unsanitary practices were observed. Cooked meats in the walk-in refrigerator were improperly labeled with incorrect discard dates, exceeding the facility's policy of a seven-day retention period for ready-to-eat foods. Additionally, the walk-in freezer had a broken or missing plastic strip air curtain and ice buildup on the floor, compromising temperature control and sanitation. Further observations revealed structural deficiencies, including a ceiling tile with a hole above the three-compartment sink, posing a risk of contamination from dust or debris. Two doors in the dietary department had peeling paint with rust underneath and did not close properly, impeding the separation of clean and dirty areas and increasing the risk of cross-contamination. These findings were confirmed by the Certified Dietary Manager during the tour, acknowledging the need for maintaining sanitary conditions to prevent food contamination and foodborne illness.
Failure to Update Facility-Wide Assessment and Staffing Plan
Penalty
Summary
The facility failed to timely review and update its facility-wide assessment to accurately reflect the specific needs of its residents, particularly those with dementia and behavioral health needs. The most recent assessment, dated July 15, 2024, did not account for changes in the resident population and staffing levels, especially for the 39 residents on the locked D1 Dementia/Memory Care Unit and the 21 residents on the C1 Male Behavioral Health Unit. The assessment lacked detailed strategies or resources necessary to care for residents with dementia, Alzheimer's disease, and behavior-related diagnoses. Additionally, the assessment tool provided during the survey did not include the activity or psychosocial needs of residents in these specialty units, and there was no documentation of a dedicated activities program or budget for these units. The facility also failed to develop and maintain a plan to maximize recruitment and retention of direct care staff, which is crucial for ensuring adequate care for the current resident population. Documentation reviewed during the survey showed a continued reliance on agency staff to meet basic staffing needs, with no evidence of initiatives to reduce this dependency or enhance permanent staff retention. The assessment did not guide budget decisions, staffing allocations, or operational adjustments necessary for compliance with licensure and certification standards. There was no documented evidence that the facility used the assessment to plan for or provide the necessary resources to safely care for its resident population.
Failure to Resolve Grievances in a Timely Manner
Penalty
Summary
The facility failed to adhere to its grievance policy, resulting in unresolved grievances and lack of timely follow-up with residents. The policy requires that upon receipt of a grievance, immediate action should be taken to prevent further violations of resident rights, and any confirmed violations should be corrected within five working days. However, the facility did not resolve a grievance regarding call bell response times, which was initially submitted in November 2024 and remained unresolved as of March 2025. The grievance official continued to add new complaints to the existing unresolved grievance instead of addressing them separately, indicating a systemic issue in handling grievances. Additionally, Resident 27 submitted a grievance on February 25, 2025, regarding missing clothing and blankets, which was not filed and reviewed until March 4, 2025, six days after submission. Despite confirming the missing items on March 7, 2025, the facility had not resolved the issue by March 28, 2025, forcing the resident to purchase new clothing. The resident expressed dissatisfaction with the facility's handling of the grievance. The Nursing Home Administrator confirmed the facility's failure to resolve grievances according to their policy.
Failure to Refund Resident Trust Funds Timely
Penalty
Summary
The facility failed to ensure that residents' personal funds held in trust accounts were refunded within 30 days of discharge or death. This deficiency affected all 42 residents sampled, as confirmed through interviews and record reviews. The residents had varying amounts remaining in their trust accounts, ranging from $9.00 to $10,949.30, with a total of $72,312.54 not refunded to the residents or their representatives. The clinical and financial records reviewed revealed that each of the 42 residents had balances in their trust accounts at the time of discharge. Despite the requirement to refund these amounts within 30 days, the facility did not comply. The Nursing Home Administrator provided documentation confirming the balances, and during interviews, both the Temporary Manager and the Nursing Home Administrator acknowledged the failure to issue the refunds within the stipulated timeframe. The deficiency was identified under the regulations 28 Pa. Code: 201.18 (b)(2)(e)(1) Management and 28 Pa. Code 201.29(a) Resident rights. The facility's inaction in refunding the trust account balances within the required period constitutes a violation of these regulations, impacting the financial rights of the residents and their estate representatives.
Failure to Ensure Adequate Surety Bond Coverage for Resident Funds
Penalty
Summary
The facility failed to ensure that the surety bond coverage met or exceeded the balance for the total residents' personal funds account over a period of four months, from October 2024 to January 2025. The surety bond, dated January 21, 2024, was set at $150,000, but the residents' personal funds account exceeded this amount on multiple occasions during the specified period. This discrepancy was confirmed through a review of the residents' personal funds account and the facility's surety bond, as well as an interview with the business office manager. Additionally, the facility did not ensure that the obligee of the surety bond was in favor of the residents. Instead, the obligee was listed as The Pennsylvania Department of Health. This was confirmed during an interview with the nursing home administrator, who acknowledged that the facility failed to assure that the residents would be compensated in case of loss. These findings indicate a failure to comply with the requirements set forth in 28 Pa. Code 201.18 (b)(2) and 28 Pa Code 201.14(a).
Failure to Maintain Cleanliness of Enteral Feeding Equipment
Penalty
Summary
The facility failed to provide necessary housekeeping services to maintain a clean and sanitary environment for a resident who required enteral feeding through a PEG tube. The facility's policy on Tube Feeding Management, last reviewed in January 2025, mandates that staff maintain and clean feeding equipment. However, observations over three consecutive days revealed dried tube feed solution on the pump, pole, stand, wall, and floor in the resident's area, indicating a lack of adherence to the policy. Resident 114, who was admitted with diagnoses including dysphagia and severe protein calorie malnutrition, required a PEG tube for enteral feeding. Despite the resident's critical need for a clean environment to prevent complications, the facility did not ensure the cleanliness of the resident's care equipment and surrounding area. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that the resident's equipment and environment were expected to be maintained in a clean and sanitary manner, which was not achieved in this instance.
Failure to Post Grievance Procedures
Penalty
Summary
The facility failed to provide and make information regarding the grievance policy and residents' rights to file a grievance readily available in prominent locations on two of the five nursing units. This deficiency was identified through observations, policy reviews, and interviews with residents and staff. Specifically, the facility's policy indicated that grievance forms and procedures should be posted on the B1, C1, C2, and D units across from the nurse's station on the bulletin boards, and in the meditation room on the B2 unit. However, during observations, it was found that the grievance procedures were not posted in the meditation room on the B2 unit or in the area across from the nursing station on the C1 unit. During a group interview with six alert and oriented residents, five residents reported that they were unaware of how to file a grievance without assistance from the Resident Council President. This indicates a lack of accessible information regarding grievance procedures for residents. The Nursing Home Administrator and Director of Nursing confirmed the facility's failure to post and provide residents with the necessary procedures for filing a grievance, which is a violation of resident rights as per 28 Pa. Code 201.29 (a)(c.1).
Misappropriation of Resident's Money by Staff Member
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property by a staff member. The incident involved a resident who was cognitively intact and had a diagnosis of multiple sclerosis. The resident reported that a nurse aide, whom he knew prior to his admission, took him to a bank to cash a check for $2,800. The aide advised the resident not to keep such a large sum of money at the facility and offered to hold $2,000 for him, which was never returned. The resident did not report the incident until two years later, as he was planning to be discharged soon and needed the money. Upon reporting the incident, the facility's Social Worker, Nursing Home Administrator, and Director of Nursing met with the resident to discuss the concern. The aide, Employee 11, was suspended and the matter was referred to local law enforcement. Employee 11 denied taking the money but admitted to taking the resident to cash the check and offering to hold the money for him. The police investigation confirmed that the resident had cashed a check for $3,925.77 from an investment company. Employee 11 admitted to accepting $2,000 from the resident for safekeeping but did not return it due to fear. She was taken into custody and charged with theft. The facility confirmed that the incident constituted misappropriation of the resident's property.
Failure to Ensure Resident Freedom from Unnecessary Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by their policy. The policy, last reviewed in January 2025, mandates that physical restraints should only be used when medically necessary and should be the least restrictive option for the shortest duration possible. However, observations revealed that the resident, who was diagnosed with end-stage renal disease, bipolar disorder, and obsessive-compulsive disorder, was subjected to the use of protective mittens, a form of physical restraint, even when calm and not agitated. The mittens were initially ordered to prevent the resident from pulling at her dialysis catheter during times of agitation, but they were observed to be in place even when the resident was calm and resting. On multiple occasions, the resident was observed in a calm state, either sleeping or being fed, yet the mittens remained in place. These observations occurred over several days, indicating a failure to adhere to the facility's policy of using restraints only when necessary and for the least amount of time. The Nursing Home Administrator and Director of Nursing confirmed that the facility did not ensure the resident was free from physical restraints and did not limit the use of mittens to the least amount of time necessary.
Failure to Implement Abuse Prohibition Procedures
Penalty
Summary
The facility failed to implement its abuse prohibition procedures by not fully screening five employees before hiring them. The facility's policy, titled Resident Abuse, requires potential employees to be screened prior to hire, which includes contacting references and obtaining pertinent information from former and current employers to assess for any past history of abuse, neglect, or professional misconduct. However, a review of personnel files revealed that Employees #12, #13, #1, #15, and #16 were hired without evidence of reference checks or employment verification. The Human Resources Director confirmed these findings during an interview, acknowledging that she had not contacted previous employers for the five employees. She stated that she was new to the job and unaware of the requirement to call prior work references as part of the employment process. This oversight indicates a failure to adhere to the facility's established procedures for ensuring the eligibility of employees in a long-term care setting.
Failure to Provide Adequate Personal Hygiene Services
Penalty
Summary
The facility failed to ensure that dependent residents received necessary services to maintain personal hygiene, as evidenced by the cases of two residents. Resident 23, who has spastic quadriplegic cerebral palsy and is completely dependent on staff for bathing, was observed with dirt under her nails, greasy hair with visible dandruff, and food stains on her hospital gown. Despite her care plan indicating scheduled bed baths twice a week, there was a lack of documentation for these services, and the resident reported not having her hair washed as requested. Observations confirmed the resident's claims, with no documented evidence of refusals or reasons for not providing the necessary hygiene care. Resident 96, diagnosed with dementia and anxiety, also did not receive adequate personal hygiene care. His care plan required bi-weekly skin checks with showers, but documentation showed only two bed baths in March, with no additional bathing or skin assessments recorded. An observation revealed the resident's feet covered in sloughing skin, thick mycotic toenails, and debris between the toes, along with jagged, dirty fingernails. Interviews with the Director of Nursing and Nursing Home Administrator confirmed the facility's failure to meet the residents' hygiene needs and preferences.
Lack of Resident-Centered Activities in Facility
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the needs, interests, and preferences of residents. During a resident group interview, six out of six residents reported that activities they enjoyed, such as trips to Walmart and gardening, had been removed from the schedule, and there was no variety in activities from week to week. A review of the activity calendars for January, February, and March of 2025 confirmed no change in activities each month. Additionally, Resident 23, who has spastic quadriplegic cerebral palsy and other physical limitations, expressed that her favorite leisure activity, coloring, had not been offered, and her participation records inaccurately reflected involvement in physical activities she could not perform. The Activity Director acknowledged the lack of a budget for resident activities and mentioned that staff members were using personal funds to purchase activity-related prizes. Observations during the survey period revealed residents sitting in front of a television without being offered or encouraged to participate in structured activities. The Nursing Home Administrator confirmed the absence of a budget for activities and recognized the facility's obligation to provide a program tailored to individual resident needs. This deficiency highlights the facility's failure to meet regulatory requirements for resident rights under 28 Pa. Code 201.29 (a).
Failure to Provide Timely Foot Care
Penalty
Summary
The facility failed to provide timely and necessary foot care for Resident 23, as observed and confirmed through clinical records and interviews. Resident 23, who was admitted with diagnoses including spastic quadriplegic cerebral palsy and contractures, was found to have excessively long toenails with evidence of dried blood and debris. Despite being cognitively intact, as indicated by a BIMS score of 15, Resident 23 reported not receiving podiatry services during her stay at the facility. The facility's Foot Care Policy mandates that residents with foot disorders or medical conditions associated with foot complications be referred to qualified professionals. However, a review of Resident 23's clinical record showed no documented evidence of podiatry services being provided. An interview with the Director of Nursing confirmed the lack of routine podiatry care for Resident 23, highlighting a deficiency in adhering to the facility's policy and professional standards of practice.
Failure to Implement Individualized Pain Management
Penalty
Summary
The facility failed to develop and implement individualized pain management programs for a resident, consistent with professional standards of practice. The deficiency was identified through a review of clinical records and staff interviews, which revealed that non-pharmacological interventions were not consistently attempted before administering narcotic pain medication. Specifically, Resident 114, who was admitted with a diagnosis of alcoholic cirrhosis of the liver, was prescribed Oxycodone to be administered as needed for pain. However, the facility did not consistently attempt non-pharmacological interventions prior to administering the medication. The resident's Medication Administration Records for February and March 2025 showed that Oxycodone was administered 23 times in February and 74 times in March. Of these administrations, 18 out of 23 doses in February and 60 out of 74 doses in March were given without attempting non-pharmacological interventions first. This was confirmed during an interview with the Nursing Home Administrator and Director of Nursing, who acknowledged the lack of evidence for consistent attempts at non-pharmacological interventions before administering the as-needed pain medication.
Expired Nurse Aide Registration Overlooked
Penalty
Summary
The facility failed to ensure that a nurse aide, identified as Employee 5, maintained an active nurse aide registration, which is a requirement for performing the duties of the role according to the facility's job description. Employee 5's Pennsylvania Nurse Aide Registration expired on February 25, 2025, and the facility was unaware of this expiration until it was discovered on a later date. Despite the expired registration, Employee 5 continued to work a total of 127.25 hours over several day shifts following the expiration date. An interview with the Nursing Home Administrator confirmed that the facility was unaware of the expired registration until it was brought to their attention, and acknowledged that Employee 5 should not have been allowed to work during that period.
Failure to Provide Required Training and Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received the required yearly 12 hours of in-service training and did not conduct annual performance reviews for five employees. A review of the facility's nurse aide training records revealed that Employees 6, 7, 8, 9, and 10 did not complete the mandated 12 hours of in-service training for the year 2024. Additionally, there was no documentation to confirm that these employees received a performance review in the last 12 months. An interview with the Director of Nursing and the Nursing Home Administrator confirmed the absence of documentation for the required training and performance reviews for the specified employees. This deficiency was identified during a survey conducted on March 28, 2025, and is a violation of 28 Pa. Code 201.19(2)(7) regarding personnel policies and procedures.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely and necessary dental services for a resident who is a Medicaid recipient. The resident, who was admitted with a diagnosis of diabetes and was cognitively intact, reported on December 16, 2024, that her lower dentures had fallen out and broken. Despite notifying the social services worker, there was no evidence of follow-up or action taken by the facility at that time. On December 31, 2024, the resident again reported her dentures were missing, but there was still no documentation of a timely dental referral or follow-up action until the resident was eventually seen by a dentist on January 27, 2025. The delay in addressing the resident's dental needs resulted in the resident being without dentures for an extended period, from December 2024 until at least March 28, 2025, when the survey was conducted. During this time, the resident coped by cutting food into smaller pieces and seeking staff assistance. The Nursing Home Administrator was unable to provide documentation to demonstrate that timely and appropriate dental services were provided following the resident's initial reports, nor could they explain the delay in the dental referral or the prolonged timeline for denture replacement.
Failure to Implement Compliance and Ethics Program Leads to Theft
Penalty
Summary
The facility failed to implement an effective compliance and ethics program, as evidenced by the lack of required training for six employees and an incident of theft involving a nurse aide and a resident. The facility's Corporate Compliance and Ethics Plan, last updated in July 2024, outlined the necessity for staff training on the Code of Conduct, which includes expectations for ethical behavior and reporting misconduct. However, during the survey, the facility could not provide a copy of its Code of Conduct or related policies, and the facility assessment did not identify the Compliance and Ethics Program as a component of risk or operations. Employee files for six staff members hired between February and March 2025 showed no evidence of ethics or compliance training. The deficiency was further highlighted by an incident involving a resident with multiple sclerosis, who reported that a nurse aide took him to a bank to cash a check and offered to hold a portion of the funds, which were never returned. The resident, who was cognitively intact, reported the incident to the Director of Social Services, and a police report confirmed the theft. The nurse aide admitted to taking the money for safekeeping but failed to return it, resulting in her arrest and charge for theft. Interviews with facility leadership confirmed that the compliance and ethics program was not part of staff orientation or ongoing training, and documentation to support its implementation was lacking.
Deficiency in Oxygen Administration and Care
Penalty
Summary
The facility failed to provide supplemental oxygen administration and care consistent with professional standards of practice for two residents. Resident 114 was observed receiving oxygen at 4.5 liters per minute on two separate occasions, yet there were no physician orders for the resident to receive oxygen either continuously or as needed. This indicates a lack of adherence to the facility's policy, which requires obtaining physician orders for oxygen therapy, including prescribed flow rates. Resident 93 was admitted with conditions including radiculopathy, hypotension, and peripheral vascular disease. The resident had physician orders to receive oxygen at 2 liters per minute as needed for shortness of breath or low oxygen levels. However, there were no orders regarding the frequency of changing the oxygen tubing, as required by facility policy. Observations revealed that the oxygen tubing was undated and had been on the floor before being used again, which was confirmed by the Nursing Home Administrator and Director of Nursing as inconsistent with professional standards of practice.
Food Temperature Deficiency in Meal Service
Penalty
Summary
The facility failed to ensure that food was served at palatable and appetizing temperatures for the First Floor D Unit. On March 25, 2025, during the lunch meal service, a test tray was requested, which included a regular diet chicken patty, roasted potatoes, corn, lemon drink, and coffee. The meal trays were delivered to the unit at 11:25 AM, but tray distribution did not begin until 11:50 AM, with the last tray served at 12:15 PM. This delay resulted in the food being served approximately 45 minutes after arrival on the unit. Upon testing the tray at 12:15 PM, the chicken patty, roasted potatoes, and corn were found to be at temperatures of 104.5 F, 107.5 F, and 106.7 F, respectively. These temperatures fall within the Danger Zone, as defined by federal regulation, and were observed to be cool and not palatable. Additionally, the ice cream on the test tray was melted, measuring 35 F, and was not palatable at the time it was served. An interview with the Nursing Home Administrator confirmed that the facility did not consistently serve food at acceptable and appetizing temperatures.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the Department of Health's most recent survey results were readily accessible to residents and visitors on two out of five units observed. During a resident council interview, six alert and oriented residents reported that they did not know where the survey results were posted. Observations revealed that on the C2 Unit, the survey results binder was located behind the nurses' station, an area prohibited to residents. Additionally, on the B2 Unit Nursing Station, the survey results were neither posted nor accessible to residents and visitors without staff assistance. The Nursing Home Administrator confirmed the facility's responsibility to make these results accessible to residents, family members, and legal representatives.
Failure to Follow Transfer Protocol Results in Serious Resident Injury
Penalty
Summary
A resident with severe cognitive impairment and total dependence on staff for transfers was admitted with a diagnosis of unspecified dementia. The resident's care plan, which was in place due to immobility, weakness, and cognitive impairment, required that transfers be performed with the assistance of two staff members. On the morning of the incident, a nurse aide transferred the resident alone, contrary to the established care plan. During this transfer, the resident's leg was injured, resulting in a deep skin tear and significant bleeding, which was only noticed after blood was observed pooling on the floor. Facility documentation and witness statements confirmed that the nurse aide failed to follow the resident's care plan, leading to a serious laceration that required emergency medical intervention. The resident was treated in the emergency department for a 6-centimeter laceration and later developed complications, including swelling, redness, and pain in the affected leg. Further hospital evaluation revealed a closed degloving injury with subcutaneous fluid accumulation, necessitating additional medical procedures. Facility leadership confirmed that the resident did not receive the necessary care and services to prevent harm, and the staff member responsible did not adhere to the required transfer protocol.
Failure to Provide Consistent Nourishing Evening Snacks
Penalty
Summary
The facility failed to provide a nourishing evening snack when more than 14 hours elapsed between the evening meal and breakfast, as required by its own policy. The scheduled mealtimes on D Wing-1 resulted in an interval of 14.83 hours between dinner and breakfast, exceeding the 14-hour limit. The facility's policy specified that a nourishing snack, defined as an item or combination of items from the basic food groups, must be provided if the interval between meals exceeded 14 hours. Interviews with two residents confirmed that nighttime snacks were not consistently provided or offered. Additionally, a review of the facility's audit and Resident Council Meeting minutes revealed that a significant number of residents (40 out of 111) reported not consistently receiving a bedtime snack. The Nursing Home Administrator acknowledged that residents continued to express concerns about the lack of consistency in receiving evening snacks, and the issue remained unresolved.
Failure to Train Agency Staff on Corrective Measures
Penalty
Summary
The facility failed to ensure that agency staff employed and working in March 2025 received the required training on corrective measures outlined in the facility's plan of correction. The plan of correction, developed after a previous survey, required immediate re-education of all licensed staff on several key policies, including abuse prevention, person-centered care planning, skin care, medication administration, restorative nursing, medication utilization, water pass, meal frequency, and infection control. Documentation provided during a follow-up visit showed that only 12 out of 75 agency staff members had completed the required training, with no evidence or tracking system in place for the remaining 63 agency staff. The Director of Nursing confirmed that the facility did not implement a monitoring system to ensure agency staff received the necessary training before working shifts. There was a failure to identify gaps in training and to ensure that agency staff were adequately educated, resulting in a breakdown of the Quality Assurance and Performance Improvement (QAPI) program. No documentation or plan was available to address the lack of training among agency personnel.
Failure to Accurately Document Controlled Substance Counts
Penalty
Summary
The facility failed to implement procedures to ensure accurate controlled medication records on one of three medication carts observed. According to facility policy, Schedule II medications are to be counted and documented by both the oncoming and outgoing nurse at each shift change. However, a review of the Control Substance Shift to Shift Count Sheet for the D unit medication cart showed that on March 19, 2025, the second shift outgoing nurse did not sign to confirm that the narcotic count was completed and correct. This lapse was confirmed by the Nursing Home Administrator during an interview, indicating inconsistent adherence to procedures for maintaining accurate controlled drug records. No specific residents or patient medical histories were mentioned in relation to this deficiency.
Failure to Provide Consistent Drinking Water
Penalty
Summary
The facility failed to provide drinking water consistent with resident needs and preferences on one of its units, specifically the D-female dementia unit. Observations on January 7, 2025, revealed that several resident rooms lacked water cups or accessible drinking water, while other rooms had Styrofoam water cups with outdated dates, some of which were empty or contained warm water. Facility protocol requires night shift nursing staff to replace and date these cups, but this was not adhered to, as confirmed by staff interviews. Interviews with staff and a resident's family member highlighted the inconsistency in providing fresh water. An LPN and an agency nurse aide both acknowledged that the night shift staff is responsible for replacing and dating the water cups, and that nurse aides are expected to refill them during each shift. However, they confirmed that water had not been passed that morning. A resident's daughter expressed concern that her mother, who needs encouragement to drink, does not consistently receive fresh water, which could impact her hydration needs. The Nursing Home Administrator confirmed the protocol but acknowledged the failure to ensure the availability of drinking water as required.
Plan Of Correction
D unit corrected day of revisit 1/7/25. House audit completed on 1/7/25 for availability of drinks. Policy entitled, "Water Pass", reviewed for any updates. All staff in-serviced on facility policy. The DON or designee will be completed random weekly audits of resident water cups to ensure they being replaced consistently x 4, then monthly x 2. Audits be presented at monthly QAPI committee for ongoing oversight.
Failure to Provide Nourishing Evening Snacks
Penalty
Summary
The facility failed to ensure the provision of a nourishing evening snack when more than 14 hours elapsed between the dinner meal and breakfast the following day for nine out of ten sampled residents. The facility's policy, last reviewed in June 2024, mandates that the time between a substantial evening meal and breakfast should not exceed 14 hours unless a nourishing snack is provided at bedtime. However, the scheduled mealtimes revealed a gap of 14.83 hours between dinner and breakfast, without the consistent provision of snacks. Interviews with residents indicated that snacks were not routinely offered or provided. Several residents reported that while a snack tray was sometimes left at the nurses' station, the snacks were not distributed to them. Some residents mentioned that they had to request snacks to receive them, and others noted that snacks were previously provided but had not been for months. The Nursing Home Administrator was unable to explain why residents were not routinely offered and provided with an evening snack.
Plan Of Correction
- B15, B6, B7, B8, B9, B150 (typo) B15, B11, B12 and B13 - Assessed for preferences of h.s. snacks. - House audit completed on all other residents requiring an h.s. snack and preferences to meet the resident needs. On admission, readmission, quarterly and PRN, the residents will be interviewed to discuss preferences for h.s. snacks. - Policy entitled, "Frequency of Meals", reviewed and re-education provided to all nursing staff and dietary staff. Education to nursing staff also included not only providing the preferred snack to the resident but also providing assistance to those residents in need of assistance and documentation of the snack and if consumed. - Facility re-established par levels for each unit for snack options on 2/3/25. - The DON or designee will complete weekly audits x 4, then monthly x 2. Auditing will include random resident interviews on snacks delivery and preferences. - Audits will be presented at the monthly QAPI committee for ongoing oversight.
Inadequate Provision of Assistive Dining Devices
Penalty
Summary
The facility failed to provide appropriate assistive dining devices for a resident, identified as Resident A11, who was diagnosed with dementia and dysphagia. The resident's physician had ordered a regular diet with dysphagia/advanced consistency, thin liquids, and the use of a spouted sip cup for all liquids, explicitly prohibiting the use of straws. However, during an observation, Resident A11 was found with a meal tray that included a straw and lacked the prescribed spouted sip cup. The resident's daughter confirmed that her mother had difficulty drinking at mealtimes and required a handled sippy cup, as per the physician's order, but was instead provided with a straw, which the resident could not use. Despite informing the facility administration, no corrective actions were taken. Further investigation revealed that the facility's inventory of adaptive dining equipment was insufficient to meet the needs of all residents requiring such devices. The facility had only one sippy cup available, while four residents required two-handled cups, six residents required Kennedy cups, and three residents required nosey cups. The corporate dietary manager confirmed the inadequacy of the adaptive dining equipment supply and acknowledged that the facility was responsible for obtaining the necessary equipment, despite outsourcing dietary services to an external vendor. The dietary manager was unable to provide information on how the dietary department ensured quality assurance for the availability of adaptive equipment.
Plan Of Correction
- A11-provided necessary devices when noted on 1/7/2025. - House audit completed on residents needing assistive devices on 1/7/2025. - House audit completed on par levels for adaptive equipment on 1/7/2025. - Re-education provided to all nursing staff and dietary staff on adaptive equipment and procedure if missing adaptive equipment noted. - The DON or designee will conduct weekly audit x 4, then monthly x 2 for adaptive equipment. - Audits will be presented at the monthly QAPI committee for ongoing oversight.
Deficiencies in Abuse Prevention and Dementia Care
Penalty
Summary
The facility failed to implement effective interventions to prevent resident abuse, dementia care, and unnecessary psychoactive medication use. An incident involving a resident, identified as Resident A16, occurred on December 27, 2024, where the resident was physically mishandled by staff, escalating into verbal threats and inappropriate conduct. This incident was not identified as abuse or appropriately addressed by the facility's QAPI committee. Resident A16, who exhibited aggressive and disruptive behaviors with documented cognitive impairments, did not receive care aligned with his plan of care, including 1:1 supervision. The facility's interventions were inadequate to address the resident's behaviors and care needs, resulting in repeated incidents of wandering, aggression, and unsafe situations. Additionally, the facility failed to ensure physician documentation met criteria for the continued use of psychoactive medications prescribed to Resident A16, lacking resident-specific rationale or evidence of compliance with gradual dose reduction requirements. Despite implementing a directed plan of correction after a previous survey, the facility failed to sustain corrective measures. Monitoring plans to audit abuse prevention, dementia care interventions, and psychoactive medication use did not identify ongoing deficiencies. Interviews with the Director of Nursing and Nursing Home Administrator confirmed that the QAPI committee did not adequately identify root causes, analyze trends, or implement sustained corrective actions to address the continued deficiencies.
Plan Of Correction
- The QA process reviewed by the temporary management company on 1/22/2025. - QA committee observation completed 1/22/2025 by the temporary management company. Review of current identified areas of needs identified through survey process and facility identified issues. - Re-education completed by the temporary management company to facility department heads and administration on policy entitled, "Quality Assurance and Performance Improvement (QAPI)." - Audits will be completed monthly and prn by the temporary management company x 3. - Audit will be presented at the monthly QAPI committee for ongoing oversight.
Delayed Infection Control Measures Lead to Spread of Gastrointestinal Symptoms
Penalty
Summary
The facility failed to timely implement effective interventions to prevent the spread of infections among residents. The deficiency was identified through a review of clinical records, facility policy, infection control documents, and staff interviews. Specifically, 15 residents exhibited gastrointestinal symptoms such as vomiting and diarrhea over several days, starting from January 2, 2025. Despite the early onset of symptoms, the facility did not initiate documented infection prevention interventions until January 6, 2025. This delay allowed the symptoms to spread to additional residents across different units. The facility's Infection Preventionist (IP) had assumed the role in mid-December 2024 and was still acclimating to the position. During the weekend when most symptoms were reported, the IP was not on duty, and a consultant nurse was primarily responsible for infection prevention duties. The IP became aware of the situation upon returning to work on January 6, 2025, and conducted in-service training on the D Unit. However, the IP could not explain why interventions were not initiated earlier, specifically on January 3, 2025, when the symptoms began.
Plan Of Correction
- A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, A13, A14 and A15 ERS completed on 1/8/2025. - House audit completed to determine any other outstanding infection control issues related to reporting and any other infection control issues pertaining to the tag that was identified. - Policy entitled, "Infection Control", reviewed for any updates. - Re-education provided to all staff on facility policy. - The DON or designee will conduct weekly and PRN Infection Control audits x 4, then monthly x 2. - Audits will be presented at the monthly QAPI committee for ongoing oversight.
Failure to Resolve Resident Grievance Timely
Penalty
Summary
Aventura at Terrace View failed to correct deficiencies related to resident grievances as outlined in 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities. The facility did not demonstrate timely and adequate efforts to resolve grievances, specifically for one resident, identified as Resident C1. The facility's policy required that grievances be addressed within five working days, but this was not adhered to in the case of Resident C1. Resident C1 was admitted to the facility with diagnoses including overactive bladder and muscle weakness. A grievance was filed on behalf of Resident C1 on October 4, 2024, by the resident's responsible party, expressing concerns about inadequate incontinence care, as the resident was soaking through multiple pairs of pants daily. However, the grievance was not resolved until December 16, 2024, 73 days later, and the resolution was noted only as "resident deceased," with no further follow-up possible. The facility failed to provide evidence that the grievance was addressed or investigated in a timely manner. At the time of the survey on January 8, 2025, there was no documentation showing that the facility had evaluated the grievance or determined if the resident and their responsible party felt the issue was resolved. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the facility's failure to resolve the grievance adequately and promptly.
Plan Of Correction
- As of 12/15/24, C1 no longer resides as facility. - All grievances from 1/7/25 forward reviewed and follow-ups completed with resident and responsible party. - Grievance policy reviewed and education provided to all staff, including administrative staff. - NHA or designee will conduct QA auditing 5 days a week for 3 months. - Audit results will be presented at the monthly QAPI meeting.
Failure to Investigate Alleged Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin and an allegation of physical abuse involving a resident with severe cognitive impairment. The resident, who was admitted with vascular dementia and required 1:1 supervision due to aggressive behaviors, was involved in an incident where a nurse aide allegedly restrained the resident inappropriately. Despite conflicting accounts from staff members, the facility did not suspend the involved employee immediately, as required by their abuse prevention policy, nor did they conduct a comprehensive investigation to rule out abuse, neglect, or mistreatment. The incident occurred when a nurse aide was observed holding the resident in a chokehold while attempting to remove the resident from behind the nurse's station. An altercation between staff members ensued, involving yelling and profanity in the presence of residents and staff. The facility's failure to ensure immediate protective measures and consistent supervision of the resident highlighted systemic deficiencies in safeguarding residents from potential abuse and maintaining a safe environment. Additionally, the facility did not investigate a bruise found on the resident's hip, failing to interview relevant staff or document witness statements as required by their policy. This lack of investigation into the injury of unknown origin compromised the facility's ability to identify and address potential abuse, neglect, or mistreatment, thereby jeopardizing the safety and well-being of residents under their care.
Plan Of Correction
- A16 investigation and follow-up completed on 1/23/25. A16 chart review completed and plan of care reviewed and updated to include behavior management plan to meet his individual needs. Staff involved in the investigation were re-educated on the facility policy and appropriate action taken per facility policy for the employees. - Facility wide audit completed on current residents to rule out any allegations of abuse, neglect or mistreatment. The facility will implement a new screening process for potential residents who require the memory support unit and appropriateness of admitting to the unit. - Immediate staff re-education provided to the administrative team related to the policy entitled, "Resident to Freedom from Abuse, Neglect, and Exploitation." 2/3/2025. All other facility staff mandatory education to be completed by directed in-service on 2/11/2025. This training shall include recognizing signs and symptoms of potential abuse, including bruises of unknown origin. Proper reporting protocols and the process for conducting a thorough internal investigation. New employees will also receive this training as part of their onboarding with annual refresher training. - Root Cause Analysis conducted in conjunction with QAPI and governing body and incorporated into the intervention plan (POC). - The DON or designee will conduct daily audits for any allegations of abuse and/or neglect for 3 months, then weekly for 4 weeks, then monthly for 2 months. - Findings will be reported to the QAPI Committee monthly for ongoing oversight. - Leadership will conduct unannounced compliance audits to ensure reporting and investigation processes are being followed. - The facility will seek feedback from residents and families through random interviews and resident council meetings to ensure a culture of safety.
Failure to Implement Comprehensive Care Plan for Pressure Sore Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident identified as at risk for skin breakdown due to decreased mobility. The resident, who was admitted with dementia and severe cognitive impairment, required staff assistance for activities of daily living. Despite these needs, the care plan did not include specific and individualized interventions for pressure sore prevention from June 6, 2024, to December 12, 2024. This lack of preventative measures led to the development of pressure-related skin issues, including a non-blanchable area on the resident's left heel and a bruise on the great toe. The deficiency was confirmed during a staff interview, where the Director of Nursing acknowledged the failure to include preventative interventions tailored to the resident's risk for pressure sore development. Clinical documentation revealed that treatment orders for the left heel and first toe were only initiated after the skin issues were identified, indicating a lapse in proactive care planning. Preventative measures such as repositioning, use of pressure-relieving devices, or routine skin assessments were not documented prior to the development of the noted skin issues.
Plan Of Correction
- A17 care plan updated to include skin care interventions. - Current review of residents care plans related to potential or actual pressure injuries completed. In addition, the review will include reviewing and revising current residents for person centered care to meet each individual resident needs. After initial review care plans the facility will make updates with admissions, readmissions, quarterly, annually and PRN. - Policy entitled, "Comprehensive Person-Centered Care Planning", and (NEED SKIN CARE POLICY), reviewed for any updates. Nursing staff re-educated on both policies. - DON or designee will conduct weekly audits on care plans x 4, then monthly x 2. Audits will be presented at the monthly QAPI committee for ongoing oversight.
Medication Administration Error Due to Identity Verification Failure
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice by not following physician's orders and ensuring accurate medication administration for a resident. Specifically, a licensed practical nurse (LPN) administered medications intended for another resident to Resident B4. This error occurred because the LPN relied on names and photos on the doorway instead of independently verifying the resident's identity before administering the medications. As a result, Resident B4 received Seroquel, Xanax, and Gabapentin, which were not prescribed for them, leading to increased fatigue. Resident B4 was admitted to the facility with diagnoses including metabolic encephalopathy, pneumonia, and dementia, and was severely cognitively impaired with a BIMS score of 3. The medication error was discovered when the intended recipient, Resident B15, reported not receiving their morning medications. The Director of Nursing confirmed the error and acknowledged the failure to follow professional standards and physician orders during medication administration.
Plan Of Correction
- B4 Assessed with no new recommendations. House audit on current resident completed to determine any medication errors. Policy entitled, "Administering Medications", reviewed for any revisions. Licensed nursing staff re-educated on policy. Medication administration audits completed on all licensed staff to determine competency, along with Narcotic accountability protocol. Random medication administration audits will be completed along with Narcotic accountability for licensed nursing staff weekly x 4, then monthly x 2 by DON or designee. Audits will be presented at the monthly QAPI committee for ongoing oversight.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to consistently provide restorative nursing services as planned to maintain mobility for two residents, identified as B1 and B2, out of a sample of 34 residents. The facility's Restorative Nursing Services Policy, last reviewed on June 19, 2024, mandates that residents receive restorative care to promote safety and independence. However, the facility did not adhere to this policy for the two residents in question. Resident B1 was admitted with conditions including heart failure, hypertension, and asthma, and was severely cognitively impaired. The resident's care plan included a goal to ambulate 25-50 feet with assistance, but the restorative nursing program for ambulation was not provided on 5 out of 7 days as ordered. Similarly, Resident B2, who had a history of cerebral infarction and Parkinson's disease, was also severely cognitively impaired and required assistance for mobility. The care plan for Resident B2 included a goal to ambulate 50-75 feet with assistance, but the restorative nursing program was not provided on 6 out of 7 days as ordered. Interviews with the Director of Rehab and the Nursing Home Administrator confirmed that the facility failed to implement the planned restorative nursing programs for these residents. The documentation showed inappropriate use of "NA" (not applicable) as a response, indicating that the restorative services were not provided as required, which was acknowledged by the facility's administration.
Plan Of Correction
- B1 & B2 reassessed by therapy to determine current needs. - House audit completed on current residents to determine any decline in ROM/Mobility. Any resident who missed scheduled ROM exercises to receive a therapy evaluation to assess for potential functional decline, and interventions will be implemented as needed. - Facility policy entitled, "Restorative Nursing Services", updated to include documentation requirements, specifying the reason when ROM exercises are not provided. Policy will also include prohibiting the use of "NA" not applicable when charting and should give a reason for refusal. - Mandatory directed in-service training will be completed on 2/11/2025 for nursing staff, therapy staff, and administrative staff on ROM exercises. This would include but not limited to importance of consistent range of motion and proper techniques along with correct documentation. - Root cause analysis (RCA) completed with the assistance of the QAPI committee and governing body. The results of the RCA will be incorporated into the POC. - The DON or designee will conduct weekly audits x 4 weeks then monthly x 2 to ensure staff compliance with ROM procedures and documentation. - Audits will be presented at the monthly QAPI committee for ongoing oversight.
Failure to Implement Individualized Incontinence Care
Penalty
Summary
The facility failed to implement individualized approaches to maintain continence for Resident C1, who was admitted with diagnoses of overactive bladder and muscle weakness. The resident's quarterly Minimum Data Set assessment indicated that the resident was always incontinent of bladder and bowel. However, the facility did not identify the type of incontinence or treatment options for the resident in the Elimination Continence Care Screen. Additionally, the resident's care plan for Incontinence Management included an intervention for the resident to be checked and changed at least every hour while awake. Despite this, there was no documentation in the clinical record to confirm that the resident was being checked and changed as outlined in the care plan. The Director of Nursing confirmed the lack of documented evidence that incontinence care was provided to Resident C1.
Plan Of Correction
- C1 no longer resides in facility since 12/15/24. - House audit completed on current residents to determine any additional changes in bowel and bladder. Initial resident centered audits will be conducted with house audit and then quarterly and PRN to determine the effectiveness of each residents person centered plan of care. - Policy entitled, "(Need policy)" reviewed and education provided to all nursing staff. - DON or designee will conduct auditing weekly x 4 then monthly x 2 on resident toileting needs. - Audits will be presented at the monthly QAPI committee for ongoing oversight.
Failure to Implement Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with vascular dementia, who displayed aggressive and wandering behaviors. The resident, admitted on November 20, 2024, was noted to be severely cognitively impaired with a BIMS score of 5. Despite a physician's order for 1:1 supervision due to aggressive and disruptive behaviors, the facility did not consistently implement this intervention. The care plan initiated on November 21, 2024, lacked specific interventions to address the resident's aggressive and wandering behaviors, which led to multiple instances of verbal and physical aggression and an elopement incident. Facility documentation revealed that the resident eloped through an open hallway window and was involved in several aggressive incidents towards staff and other residents. On December 27, 2024, the resident was physically restrained by staff, including being grabbed around the neck. Interviews with the Nursing Home Administrator confirmed that the facility's dementia program, which was updated after a previous survey, was not effectively implemented for this resident. The program was supposed to provide individualized, person-centered interventions, but the resident's care plan did not reflect these practices.
Plan Of Correction
- A16 care plan reviewed and developed an individualized person centered plan of care to address and manage dementia related behaviors. Current residents residing on the C1 and D units will have their care plans reviewed and updated to be individualized and person centered to address any dementia related behaviors. - Current dementia programming reviewed and updated to meet each of the resident behavior needs. Mandatory Directed In-service training will be completed 2/11/2025 on dementia-related behaviors, person-centered care planning, and behavior management techniques. Training will include de-escalation techniques, recognizing triggers, and effective redirection methods. Competency test will be completed to ensure staff can apply learned techniques. Additional education and support will be provided by the LTC RISE program. - Implementation of a "behavior management" committee will be initiated to include but not limited to nursing, activities, social service, and pharmacy. Pharmacy consultant will provide monthly recommendations for gradual dose reduction (GDR) requirements, focusing on reducing unnecessary medications and implementing alternative, non-pharmacological interventions. - Ongoing care conferences will continue with residents and/or resident representative (RR) to discuss behavioral interventions and gather input on personalized care approaches. RR will be offered on dementia care and strategies they can reinforce during visits. - DON or designee will be responsible to oversee implementation and compliance and conduct audits of care plans and direct observations of residents. - Root cause analysis will be conducted in coordination of the QAPI committee and governing body. The result of the RCA will be incorporated into the POC. - The DON or designee will conduct weekly audits x 4 weeks, then monthly x 2 of dementia care and individualized person center care. Audits will be presented at the monthly QAPI committee for ongoing oversight.
Inaccurate Accounting of Narcotic Medications
Penalty
Summary
The facility failed to implement procedures to ensure accurate accounting of narcotic medications for a resident and accurate controlled medication records on a medication cart. Specifically, a review of a resident's clinical record revealed that doses of Oxycodone, a narcotic opioid pain medication, were signed out by nursing staff but not recorded on the resident's Medication Administration Record on two separate occasions. This discrepancy indicates a failure in the administration and documentation process for controlled substances. Additionally, the facility's "Control Substance Shift to Shift Count Sheet" for a medication cart showed multiple instances where nurses failed to sign off on the narcotic count, indicating that the count was completed and correct. These omissions occurred over several days, further demonstrating inconsistencies in the facility's procedures for maintaining accurate controlled drug records. The Director of Nursing confirmed these inconsistencies during an interview, acknowledging the facility's failure to consistently implement procedures for promoting accurate controlled drug records.
Plan Of Correction
- C2-assessed with no negative outcomes. - Facility Narcotic Records assessed for any other issues with Narcotic count on 1/7/25 with no ill regularities noted. - Employee responsible for inadvertent signing re-educated on 1/7/25. Mandatory Directed Inservice training will be completed with all licensed staff. This includes but not limited to policy entitled, "Administering Medications". This also includes but not limited to proper shift to shift narcotic counts, documentation requirements and procedures for addressing discrepancies. - A root cause analysis will be conducted with the assistance from the QAPI committee and governing body. - The DON or designee will conduct weekly audits x 4, then monthly x 2. - Audits will be presented at the monthly QAPI committee for ongoing oversight.
Inadequate Documentation for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper management and monitoring of medication regimens for a resident, identified as Resident A16, who was admitted with vascular dementia with mood disturbances. The resident was prescribed multiple psychotropic medications, including Ativan, Seroquel, and Trazodone, without adequate documentation of a specific medical diagnosis justifying their use. The clinical record review revealed that the attending physician's documentation did not meet the criteria for the use of these psychoactive medications, as there was no resident-specific rationale provided for their continued use. During the survey, it was confirmed by the Director of Nursing that the physician documentation lacked accurate resident-specific details to support the use of the psychoactive medications. This deficiency was identified through clinical record review and staff interviews, indicating a failure to promote or maintain the resident's highest practicable well-being in relation to the use of psychoactive medications.
Plan Of Correction
- A16 reviewed by physician to complete appropriate documentation for use of the PRN medication. - A house audit completed on current residents related to psychotropic medications/PRN use to determine any irregularities. - Policy entitled, Medication Utilization and Prescribing - Clinical Protocol reviewed and education provided to licensed staff, social service, and attending physician. - DON or designee will conduct weekly audits x 4, then monthly x 2 for psychotropic medication/PRN usage and appropriate documentation for the use of medication. - Audits will be presented at the monthly QAPI committee for ongoing oversight.
Medication Labeling Error Leads to Resident Receiving Wrong Drug
Penalty
Summary
The facility failed to ensure accurate labeling of medication for a resident, identified as Resident B3, which led to a medication error. The resident, who was cognitively intact and had a history of irritable bowel syndrome and chronic pain syndrome, was supposed to receive Dicyclomine HCl 20 mg for her condition. However, due to a pharmacy packaging error, the medication labeled as Dicyclomine was actually Doxycycline, an antibiotic. This error was discovered after the resident experienced nausea and vomiting following the administration of the incorrect medication. The incident occurred when the resident refused her nighttime dose, citing adverse effects from the previous dose. Upon investigation, it was confirmed that the medication package was mislabeled, and the resident had been given Doxycycline instead of Dicyclomine. The nurse administering the medication noted the discrepancy in capsule size but proceeded with administration. The facility's policy required verification of medication labels three times before administration, which was not effectively followed in this case, leading to the error.
Plan Of Correction
- B3-label corrected for appropriate medication with appropriate label. - House audit completed on current residents related to labeling of medications. The NHA and DON addressed the current pharmacy in relationship to the mislabeling of the medication. Nursing staff have been re-educated on protocol for receiving and checking in medication once received from the pharmacy. - Re-education on policy entitled, "Administration of Medications", reviewed with all licensed staff. - The DON or designee will conduct weekly audits x 4, then monthly x 2 on medication administration and the receiving medications from pharmacy. - Audits will be presented at monthly QAPI committee for ongoing oversight.
Resident Elopement Due to Inadequate Supervision and Unsecured Windows
Penalty
Summary
The facility failed to ensure adequate supervision and effective safety measures for a newly admitted resident who was identified as a wandering risk. The resident, who was severely cognitively impaired with a BIMS score of 5, had a history of exit-seeking behaviors and was at high risk for wandering. Despite these known risks, the resident was able to elope from the facility through an unsecured window, which was not promptly identified by the staff. On the evening of the incident, the resident was observed wandering the unit, expressing concerns about his truck, and attempting to open doors. Staff attempted to redirect the resident but did not maintain adequate supervision. The resident was last seen at 11:45 PM, and it was not until a call from the police at 12:33 AM that staff realized the resident was missing. The resident had exited through a window, which was found open with the screen pushed out, and was located by police approximately one mile from the facility, wet and cold from the rain. The facility's failure to secure windows and maintain adequate supervision placed the resident in immediate jeopardy. The maintenance director later found that several windows in the facility were not secured, allowing them to be opened completely. This oversight, combined with the lack of timely identification of the resident's absence, contributed to the resident's elopement and the potential for serious harm.
Removal Plan
- Resident was given a full RN assessment and placed on 1:1.
- Wandering risk assessments were completed by Unit Managers for all residents and updated where necessary.
- The window identified as the residents exit point was secured so it could not be open more than 7 inches. All other facility windows were checked and/or secured to ensure they could not be opened more than 7 inches.
- Environmental rounds will be conducted by maintenance department to ensure all windows remain secure.
- Facility began staff education on the updated facility elopement policy and resident safety checks. All nonscheduled staff will be educated prior to their next scheduled shift, and no staff will be permitted to work until they have received the education.
- All new admissions assessed as high risk for elopement will be placed on 15-minute safety checks for the first 24 hours.
- Facility QAPI committee will convene to review and complete this plan.
Failure to Monitor Resident Leads to Elopement
Penalty
Summary
The facility's administration failed to effectively use its resources to ensure resident safety and maintain the highest practicable physical and mental functioning of its residents. This deficiency was identified through a review of clinical records, investigative reports, and staff interviews, which revealed that the facility did not adequately monitor the whereabouts of one resident, leading to an elopement incident. The failure to provide necessary supervision and effective safety measures placed 29 residents, identified as at risk for elopement, in immediate jeopardy to their health and safety. The deficiency was cited under the Code of Federal Regulatory Groups for Long Term Care, Quality of Care (F689) 483.25(d)(1)(2) Accidents, indicating that both the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not fulfill their essential job duties to ensure resident safety and adherence to regulatory guidelines. The job descriptions for both the Administrator and the Director of Nursing Services outlined their responsibilities, which include ensuring compliance with facility policies and maintaining high standards of care, but these were not met in this instance.
Resident Fall Due to Insufficient Staffing Leads to Hospitalization and Death
Penalty
Summary
The facility failed to provide adequate care and services to prevent physical harm to a resident, resulting in a fall and subsequent injuries. The resident, who had dementia and atrial fibrillation, required assistance from two staff members for bed mobility and transfers. However, during an incident, only one nursing assistant was present, leading to the resident rolling out of bed and sustaining head lacerations. The resident was on Warfarin Sodium, a blood-thinning medication, which increased the risk of bleeding. After the fall, the resident was transferred to the hospital where she received treatment for her head injuries, including the application of staples. A CT scan with contrast was performed, after which the resident experienced rapid atrial fibrillation with RVR, potentially due to an allergic reaction to the contrast dye. The resident's condition deteriorated, and she was admitted to the Progressive Care Unit, where she continued to decline and eventually passed away. The Director of Nursing confirmed that the resident required two staff members for bed mobility, and the failure to provide this level of assistance led to the incident and subsequent hospitalization.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide timely and consistent person-centered care and planned services for Resident 24, who was admitted with spastic quadriplegic cerebral palsy and three Stage 3 pressure ulcers. Despite having a pressure-reducing device for the chair and bed, the facility did not conduct thorough assessments or document detailed evaluations of the resident's pressure ulcers. The facility's Wound Care Management Policy required weekly documentation of wound progress, but only measurements were recorded without detailed assessments. The resident's condition worsened, resulting in Stage 4 pressure ulcers, infection, osteomyelitis, and hospitalization. Resident 24's care was further compromised when staff continued to apply discontinued treatments, as evidenced by the Treatment Administration Record showing both Xeroform and Aquacel AG treatments being signed off. The facility's failure to effectively monitor and evaluate the resident's pressure ulcers was confirmed by the Director of Nursing, who acknowledged the lack of registered nurse involvement in the assessment process. The resident's condition deteriorated to the point where a scheduled urological procedure was canceled due to the severity of the pressure ulcers, leading to the resident's hospitalization. Resident 27, who was admitted with dementia and other conditions, was at risk for pressure ulcer development but did not have any upon admission. The facility identified the resident's risk for skin alteration but failed to implement adequate interventions to prevent the development of a sacral pressure ulcer. Despite being on hospice services and dependent on staff for all activities of daily living, the resident developed a Stage 2 pressure ulcer, which required debridement and a change in treatment. The Director of Nursing confirmed the lack of adequate preventive measures for Resident 27's pressure ulcer development.
Failure to Implement Fall Prevention Measures for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement necessary individualized safety measures and staff supervision for a resident identified with poor safety awareness and a history of falls, resulting in a fall with serious injury. The resident, who was severely cognitively impaired with Alzheimer's disease, had a history of falls and was assessed as high risk for falling. Despite this, the facility did not consistently provide the required assistance with ambulation as indicated in the resident's care plan and documentation. The resident's care plan included interventions such as wearing non-skid footwear, using a wheelchair as needed, and ensuring the call bell was within reach. However, the facility's investigation revealed that the resident's socks were not properly positioned, which contributed to the fall. The fall was unwitnessed, and the resident was found on the floor with a large laceration on her forehead, which required hospital treatment for a traumatic subarachnoid bifrontal hemorrhage. The facility's investigation into the incident was inadequate, as it failed to provide additional staff witness statements or evidence that individualized fall prevention interventions were implemented. The interim Director of Nursing confirmed that the fall with head laceration was not adequately investigated, highlighting a deficiency in the facility's nursing services.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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