Bristol Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bristol, Pennsylvania.
- Location
- 905 Tower Road, Bristol, Pennsylvania 19007
- CMS Provider Number
- 395258
- Inspections on file
- 50
- Latest survey
- July 29, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Bristol Health & Rehab Center during CMS and state inspections, most recent first.
A resident with documented sensory-neural hearing loss and cognitive intactness did not have a comprehensive care plan addressing their hearing impairment. Despite receiving hearing aids and staff awareness of the resident's difficulty hearing, no care plan with specific interventions or goals was developed.
A resident with a history of skin impairment risk developed a right lower extremity wound that was not timely identified, assessed, or treated by staff, despite care plans and physician orders for regular skin checks. Multiple staff failed to follow policies for reporting and documentation, with one LPN falsifying records and another failing to provide necessary care. The wound was only discovered after it had worsened, resulting in exposed bone and infection, and the resident required hospital transfer.
A nurse failed to follow infection prevention protocols by bringing the entire wound care supply cart into a resident's room during treatment of a stage four pressure ulcer. This action was inconsistent with facility policy and CDC guidelines, which require separation of clean and soiled equipment to prevent cross-contamination.
A resident with decreased mobility and increased risk for pressure ulcers did not receive appropriate offloading interventions as recommended by the wound care practitioner. The care plan was not updated to address the resident's higher risk, and staff failed to document or obtain orders for the use of TED stockings, resulting in both a Stage II pressure ulcer on the right heel and an abrasion wound. Facility staff did not complete root cause analysis or implement corrective actions following the skin alterations.
Multiple residents were observed without prescribed heel lift boots in place, despite facility policy and wound care practitioner recommendations for pressure ulcer prevention. In several cases, heel boots were found unused on furniture or the floor, and there was no documentation of resident refusal or clinical justification for not applying them. This resulted in a failure to provide wound prevention services according to professional standards.
The facility did not implement timely nutritional assessments or increase monitoring for two residents experiencing significant weight loss. One resident experienced ongoing weight loss over several months without prompt reassessment or intervention, while another was not weighed monthly and lacked proper documentation or physician orders for weight monitoring. These actions did not follow facility protocols for nutrition and weight management.
A resident's meal intake records were not consistently documented in real time, with many breakfast and lunch entries completed simultaneously rather than as meals occurred. Additionally, several meal entries were missing altogether. The DON confirmed that staff are expected to document in real time, but this standard was not met for the resident.
A resident developed a dark, elevated area on the anterior left foot, which was observed by nursing staff over several days. Despite facility policy requiring prompt notification and documentation, there was no evidence in the clinical record that the physician or the resident's representative were informed of this change in condition.
A resident with bilateral lower extremity venous ulcers did not receive tubi-grip compression as recommended by a wound care practitioner. Observations confirmed the absence of compression measures, and staff interviews verified that the treatment was not provided. There was no physician order or documentation indicating the resident was offered or received the recommended care.
Nursing staff did not demonstrate required competencies for PICC line care, as evidenced by missing documentation of dressing changes and catheter measurements for two residents. The facility could not provide proof of completed PICC line care competencies for the nurses involved, and a nurse educator confirmed that such competencies had not been completed.
The facility did not ensure proper implementation of enhanced barrier precautions for multiple residents with wounds and indwelling devices, as required by policy. PPE was not available near rooms where EBP signage was posted, and a nurse failed to wear a gown during the initial stages of wound care, only putting it on after cleaning the wounds.
A resident at Silver Lake Healthcare Center, with a known nut allergy, was served a cookie containing peanuts, leading to an allergic reaction. The resident experienced an itchy throat and difficulty swallowing after consuming part of the cookie. Nursing staff administered Benadryl and an EpiPen, and the resident's condition stabilized after assessment by an on-site NP.
A resident with a history of mental health and cognitive impairments eloped from the facility for four hours due to inadequate supervision and security measures. The resident exited through two doors that were supposed to be locked and alarmed, but no alarm was heard by staff. The facility's elopement prevention policy was not effectively implemented, leading to an Immediate Jeopardy situation.
A resident with schizoaffective disorder and moderate memory impairment eloped from the facility, walking over 4 miles before contacting police to return. The resident exited through an unlocked kitchen door and an alarmed door that did not sound, with staff unaware of the absence until police notification. This incident resulted from failures in management and operational oversight by the NHA and DON.
A resident with dementia and hypertension was mistakenly given medications intended for another resident due to a transcription error by a nurse. The error was discovered after the resident's daughter noticed changes in the resident's condition, leading to the resident being sent to the ER for evaluation. The facility's staff identified the mistake and informed the family and physician.
A resident with a history of substance abuse experienced multiple overdoses due to the facility's failure to implement a comprehensive care plan. Despite being cognitively intact and having a history of alcohol, heroin, and fentanyl abuse, the facility did not address the resident's addiction or potential for relapse. The facility also failed to investigate reports of drug distribution among residents, leading to an Immediate Jeopardy situation.
A resident with a history of substance abuse experienced multiple drug overdoses due to inadequate supervision and lack of a comprehensive care plan. The facility failed to investigate the sources of illegal substances and did not implement effective monitoring or interventions, leading to an Immediate Jeopardy situation.
The facility failed to serve meals timely on two nursing units, with lunch trays delivered significantly later than scheduled. Residents expressed dissatisfaction, noting consistent delays and unresponsiveness from the dietary department. The Dietary Director confirmed the inconsistency in dining times.
The facility failed to maintain an effective infection control program, lacking infection surveillance, reporting, and enhanced barrier precautions. A resident with a feeding tube and urinary catheter did not receive necessary precautions despite having multi-drug resistant organisms. Another resident with a urinary tract infection was inadequately monitored. The facility lacked infection surveillance data, staff training, and documentation of infection committee meetings.
A resident was subjected to derogatory language by an LPN who entered the resident's room without knocking and failed to close the privacy curtain. The LPN admitted to calling the resident a 'wicked witch' following a confrontation involving racial slurs. The incident led to the LPN's termination.
A facility failed to create an individualized care plan for a resident with non-Alzheimer's dementia. Despite receiving antipsychotic and antidepressant medications, the resident's care plan lacked specific goals and interventions for dementia care. This deficiency was confirmed by the DON during an interview.
The facility exceeded the acceptable medication error rate, with two incidents involving residents. A nurse administered the wrong eye drops to a resident, while another nurse could not provide a prescribed anxiety medication due to its unavailability. These errors led to a medication error rate of 7.69%.
A resident with Acute Osteomyelitis was prescribed Cefepime for a diabetic foot ulcer, but a nurse administered Daptomycin instead. The error was confirmed by the nurse and reported to the State Survey Agency. The DON noted no adverse reactions and confirmed the physician was notified.
The facility failed to honor resident meal preferences, as observed on one nursing unit. Residents were served meals not aligned with their preferences, and some were unaware of how to change their orders. Staff interviews revealed that menus were not posted or distributed in advance, and meal tickets were not followed. A group meeting confirmed that residents were not offered food choices per their preferences.
The facility failed to comply with food service safety standards, as dietary staff were observed preparing food without hair nets, and several refrigerated food items were either not dated or improperly dated. These actions violate the facility's policy and USDA standards, leading to a deficiency in maintaining food service safety.
The facility did not ensure that the QAA committee met quarterly as required by their QAPI program. Meetings were only documented in January, July, and August 2024, contrary to the facility's policy of monthly meetings. The Nursing Home Administrator confirmed the absence of documentation for other months and acknowledged the deficiency.
The facility failed to maintain an effective antibiotic stewardship program for two residents, as evidenced by the lack of infection surveillance data and discrepancies in prescribed antibiotics. One resident with multiple diagnoses, including a multi-drug resistant organism, did not have a completed Antibiotic Time-Out tool. Another resident with a urinary tract infection was prescribed antibiotics without proper documentation. The DON was unable to provide evidence of infection surveillance or collaboration with the clinical team, leading to the deficiency.
The facility failed to designate a qualified infection preventionist, as required by policy, to oversee its infection prevention and control program. The role was shared between the DON and ADON, neither of whom had completed the necessary training. The facility was in the process of hiring a nurse for this role.
The facility failed to maintain safe handrails in corridors on the First and Second floor nursing units. Observations revealed broken, cracked, and missing handrails, with some having exposed sharp edges or being covered with tape. The Nursing Home Administrator confirmed these deficiencies and acknowledged the need for a full audit of all handrails.
A resident received a medication error involving Keppra, which was not prescribed to them. Despite the error being noted and the resident being monitored, the facility failed to conduct a thorough investigation to rule out neglect, as confirmed by interviews with the Assistant DON and the Nursing Home Administrator.
A facility failed to address hospital recommendations for a resident with multiple medical conditions, including a fracture and a Stage 4 pressure ulcer. Although a Rom Knee Brace was in place, the facility did not follow physician orders or schedule a cardiologist appointment as recommended. Interviews with staff confirmed these oversights, indicating a failure to provide appropriate care.
A resident with multiple health issues developed a Stage 4 pressure ulcer on the right heel and an unstageable pressure ulcer on the left thigh due to inadequate care. Despite recommendations to float the heels, the resident was found without heel boots or pillows. Additionally, ordered treatments for a skin tear were not documented or completed on several occasions, as confirmed by facility staff.
Failure to Develop Care Plan for Hearing Loss
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan addressing hearing loss for a resident diagnosed with sensory-neural hearing loss in both ears. The resident, who was cognitively intact as indicated by a BIMS score of 15, reported being hard of hearing and had recently received hearing aids, though they were not provided to him on the morning of the interview. Staff interviews confirmed the resident's hearing difficulties and acknowledged that no care plan had been created to address his hearing impairment, including the absence of specific focus, interventions, or goals related to this diagnosis. Review of the clinical record and audiology consultation further substantiated the resident's hearing loss, yet no corresponding care plan was documented.
Failure to Timely Identify and Treat Resident Wound Resulting in Harm
Penalty
Summary
A deficiency occurred when facility staff failed to timely identify, assess, and provide treatment for a resident's right lower extremity wound. The resident, who had a history of psoriasis vulgaris and absence of the left foot, was assessed as being at risk for skin impairment and pressure ulcers. Despite care plans and physician orders requiring weekly skin assessments and daily monitoring, documentation showed that no wounds or pressure areas were identified in multiple weekly assessments, and there was a lack of evidence that staff properly assessed or documented the resident's skin condition during this period. On June 1, a nurse aide observed a closed, red area on the resident's right leg and reported it to a nurse, but the nurse later stated she was unaware of any skin concerns and did not recall being notified. Subsequent investigation revealed that three licensed nurses and one nursing assistant failed to follow facility policies regarding reporting, documentation, assessment, and provider notification for changes in skin integrity. One nurse was found to have falsified documentation, concealing evidence of negligence, while another failed to provide necessary treatment and ensure appropriate care. The wound was ultimately discovered on June 3, at which point it was found to be open with exposed bone, and the resident was transferred to the hospital with a diagnosis of wound infection and arterial insufficiency. Interviews with facility staff, including the DON, wound nurse practitioner, and CRNP, confirmed that the wound had not been identified or reported prior to June 2. The resident's hospital records indicated admission for a worsening right lower extremity wound, cellulitis, and arterial blockages. The facility's internal investigation substantiated neglect, citing failures in timely identification, assessment, and intervention for the resident's wound, which resulted in actual harm requiring hospitalization.
Infection Control Breach During Wound Care
Penalty
Summary
A deficiency was identified when a licensed nurse failed to follow infection prevention protocols during wound care for a resident with a stage four pressure ulcer. The nurse transported the entire wound care supply cart into the resident's immediate care area, contrary to facility policy and CDC guidelines, which require maintaining separation between clean and soiled equipment to prevent cross-contamination. The nurse also accessed the supply cart while in the resident's room, which is not permitted according to best practice standards and state health department literature. The resident involved required assistance with personal care and had a physician's order for daily wound treatment to the sacrum. During the observed wound care, the nurse followed the clinical treatment order but did not adhere to infection control protocols, as confirmed by the nurse at the time. This lapse in infection prevention was documented through observations, policy review, and staff interviews, and was found to be inconsistent with established infection control practices designed to prevent cross-contamination.
Failure to Implement Pressure Ulcer Prevention Measures Resulting in Resident Harm
Penalty
Summary
The facility failed to develop and implement care and services consistent with professional standards of practice to prevent the development of a pressure ulcer, resulting in actual harm to a resident who developed a Stage II pressure ulcer on the right heel. The resident, who had a history of dementia and cognitive deficit, was readmitted after a hip fracture and surgical repair, which led to a significant decline in mobility and increased dependence on staff for bed mobility and transfers. Despite these changes, the care plan was not updated to reflect the resident's increased risk for pressure ulcers, and individualized interventions were not implemented. Clinical records and wound care practitioner notes repeatedly recommended offloading the resident's heels while in bed, but there was no documented evidence that this intervention was provided. Observations confirmed that while a heel boot was applied to the right heel, the left heel remained unprotected and flat on the bed. Additionally, the resident was found to be wearing a brace that limited movement, further increasing the risk for pressure injury. The facility also failed to document or obtain a physician's order for the use of TED stockings, which led to an abrasion wound on the right dorsal foot. Interviews with facility staff, including the wound care nurse and DON, revealed that root cause analysis and corrective actions were not completed following the identification of skin alterations. The lack of implementation of recommended interventions and failure to update the care plan contributed directly to the development of a Stage II pressure ulcer on the resident's right heel.
Failure to Apply Heel Boots and Implement Wound Prevention Measures
Penalty
Summary
The facility failed to ensure that treatments and services provided to prevent the development of wounds met professional standards of practice for four residents. Facility policy required the development of care plans for pressure ulcer prevention, including interventions such as evaluating areas of impaired sensation, instructing residents to notify staff of skin changes, positioning with support devices, and monitoring treatment plans for conditions that increase skin impairment risk. However, observations revealed that heel lift boots, which are intended to offload pressure and prevent wounds, were not applied as recommended. In several cases, heel boots were found on wheelchairs, air-conditioning units, or the floor, rather than being used by the residents as directed. For one resident with a full-thickness Kennedy terminal ulcer on the left heel, the heel lift boot was not in use, and there was no documentation of refusal or explanation for the omission. Another resident with two wounds on the right lower extremity was observed with only one heel boot applied, leaving the other heel unprotected despite repeated recommendations from the wound care practitioner to float both heels. Additional residents were also observed without their prescribed heel boots in place, and clinical records did not indicate any refusals or reasons for not following the prescribed interventions. These findings demonstrate a failure to implement and document required wound prevention measures according to professional standards.
Failure to Implement Timely Nutritional Interventions and Weight Monitoring
Penalty
Summary
The facility failed to implement timely and appropriate interventions to maintain acceptable nutritional parameters for two residents. For one resident, significant weight loss was documented over several months, with repeated instances where nutritional assessments were delayed and not completed until weeks after the weight loss was identified. The resident was not reweighed in a timely manner to confirm the weight loss as required by facility protocol, and there was no evidence that weight or nutritional monitoring was increased in response to the ongoing weight loss. Documentation repeatedly noted that weight changes were not new and continued the current diet, despite ongoing significant weight loss. For another resident, there was no evidence that monthly weights were obtained, no physician order for monthly weights, and no documentation of reasons for not obtaining weights or of resident refusal over a one-year period. An interview with the Medical Record Nurse confirmed the absence of orders and documentation for monthly weights for this resident. These findings indicate that the facility did not follow its own policies and procedures regarding weight monitoring and nutritional assessment for residents at risk.
Failure to Document Meal Intake in Real Time and Missing Entries
Penalty
Summary
The facility failed to adhere to accepted standards of practice for medical record documentation for one resident. Review of the facility's policy on height and weight documentation indicated that nurses are required to document resident information in real time or as soon as practicable, and to avoid excessive use of late entries. However, documentation of meal intake for the resident over several months showed that records for breakfast and lunch were often completed at the same time of day, rather than in real time. Additionally, there were multiple instances where meal intake documentation was missing for certain meals, including missing dinner and lunch entries on specific dates. Interviews with staff, including the Director of Nursing, confirmed that facility staff are expected to document in real time, which was not consistently done in this case. The findings were based on a review of clinical records, facility policies, and staff interviews, and demonstrated a failure to maintain timely and accurate medical records in accordance with both facility policy and regulatory requirements.
Failure to Notify Physician and Representative of Change in Skin Condition
Penalty
Summary
The facility failed to promptly notify a resident's physician and representative of a change in the resident's skin condition. During an observation, a dark colored elevated area approximately 2 inches in diameter was noted on the anterior left foot of a resident. A Licensed Nurse Supervisor identified the area and stated it could be a bruise or blood-filled blister. A nurse aide reported having seen the area two days prior and stated she had informed the wound care nurse, as well as having observed the area on previous days. A review of the resident's clinical record revealed no documented evidence of the skin area or that the physician or resident's representative had been notified of the change. The facility's policy requires prompt notification of the resident, physician, and representative when there is a significant change in condition, and documentation of the notification and interventions in the medical record. The Nursing Home Administrator confirmed that there was no documentation regarding the cause of the area, any investigation, or notification to the physician about the change in skin condition.
Failure to Provide Physician-Recommended Compression Treatment for Venous Ulcers
Penalty
Summary
A resident with bilateral lower extremity venous ulcers did not receive treatment and care as recommended by the wound care practitioner. Specifically, recommendations were made on two separate occasions for the application of tubi-grip compression to the lower extremities during the day and removal at night. However, review of the resident's clinical record and physician orders revealed that there was no order for tubi-grip in place, and the Treatment Administration Record showed no evidence that the tubi-grip was offered or applied as recommended. During an observation, the resident was seen sitting in a wheelchair with her feet on the floor and was not wearing any tubi-grip or compression measures. An ulcer was noted on the left calf, and a new fluid-filled blister was observed on the right lower extremity. Staff interviews confirmed that the tubi-grip was not in use and explained its intended purpose for preventing swelling and ulcer development. The lack of implementation of the recommended treatment constituted a failure to provide care and services according to the practitioner's recommendations.
Lack of PICC Line Care Competency Among Nursing Staff
Penalty
Summary
Nursing staff failed to demonstrate appropriate competencies and skill sets in the care of residents with peripherally inserted central catheters (PICC lines). For two residents with PICC lines, there was no documentation on the dressings to indicate the date and time of the last dressing change, and staff did not document the measurement of external catheter length as ordered by the physician. One resident reported that staff did not change her dressing weekly as required. When requested, the facility was unable to provide evidence of completed PICC line care and management competencies for the registered nurse and licensed nurse involved. An interview with the registered nurse responsible for staff education confirmed that the facility had not completed competencies for PICC line dressing changes.
Failure to Implement Enhanced Barrier Precautions and Infection Control Measures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding the implementation of enhanced barrier precautions (EBP) for residents with wounds and indwelling medical devices. Observations revealed that several residents who required EBP, including those with pressure ulcers and tube feedings, did not have appropriate signage on their doors or readily accessible personal protective equipment (PPE) such as gowns and gloves in or near their rooms. In multiple instances, door signs indicated EBP was required, but PPE was not available as per facility policy. Additionally, during a wound care procedure for a resident on EBP, the wound care nurse began the process and removed soiled dressings without wearing a gown, only donning the gown after cleaning the wounds. This action was not in accordance with the facility's EBP policy, which requires gown and glove use during high-contact resident care activities, including wound care. These deficiencies were confirmed through staff interviews and direct observation.
Failure to Accommodate Resident's Nut Allergy
Penalty
Summary
Silver Lake Healthcare Center was found to be non-compliant with federal and state regulations regarding the accommodation of resident allergies. The deficiency was identified during an abbreviated survey conducted in response to complaints. The survey revealed that the facility failed to provide food that accommodated a resident's known nut allergy. Specifically, the resident, who is allergic to nuts, was served a cookie containing peanuts, which was not in accordance with her dietary restrictions as noted on her meal ticket. The incident occurred when the resident consumed part of the cookie and began experiencing an allergic reaction, characterized by an itchy throat and difficulty swallowing. The nursing staff responded by administering Benadryl and an EpiPen, as the resident had a history of serious allergic reactions. The resident was assessed by an on-site nurse practitioner, and her condition stabilized following the administration of the medication. Interviews with staff confirmed the occurrence of the allergic reaction and acknowledged that the cookie appeared to be a sugar cookie but contained nuts, which had not happened before.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. 1. Corrective Action for Resident #1: Resident #1 was discharged from the facility on 01/14/2025. 2. Identification of Other Residents Potentially Affected: All residents currently in the facility have the potential to be affected by the alleged deficient practice. An audit of all residents was conducted on 01/21/2025 by Dietitian to ensure that allergies are accurately documented in both the Electronic Medication Administration Record (EMAR) and the Meal Tracker system. Any inaccurate or missing allergies will be corrected. 3. Systemic Changes to Prevent Recurrence: The Executive Director/designee will provide in-service training to Dietary, Activity Staff and Clinical staff on ensuring meal tray accuracy by 01/24/2025. The training will emphasize the importance of adhering to dietary restrictions and ensuring that meal trays are accurate based on the resident's documented needs and the information on meal tickets. The Executive Director/designee will implement an audit process to verify the accuracy of meal trays. 4. Monitoring and Quality Assurance: - Audits will be completed by Executive director /designee to review meal trays for 3 random residents to ensure the meal contents match the items listed on the meal tickets. This will be completed 5x's weekly for 4 weeks, then weekly for 3 months, and subsequently on a random basis. - Findings from the meal tray accuracy audits will be reported during the monthly Quality Assurance and Performance Improvement (QAPI) meetings for a period of 3 months. Afterward, monitoring and reporting will continue on a random basis.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as Resident R1, who managed to exit the facility through two doors that were supposed to be locked and alarmed. This incident resulted in the resident eloping from the facility for approximately four hours, creating an Immediate Jeopardy situation. The facility's policy on Elopement Prevention and Management was not effectively implemented, as evidenced by the resident's ability to leave the premises without staff awareness. Resident R1, who has a history of schizoaffective disorder, bipolar disorder, intellectual disabilities, and epilepsy, was admitted to the facility with a moderate memory impairment. Despite these conditions, the resident's Minimum Data Set (MDS) did not indicate wandering behaviors. On the night of the incident, the resident left the facility unnoticed and walked over four miles before contacting the police to return to the facility. Interviews with staff revealed that no alarm was heard when the resident exited, and the facility's documentation showed that the doors, locks, and alarms were not tested on the day of the incident. The facility's documentation and interviews indicated that the doors were checked regularly and found to be functional, yet the resident was able to exit without triggering an alarm. The resident reported that the first door was unlocked, and the second door opened after being pushed for 15 seconds, as per fire safety protocols. This lapse in security measures and supervision allowed the resident to leave the facility, highlighting a significant deficiency in ensuring a safe environment for residents at risk of elopement.
Removal Plan
- Incident Response: Resident was assessed by facility registered nurse and found to have no injuries. Resident was placed on 1:1 observation awaiting psychiatric evaluation. Charge nurse completed wandering risk assessment, skin assessment, and pain assessment. The care plan was updated to include elopement risks. All facility doors were inspected by maintenance and all were found to be in working order. A head count was conducted by nursing staff, confirming all residents were accounted for. All access codes for egress doors were changed.
- Wandering risk assessment: an order listing report for all residents with Wander Guards was generated and checked for proper placement and function by Unit Managers. Care plans were reviewed and elopement book was updated. Resident named in deficient practice was added to the elopement risk list. Full house assessed for elopement risk, no new residents noted. Audit completed by Unit Managers.
- Staff Education: All staff present received education on the elopement process, effective rounding, and proper operation of all egress doors from the RN Supervisor. Staff not present received the same training from the Staff Development Coordinator/ designee. New staff will receive education on the elopement process during their orientation by the DON or designee.
- Elopement Drills: Elopement drill will be conducted across all shifts, overseen by the NHA and maintenance director.
- Interdisciplinary Team Meeting: The IDT convened to discuss the resident's high risk for elopement, and the care plan was updated accordingly.
- Behavior Monitoring: The DON or designee will monitor the clinical dashboard for any changes in behavior, including exit-seeking. Findings will be reviewed by the IDT, and new interventions will be implemented as needed to prevent future incidents.
- Security Enhancements: The lock on the kitchen door was changed to an automatic lock, and the key code for all egress doors was updated.
Resident Elopement Due to Management Failures
Penalty
Summary
The Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility, leading to an Immediate Jeopardy situation involving a resident's elopement. The resident, who had a history of schizoaffective disorder, bipolar disorder, intellectual disabilities, and epilepsy, was assessed with moderate memory impairment and did not exhibit wandering behaviors according to their most recent Minimum Data Set. Despite this, the resident managed to leave the facility undetected, walking approximately 4.2 miles before contacting the police to return to the facility. Interviews and facility documentation revealed that the resident was last seen in bed shortly before the elopement, and no alarm was heard when the resident exited the facility. The resident was able to leave through an unlocked kitchen door and an alarmed door that did not sound. Staff were unaware of the resident's absence until notified by the police. This incident highlights a failure in the facility's management and operational oversight, as the necessary precautions to prevent such an event were not effectively implemented.
Medication Administration Error Due to Transcription Mistake
Penalty
Summary
The facility failed to ensure that a resident received the correct medications as ordered by their physician, resulting in the administration of medications intended for another resident. This error occurred due to a transcription mistake by a registered nurse, who entered medications for a newly admitted resident with the same last name into the wrong resident's chart. As a result, the resident received Ferrous Sulfate, Gabapentin, Lipro insulin, and Keppra, which were not prescribed for them. The error was discovered after the resident's daughter noticed a change in the resident's condition, prompting a review of the medication orders. The resident, who has a diagnosis of dementia and hypertension, was subsequently sent to the emergency room for evaluation due to confusion and lethargy. Hospital records indicated that the resident was admitted for monitoring after presenting with altered mental status and slurred speech. The facility's nursing staff, including the LPN and supervisor, identified the error and informed the resident's family and physician. The incident highlights a failure to adhere to the facility's medication administration policy, which emphasizes the importance of verifying the right resident, medication, dose, time, and route.
Failure to Implement Care Plan for Resident with Substance Abuse History
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a documented history of substance abuse, leading to multiple incidents of drug overdose. The resident, who was cognitively intact, had a history of alcohol, heroin, and fentanyl abuse, and was admitted to the facility with diagnoses including major depressive disorder and adjustment disorder. Despite this, the facility did not create a care plan addressing the resident's substance abuse history and potential for relapse. The resident experienced several overdoses, requiring emergency medical intervention, yet there was no evidence of an interdisciplinary care planning meeting to address the resident's addiction, identify triggers, or provide support and counseling. The facility's policies on care planning and substance abuse were not followed, as there was no documented evidence of consistent psychiatric or psychological counseling provided to the resident. Additionally, the facility did not investigate reports that the resident obtained drugs from another resident, nor did it implement measures to prevent drug distribution within the facility. Interviews with the Nursing Home Administrator confirmed the lack of a comprehensive care plan and investigation into the resident's drug access. The facility's inaction resulted in an Immediate Jeopardy situation, as the resident continued to access and use illegal substances, leading to repeated overdoses. The facility's failure to address the resident's substance abuse needs and ensure a safe environment for all residents was a significant deficiency.
Removal Plan
- Resident named in deficient practice has been discharged from the facility.
- Assessment of all residents currently residing in the facility for history of substance abuse was completed. The Facility ensured that care plans were in place for each resident with history of substance abuse disorder. Any residents that were found to have a history of substance abuse were also assessed for signs of current illicit drug use and room checks completed during the shore rooms for free from hazardous materials. No residents were found to be suspicious for current use or found to have any materials.
- All residents identified to have substance abuse history received physician's orders to monitor for signs of impairment upon return from the hospital or leave of absence.
- All direct care staff will be educated by Assistant Director of Nursing or designee on how to monitor for signs of substance abuse, monitoring residents and with permission, residents, personal belongings and room check following leave of absence and hospital stay. And policy title, residents, substance abuse and facility.
- Audits will be completed by administrator or designee five times weekly for four weeks and then monthly for three months to ensure all residents are assessed for history of substance abuse upon admissions and that those residents with history of substance abuse will be monitored. Following any hospital stays and leave of absence, audits will be reported to the Quality Assurance Performance Improvement committee for further review and consideration.
- 67% of our direct care staff have completed training focused on key areas related to resident substance abuse. This training includes: Resident substance abuse in the facility. Entry assessments. Management of acute episodes. Observations of residents suspected or confirmed of usage. Care planning and resident education. Overview of substance use disorder. Identifying science. Acceptance use disorder. Understanding types of substance use disorders implementing person centered care applying harm reduction strategies Developing individualized patient care center plans individualized care planning effective interventions, implementations and evaluations creating care plans that truly work.
- 100% compliance in staff education.
Failure to Supervise Resident with Substance Abuse History
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as Resident R135, who had a documented history of substance abuse. This lack of supervision resulted in the resident accessing and using illegal substances, leading to four separate incidents of drug overdose. These overdoses required immediate medical intervention, including the administration of Narcan and emergency medical management. The facility's policies and procedures were not effectively implemented to address the resident's substance abuse history, as there was no baseline care plan developed within 48 hours of admission, nor a comprehensive person-centered care plan addressing the resident's potential for relapse. The facility's failure to conduct thorough investigations into the sources of illegal substances within the facility further exacerbated the situation. Despite multiple incidents where Resident R135 was found unresponsive due to drug overdoses, there was no documented evidence of environmental or behavioral monitoring to identify potential sources of illegal substances. Interviews with facility staff, including the Nursing Home Administrator and the Assistant Director of Nursing, revealed that no investigations were conducted regarding the resident's reports of obtaining drugs from other residents or visitors within the facility. The facility's inaction in implementing steps and interventions to prevent the distribution of drugs to other residents was evident. Despite the resident's repeated overdoses and reports of purchasing drugs from other residents, the facility did not take adequate measures to monitor or control the environment to prevent further incidents. This lack of action and supervision resulted in an Immediate Jeopardy situation, as the resident continued to access and use illegal substances, posing a significant risk to their health and safety.
Removal Plan
- Resident named in deficient practice has been discharged from the facility.
- Assessment of all residents currently residing in the facility for history of substance abuse was completed. The Facility ensured that care plans were in place for each resident with history of substance abuse disorder. Any residents that were found to have a history of substance abuse were also assessed for signs of current illicit drug use and room checks completed during the shore rooms for free from hazardous materials. No residents were found to be suspicious for current use or found to have any materials.
- All residents identified to have substance abuse history received physician's orders to monitor for signs of impairment upon return from the hospital or leave of absence.
- All direct care staff will be educated by Assistant Director of Nursing or designee on how to monitor for signs of substance abuse, monitoring residents and with permission, residents, personal belongings and room check following leave of absence and hospital stay. And policy title, residents, substance abuse and facility.
- Audits will be completed by administrator or designee five times weekly for four weeks and then monthly for three months to ensure all residents are assessed for history of substance abuse upon admissions and that those residents with history of substance abuse will be monitored. Following any hospital stays and leave of absence, audits will be reported to the Quality Assurance Performance Improvement committee for further review and consideration.
- 67% of our direct care staff have completed training focused on key areas related to resident substance abuse. This training includes: Resident substance abuse in the facility. Entry assessments. Management of acute episodes. Observations of residents suspected or confirmed of usage. Care planning and resident education. Overview of substance use disorder. Identifying science. Acceptance use disorder. Understanding types of substance use disorders implementing person centered care applying harm reduction strategies Developing individualized patient care center plans individualized care planning effective interventions, implementations and evaluations creating care plans that truly work.
- 100% compliance in staff education.
Inconsistent Meal Service Times
Penalty
Summary
The facility failed to ensure that meals were served timely on two of three nursing units observed, specifically the first and second-floor nursing units. Observations revealed inconsistencies in meal delivery times, with lunch trays being delivered significantly later than the scheduled times. For instance, on the first floor, lunch was observed to be served as late as 1:14 p.m., despite the scheduled time being 12:00 p.m. Residents expressed dissatisfaction with the meal service, noting that meals were consistently late, and one resident reported that the dietary department was unresponsive to complaints. The Dietary Director acknowledged the inconsistency in dining times. On the second floor, similar issues were observed, with the first lunch truck arriving at 12:40 p.m. and the second truck not arriving until 1:37 p.m. Afternoon snacks were also delivered late at 1:41 p.m. A group meeting with nine alert and oriented residents confirmed that meals were regularly served late. The facility's policy requires meals to be served at regular times comparable to normal mealtimes in the community, which was not adhered to, leading to the deficiency.
Inadequate Infection Control and Surveillance in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by inadequate infection surveillance and reporting, lack of enhanced barrier precautions, and insufficient infection committee meetings. The facility's policy on infection prevention, last reviewed in February 2022, outlines the responsibilities of the Infection Preventionist, including monitoring infections and completing monthly reports. However, during the survey, it was revealed that the role of the infection preventionist was shared between the Director of Nursing and the Assistant Director of Nursing, who did not perform any infection preventionist functions. This led to a lack of infection surveillance data and failure to implement enhanced barrier precautions for residents with infections or indwelling medical devices. Resident R154, who had a feeding tube, urinary catheter, and a stage four pressure ulcer, was not provided with enhanced barrier precautions despite having multi-drug resistant organisms and other serious infections. Hospital records indicated that the resident required specific intravenous antibiotics, but the facility failed to administer one of the recommended antibiotics. Similarly, Resident R33, who had a urinary tract infection, was not adequately monitored for infection surveillance. The facility's wound tracking logs showed a significant number of residents with wounds, yet enhanced barrier precautions were only posted for two residents. Additionally, Resident R165, who had a PICC line and required enhanced barrier precautions, did not receive the necessary precautions during medication administration. The Director of Nursing was unable to provide evidence of infection surveillance, staff training on enhanced barrier precautions, or access to the Pennsylvania Patient Safety Reporting System. Furthermore, there was no documentation of infection committee meetings, indicating a systemic failure in the facility's infection control program.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by an incident involving a licensed nurse, Employee E20, and Resident R65. On February 10, 2024, it was reported that Employee E20 called Resident R65 a 'wicked b*!*h' during an interaction. The incident occurred when Employee E20 entered Resident R65's room without knocking and pulled open the privacy curtain without closing it. Resident R65, who was in the hallway at the time, expressed dissatisfaction with the nurse's actions and was subsequently subjected to derogatory language. Further investigation revealed that Employee E20 admitted to calling Resident R65 a 'wicked witch' after a confrontation where Resident R65 allegedly yelled racial slurs and criticized the nurse's presence in the facility. The investigation concluded on February 14, 2024, with the termination of Employee E20. This incident highlights a failure in maintaining the dignity and respect of residents, as required by facility policies and regulations.
Failure to Develop Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with non-Alzheimer's dementia. The resident, identified as R141, was admitted to the facility and had active diagnoses of dementia, for which they were receiving antipsychotic and antidepressant medications. A review of the Minimum Data Set (MDS) assessment dated August 20, 2024, confirmed these diagnoses. However, on September 5, 2024, it was found that the resident's interdisciplinary plan of care lacked measurable goals and interventions specifically addressing their dementia care needs. This deficiency was confirmed by the Director of Nursing during an interview, who acknowledged the absence of a specific care plan for the resident's dementia care needs.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two incidents involving residents during medication administration. On September 4, 2024, a Licensed Nurse administered the incorrect medication, Artificial Tears, to a resident who was prescribed Pataday Ophthalmic Solution for allergic conjunctivitis. The nurse confirmed the error upon review. Additionally, a Registered Nurse was unable to administer busPIRone HCl Oral Tablet to another resident due to its unavailability, despite searching the medication cart and storage areas. The physician's order required this medication for anxiety and depression. These incidents resulted in a medication error rate of 7.69% for the facility.
Medication Administration Error
Penalty
Summary
The facility failed to administer medications correctly in accordance with physician orders, resulting in a significant medication error for one resident. Resident R159, who was admitted with diagnoses including Acute Osteomyelitis of the right ankle and foot, was prescribed Cefepime HCl Solution 1 GM/50ML 1 gram for a diabetic foot ulcer. However, on the night shift of August 7, 2024, a licensed nurse, Employee E24, administered Daptomycin Solution Reconstituted 500 MG intravenously instead of the prescribed Cefepime. The error was confirmed by Employee E24 and documented in the facility's report to the State Survey Agency. The Director of Nursing confirmed the findings, noting that there were no adverse reactions or consequences observed, and the physician was notified. The report highlights the facility's failure to adhere to physician orders in medication administration, as evidenced by the incorrect administration of Daptomycin instead of Cefepime to Resident R159.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to provide meals that honored food preferences for residents on one of its nursing units. The facility's policy required that individual tray assembly tickets identify all food items appropriate for each resident based on diet orders, allergies, intolerances, and preferences. However, observations and interviews revealed that residents were not receiving meals according to their preferences. On September 3, 2024, residents were served tuna salad sandwiches instead of the planned tuna melt sandwiches, and some residents expressed dissatisfaction with the meals provided. One resident did not know how to change her order, and another stated that they never received what they wanted to eat. Further observations on September 4, 2024, showed a resident sending back their entree and being told by kitchen staff that it was too late to change the order. Interviews with staff and residents indicated that the menu was not posted or handed out ahead of time, and meal tickets were not being followed. A group meeting with nine alert and oriented residents confirmed that the facility did not offer food choices per residents' preferences, and the menu on the wall was not up to date. This failure to provide meals according to residents' preferences and the lack of communication about meal options led to dissatisfaction among residents.
Deficiency in Food Service Safety Standards
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial tour of the food service department, it was observed that dietary staff members were preparing food without using hair nets, which is a violation of the facility's policy requiring all staff to have their hair confined in a hair net or cap. Additionally, the walk-in refrigerator contained several food items that were either not dated or improperly dated, including a container of pork, vegetables, barbecue chicken, tuna salad, macaroni and cheese with ham, rice, baked ziti, baked beans, egg salad, chicken salad, and coleslaw. These observations were confirmed by dietary staff, who could not provide an explanation for the misdated and expired items. Further observations revealed continued non-compliance with the dress code, as employees were again seen without hair nets during a follow-up tour. The facility's failure to adhere to its own policies and the standards set by the United States Department of Agriculture, Food Safety and Inspection Services, regarding the labeling and dating of refrigerated food items and the use of hair nets, constitutes a deficiency in maintaining food service safety. This deficiency was identified under the regulations 28 Pa. Code 201.14 and 28 Pa. Code 201.18 (b) (3).
Failure to Conduct Quarterly QAA Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met at least quarterly to coordinate and evaluate activities under the Quality Assurance and Performance Improvement (QAPI) program as required. The facility's policy stated that QAPI meetings should occur monthly, with quarterly data reviewed over a quarter time frame during these meetings. However, documentation showed that meetings were only conducted in January, July, and August 2024, with no records available for other months. The Nursing Home Administrator, who had recently started working at the facility, confirmed the lack of documentation and meetings, acknowledging that the August meeting was conducted to review the facility's QAPI program.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program for two residents, as determined by a review of facility policies, documentation, clinical records, and staff interviews. The facility's policy on antibiotic stewardship, revised in March 2022, outlined the need for surveillance, tracking, trending, and reporting to optimize antibiotic use. However, the facility did not adhere to these practices, as evidenced by the lack of infection surveillance data, criteria, and clinical assessments for the residents involved. Resident R154, who had multiple diagnoses including multi-drug resistant organism, pneumonia, septicemia, and a sacral pressure ulcer, was readmitted to the facility with a recommendation to continue intravenous antibiotic treatment. Despite this, there was no completion of an Antibiotic Time-Out tool for this resident, which is a standardized practice for evaluating antibiotic use. Similarly, Resident R33, who had a urinary tract infection, was prescribed antibiotics without proper documentation of infection surveillance data or criteria on the Antibiotic Time-Out tool. The Director of Nursing was unable to explain the discrepancies in the prescribed antibiotics and the lack of infection surveillance data. The Director of Nursing also failed to provide evidence of infection surveillance, tracking of infectious symptoms, or evaluation of the appropriateness of prescribed antibiotics. There was no documentation of infection committee meetings or collaboration with the clinical team, prescribing physicians, or medical director regarding antibiotic use. This lack of adherence to the facility's antibiotic stewardship policies and practices led to the deficiency identified by the surveyors.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist to oversee its infection prevention and control program. According to the facility's policy, an infection preventionist should be a trained health professional responsible for preventing the spread of germs within the healthcare facility. The policy outlines specific responsibilities, including infection surveillance, reporting outbreaks, compliance review, staff education, and reporting findings to the QAPI committee. However, during the survey, it was revealed that the role was shared between the Director of Nursing and the Assistant Director of Nursing, neither of whom had completed the required specialized training. During interviews, the Assistant Director of Nursing admitted to not performing any functions related to the infection preventionist role. The Director of Nursing also confirmed the lack of documentation proving that either she or any other staff member had completed the necessary training in infection prevention and control. The facility was in the process of hiring a nurse for the infection preventionist role, but at the time of the survey, no qualified individual was designated to fulfill these critical responsibilities.
Deficiency in Corridor Handrails
Penalty
Summary
The facility failed to equip corridors with safe handrails on each side in two of the three nursing units observed, specifically on the First and Second floor nursing units. During an observation on the First Floor Nursing Unit, it was noted that the handrail by two rooms was broken, with one having the top part coming off. On the Second Floor Nursing Unit, a handrail by one room was cracked with exposed sharp edges, another was broken and covered with tape, and a handrail between two rooms was missing. The Nursing Home Administrator confirmed the issues with the handrails during an interview, acknowledging that they were broken or missing. The administrator also confirmed that a full audit of all handrails would be conducted.
Failure to Investigate Medication Misappropriation
Penalty
Summary
The facility failed to conduct a thorough investigation of a medication misappropriation incident involving a resident. The resident, who was admitted with multiple medical conditions including a fracture, acute kidney failure, and neuromuscular dysfunction, reported receiving medications that were not prescribed to them. Specifically, the resident received Keppra, a seizure medication, which was intended for another resident. The clinical records did not indicate that Depakote was administered, despite the resident's claim. A progress note from the date of the incident confirmed the medication error and noted that the resident was monitored for 48 hours following the error. Interviews with facility staff, including the Assistant Director of Nursing and the Nursing Home Administrator, confirmed that no investigation was conducted regarding the medication error. The facility's policy on abuse, neglect, and misappropriation requires that such incidents be thoroughly investigated to rule out neglect. The lack of investigation into the medication error represents a failure to adhere to this policy, as confirmed by the staff interviews.
Failure to Address Hospital Recommendations for Resident Care
Penalty
Summary
The facility failed to address hospital recommendations for a resident, identified as Resident R1, who was admitted with multiple medical conditions including a fracture of the left femur, acute kidney failure, and postlaminectomy syndrome. The resident, who was cognitively intact as per the Minimum Data Set assessment, developed a Stage 4 pressure ulcer on the right heel. Hospital records from April 2, 2024, indicated that the resident was prescribed a Rom Knee Brace, and discharge records from July 17, 2024, recommended scheduling a cardiologist appointment within two weeks. Interviews with facility staff, including a licensed nurse and the Assistant Director of Nursing, confirmed that while the Rom Knee Brace was in place, the facility failed to ensure that physician orders were followed according to the nurse practitioner's recommendation and hospital records. Additionally, there was no cardiologist appointment scheduled for the resident as recommended. This oversight indicates a failure to provide appropriate treatment and care according to hospital recommendations and resident care policies.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate treatment and interventions for a resident with pressure ulcers, leading to a deficiency in care. The resident, who was cognitively intact, was admitted with multiple health issues, including a fracture, acute kidney failure, and difficulty walking. The resident developed a suspected deep tissue injury on the right heel, which progressed to a Stage 4 pressure ulcer. Despite a recommendation from a nurse practitioner to float the resident's heels using heel boots, the resident was observed without heel boots or pillows to elevate the heels, as confirmed by a nurse. Additionally, the resident developed a skin tear on the left thigh, which was ordered to be treated with normal saline, Santyl, and covered with gauze daily. However, the treatment was not documented as completed on several dates in July 2024, and nursing notes did not provide any related information. The Assistant Director of Nursing and the Administrator confirmed that the wound care was not completed as per the physician's order, resulting in the skin tear developing into an unstageable pressure ulcer.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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