Bryn Mawr Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Bryn Mawr, Pennsylvania.
- Location
- 773 East Haverford Road, Bryn Mawr, Pennsylvania 19010
- CMS Provider Number
- 395095
- Inspections on file
- 27
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Bryn Mawr Village during CMS and state inspections, most recent first.
Two residents reported verbal and physical abuse by nurse's aides, including rough care, yelling, and being left in bed for extended periods. Despite these allegations and facility policy requiring prompt investigation, there was no documented evidence that a thorough investigation was conducted or that findings were recorded by the DON or Social Worker.
A resident with severe protein calorie malnutrition, who was cognitively intact, reported multiple times that a night shift nurse's aide was rough and yelled during care. Despite the resident and a medication nurse submitting written complaints, the facility's grievance log showed no record of these grievances, and staff interviews confirmed that no investigation was conducted as required by facility policy.
The facility did not maintain and inspect its kitchen hood suppression systems, impacting the entire facility. Reports from July 2024 and January 2025 indicated failures in the system, and an interview with the Administrator and Maintenance Director confirmed that corrective actions were not completed.
The facility did not maintain the required testing of its automatic sprinkler system components, affecting the entire facility. A document review revealed that the last full flow trip test for the dry system was conducted in 2019, which was confirmed during an exit interview with the Administrator and Maintenance Director. This testing was out of the required three-year cycle.
The facility was found to be improperly using a 75-foot extension cord to power a sump pump on the front lawn. The cord was wrapped around facade lights and plugged into an external outlet, violating regulations. The Administrator and Maintenance Director confirmed this prohibited use.
The facility failed to maintain proper exit signage, as observed in the East Wing near the nursing station. Multiple illuminated exit signs led to a back courtyard with no egress, and the exterior doors had signs indicating they were not fire exits. This was confirmed in an interview with the Administrator and Maintenance Director.
The facility failed to ensure portable fire extinguishers were accessible, as observed in the multi-purpose room where two wall-mounted extinguishers were blocked by large tables. This was confirmed during an exit interview with the Administrator and Maintenance Director, indicating non-compliance with NFPA 10 standards.
The facility was found to be non-compliant with NFPA 101 standards due to exceeding the maximum allowable story height for its construction type. A two-story, Type III (200) building and a two-story, Type II (000) building, both fully sprinklered, exceeded the permitted story height by one story. These findings were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain emergency generator components, as the generator set location lacked battery back-up emergency lighting, and the 3-year, 4-hour load test report was unavailable. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain the required fire resistance rating for vertical openings, affecting two levels. The stairway between the Lower Level Kitchen and the First Floor lacked one-hour fire resistive construction. Additionally, the north side exit from the Basement had a staircase with unsheathed walls, lacking the required fire resistance. These deficiencies were confirmed during interviews with the Administrator and Maintenance Director.
The facility was found to lack two acceptable emergency exits in the basement, as the north exit is a communicating stair that does not lead to an exterior exit discharge. This deficiency was confirmed by the Administrator and Maintenance Director.
The facility was found to be non-compliant with NFPA 101 Life Safety Code as the north exit from the second floor requires passage through an intervening dining room, violating the requirement for corridors to provide access to at least two approved exits without passing through other rooms. This was confirmed during a survey and exit conference with the Administrator and Maintenance Director.
Bryn Mawr Village failed to ensure advance directives were in place for two residents, as revealed by clinical record reviews and staff interviews. One resident, admitted with COPD, and another with Acute Respiratory Failure and Multiple Sclerosis, both lacked advance directives on their face sheets and documentation of related discussions. Interviews confirmed the absence of advance directives, and no physician orders were present for either resident.
The facility failed to recognize the placement of beds against the wall as a restraint for three residents, violating their right to be free from unnecessary restraints. Observations and interviews confirmed the bed placements, which were not documented in care plans or assessments as safety measures or preferences, despite the residents' medical conditions and risks.
A facility failed to develop a baseline care plan within 48 hours for a resident admitted with multiple diagnoses, including COPD and Depression. Despite having physician orders for medications, the only care plan addressed an ADL self-care performance deficit, initiated eight days post-admission. This was confirmed by the Unit Manager.
A resident experienced significant weight loss, dropping from 180 lbs to 150.4 lbs, without a comprehensive care plan being developed to address this issue. The facility's policy mandates the creation of such plans to meet residents' needs, but no documentation was found for this resident's weight management.
The facility failed to provide necessary grooming services for two residents requiring assistance with activities of daily living. One resident, with severe cognitive impairment, had an inadequately groomed beard, and family intervention was needed for shaving. Another resident, with intact cognition, had an overgrown beard affecting his ability to eat properly. Staff confirmed the lack of grooming assistance and documentation for both residents.
A resident at risk for pressure ulcers due to immobility and bowel incontinence developed multiple pressure injuries while under care. The facility failed to implement a turning and positioning program, as confirmed by the absence of documentation and staff interviews.
The facility failed to obtain and document weekly weights as ordered by physicians for two residents. One resident, admitted with a femur fracture and muscle weakness, had no documented weekly weights or refusal to be weighed. Another resident, with pleural effusion and dysphagia, showed gaps in weight records exceeding seven days, with no documentation of attempts to weigh or refusal. The Unit Manager confirmed these documentation lapses.
A facility failed to adhere to a Registered Dietitian's recommendations for a resident receiving enteral nutrition. The resident, admitted with conditions like dysphagia, required tube feeding. Despite a recommendation for a specific feeding regimen, the facility did not promptly implement it, and there was no documented rationale for the delay in meeting the resident's caloric needs.
The facility failed to provide appropriate respiratory care for two residents. One resident received oxygen at a higher flow rate than prescribed, while another received oxygen therapy without a physician's order. Both issues were confirmed by the DON and Unit Manager.
A resident with chronic pain syndrome did not receive prescribed Oxycodone for severe pain on two occasions, despite documented pain levels of 10 and 8. The facility's policy on pain management was not followed, as there was no rationale for the non-administration, no physician notification, and no alternative pain management strategies documented.
A resident with documented opioid allergies was prescribed oxycodone and tramadol, despite known allergies. Interviews confirmed the oversight, and the facility lacked a policy addressing allergies, contributing to the medication management failure.
The facility failed to meet the required NA to resident ratios for 21 consecutive days across all shifts. During the day shift, the facility consistently scheduled fewer NA hours than required, with discrepancies ranging from 4.8 to 17.6 hours short. The evening and overnight shifts also experienced significant staffing deficiencies, with shortfalls ranging from 2.18 to 13.09 hours in the evening and 3.2 to 9.53 hours overnight. These consistent staffing inadequacies were confirmed by the facility's administrator.
The facility failed to meet the required LPN staffing levels during day and evening shifts on 9 out of 21 days. The regulation requires one LPN per 25 residents during the day and one per 30 residents in the evening. However, staffing records showed insufficient LPN hours, such as 8 hours for 37 residents when 11.84 were needed. The administrator confirmed the shortfall, indicating a pattern of non-compliance with staffing regulations.
The facility did not meet the required 3.2 hours of direct resident care per resident in a 24-hour period on 12 out of 21 days reviewed. Staffing sheets from February to March 2025 showed several days with insufficient care hours, with the lowest being 2.93 hours. This was confirmed by the facility's administrator.
A resident experienced significant weight loss due to the facility's failure to implement nutritional interventions and notify the physician. Despite recommendations from the dietician to liberalize the diet and add supplements, these were not followed. The facility also did not adhere to the approved vegetarian menu, and meal intake was inadequately monitored.
The facility did not adhere to professional standards for food service safety, as observed during a kitchen tour. The main cook was not wearing a hair net, and food items in the refrigerator were improperly labeled with a single date, indicating the open date, rather than the required use-by date. Interviews with staff confirmed the labeling did not meet professional standards.
The facility did not ensure that five nursing assistants received the required 12 hours of annual training to maintain competence. A review of documentation and interviews revealed that the facility failed to track or complete the necessary in-service training, violating state regulations.
The facility failed to maintain confidentiality and privacy for two residents. A resident's POA received medical records containing another resident's information due to improper review by staff. Additionally, a staff member provided incontinence care with the door open, exposing a resident, which was confirmed by the DON.
A facility failed to follow physician orders for weekly weight monitoring of a resident, resulting in an undocumented significant weight loss of 8% over eleven days. The last recorded weight was 170.5 pounds, and upon reweighing, the resident weighed 157 pounds. This deficiency was confirmed by a Registered Dietitian.
A resident requiring assistance with daily living activities had long and thick toenails, as observed on a specific date. Despite multiple requests from the resident's representative for a podiatrist consultation, no action was taken until the issue was confirmed by the DON. The facility had a podiatry service available, but no appointment was made until after the deficiency was noted.
A resident experienced severe weight loss over several months, but the facility failed to notify the physician or complete an assessment as required by policy. Despite recommendations from the dietician to liberalize the diet and notify the physician, the resident's weight continued to decline significantly without appropriate medical intervention.
The facility did not adhere to professional standards for medication storage. An observation revealed that a medication storage room was left unlocked, and a refrigerator containing medications was missing its lock. A LPN confirmed the unlocked status of both the room and the refrigerator.
A facility failed to follow an approved vegetarian diet for a resident, leading to nutritional inadequacy. Despite having a dietician-approved vegetarian menu extension, the Food Service Director was unaware of how to access it, resulting in undocumented calorie intake and meals for four months. This deficiency highlights a communication and training gap in dietary services.
A resident with a documented lactose allergy and intolerance was provided with fortified cereal containing dairy products, despite physician orders and personal requests for non-dairy alternatives. The resident continued to consume the cereal each morning, highlighting a failure in accommodating dietary needs.
The facility did not provide prescribed dietary items for two residents. One resident did not receive a double portion meal or a mighty shake, while another did not receive a magic cup as ordered. These issues were confirmed by an LPN and a Unit Manager.
A resident experienced significant weight loss due to the failure of the Nursing Home Administrator and DON to manage nutritional needs effectively. Despite the resident's medical conditions and dietary requirements, the facility did not implement timely nutritional interventions or notify the physician of the weight loss. The Registered Dietician's recommendations were not followed, and meal intake was inconsistently documented, leading to an Immediate Jeopardy situation.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of verbal and physical abuse for two residents, despite both residents being cognitively intact and able to report their concerns. One resident reported that a night shift nurse's aide was rough during care and yelled at him, and stated that he had submitted written complaints twice, including one written by a medication nurse on his behalf. However, the Director of Nursing and the Social Worker both confirmed that they were unaware of any grievances from this resident, and no investigation was conducted into his allegations. Another resident reported that nurse's aides were rough during care, yelled at her, and ignored her call bells, with one incident involving being left in bed for hours in feces. The resident's husband also reported concerns about his wife being manhandled. Although a Resident Concern Report was completed, there was no documented evidence of a thorough investigation, such as staff statements, findings, conclusions, or disciplinary actions. The Social Worker acknowledged interviewing the nurse's aide involved but did not document the interview or include it in the investigation file. Facility policy requires prompt reporting and thorough investigation of all abuse allegations, including interviews with all relevant parties and documentation of findings. In both cases, the facility did not follow its own policies or regulatory requirements, as there was no evidence of a complete investigation or appropriate documentation regarding the residents' allegations of abuse.
Failure to Address Resident Grievances in a Timely Manner
Penalty
Summary
The facility failed to address a resident's grievances in a timely manner, as required by its own grievance policy. The policy states that residents and their representatives have the right to file grievances orally or in writing, and that the Grievance Officer must review and investigate any allegations, submitting a written report to the Administrator within five working days. In this case, a resident with severe protein calorie malnutrition, who was cognitively intact according to the most recent MDS assessment, reported that a night shift nurse's aide was rough during care and yelled at him. The resident stated that he had submitted written complaints twice, and that a medication nurse had also written a complaint on his behalf the previous week. Despite these actions, the facility's grievance log contained no record of grievances from this resident. Interviews with staff revealed that the DON was unaware of any investigation into the resident's complaints, and the social worker, who regularly checks the grievance box, reported not finding any grievance forms related to the resident. The social worker also confirmed that no investigation had been conducted because no grievance was received. The DON further confirmed that no investigation was initiated regarding the resident's complaints about the night shift nurse's aide.
Failure to Maintain Kitchen Hood Suppression Systems
Penalty
Summary
The facility failed to maintain and inspect its kitchen hood suppression systems, which affected the entire facility. During a document review on March 17, 2025, it was found that the kitchen hood suppression system report from July 3, 2024, indicated a failure with the 'Cylinder'. Additionally, a subsequent report dated January 6, 2025, showed a failure of the 'Kitchen System'. An exit interview with the Administrator and Maintenance Director confirmed that corrective actions had not been completed.
Plan Of Correction
The kitchen hood suppression system repair is scheduled for 4/11/2025. Maintenance Director will report completion and compliance to QAPI committee.
Failure to Maintain Sprinkler System Testing
Penalty
Summary
The facility failed to maintain the required testing of automatic sprinkler system components, which affected the entire facility. During a document review on March 17, 2025, it was revealed that the quarterly sprinkler inspection reports for both wet and dry systems, dated January 20, 2025, indicated that the last full flow trip test for the dry system was conducted in 2019. This finding was confirmed during an exit interview with the Administrator and Maintenance Director on the same day, highlighting that the testing was out of the mandated three-year testing cycle.
Plan Of Correction
Full flow trip test is scheduled for 4/28/2025. A task will be entered in TELS work order system to ensure tests are completed timely. Maintenance director will report on the results and compliance to QAPI committee.
Improper Use of Extension Cord for Sump Pump
Penalty
Summary
The facility failed to comply with regulations regarding the use of extension cords, as evidenced by an observation made on March 17, 2025. A 75-foot extension cord was found wrapped around two facade fixed sconce lights above an egress exit door, outside the main entrance. This extension cord was plugged into an external electrical outlet fixed to the building and was being used to power a sump pump on the front lawn. During an interview at the exit conference, both the Administrator and Maintenance Director confirmed the prohibited use of the extension cord, which affected one of the two levels of the facility.
Plan Of Correction
The installation of an exterior outlet for the sump pump is scheduled for 4/21/2025. Maintenance director will report on completion of job to QAPI committee.
Conflicting Exit Signage in East Wing
Penalty
Summary
The facility failed to ensure proper exit signage, which is a requirement for maintaining unobstructed egress. During an observation on March 17, 2025, at 11:50 a.m., it was noted that in the East Wing near the nursing station, there were multiple illuminated exit signs in the corridor leading to a back courtyard that did not provide an egress route. Additionally, the exterior doors leading to the back courtyard had signage indicating that it was not a fire exit and should not be used in case of fire. This conflicting signage was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 2:00 p.m.
Plan Of Correction
All exit signs were audited and corrected by 4/7/2025. Maintenance director will report on compliance to QAPI committee.
Fire Extinguishers Obstructed by Tables
Penalty
Summary
The facility failed to ensure that portable fire extinguishers were accessible on one of its two levels. During an observation on March 17, 2025, at 12:15 p.m., it was noted that in the multi-purpose room, which was formerly used for Physical Therapy, two wall-mounted fire extinguishers were obstructed by large tables on each side of the room. This obstruction was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 2:00 p.m., indicating a failure to comply with the requirements for fire extinguisher accessibility as per NFPA 10 standards.
Plan Of Correction
Obstructions were corrected immediately on 3/17/2025, and staff was educated on compliance. Maintenance director will report to QAPI committee on compliance of this regulation.
Building Construction Type Exceeds Allowable Story Height
Penalty
Summary
The facility was found to be non-compliant with building construction requirements as per NFPA 101 standards. During a document review and interview conducted on March 17, 2025, it was discovered that the facility was classified as a two-story, Type III (200), unprotected ordinary construction, which was fully sprinklered. However, this classification exceeded the maximum allowable story height by one story, as the construction type only permits a maximum of two stories when sprinklered. This discrepancy was confirmed during an exit interview with the Administrator and Maintenance Director. Additionally, another component of the facility was identified as a two-story, Type II (000), unprotected noncombustible construction with a basement, which was also fully sprinklered. This component similarly exceeded the maximum allowable story height by one story, as the construction type does not allow for any stories when non-sprinklered and only permits one story when sprinklered. This finding was also confirmed during the exit interview with the facility's Administrator and Maintenance Director.
Plan Of Correction
Bryn Mawr Village would like the Department of Health and Human Services Life Safety Divisions assistance with reapplying for another FSES for two-story type III (200), unprotected ordinary construction which is fully sprinklered. The story height exceeds the maximum allowance for this construction type one story. The facility has previously submitted a waiver for this deficiency. The Administrator or designee is responsible for monitoring this and as part of the Quality Assurance Performance Improvement Program will report on Life Safety requirements and plan of correction to the Committee. Bryn Mawr Village would like the Department of Health and Human Services Life Safety Divisions assistance with reapplying for another FSES for two-story type III (200), unprotected ordinary construction which is fully sprinklered. The story height exceeds the maximum allowance for this construction type one story. The facility has submitted a TLW waiver for this deficiency. The Administrator or designee is responsible for monitoring this and as part of the Quality Assurance Performance Improvement Program will report on Life Safety requirements and plan of correction to the Committee.
Emergency Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain required emergency generator components, which affected the entire facility. During an observation on March 17, 2025, it was noted that the emergency generator set location inside the transformer room in the basement lacked battery back-up emergency lighting. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day. Additionally, a documentation review revealed that the facility did not have the required 3-year, 4-hour load test report available for the generator that supports the emergency electrical system. This lack of documentation was also confirmed during the exit interview with the Administrator and Maintenance Director.
Plan Of Correction
Emergency lighting installation is scheduled for 4/21/2025. A 4-hour load test was completed on 3/31/2025. A task will be entered in TELS work order system to ensure tests are completed timely. The maintenance director will report on results to the QAPI meeting.
Failure to Maintain Fire Resistance Rating for Vertical Openings
Penalty
Summary
The facility failed to maintain the required fire resistance rating for vertical openings, specifically affecting two levels within the building. During a document review and interview conducted on March 17, 2025, it was discovered that the communicating stairway between the Lower Level Kitchen and the First Floor did not have the necessary one-hour fire resistive construction. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director. Additionally, the facility did not maintain the fire resistance rating for stair towers, impacting one of two floors within the building. A document review revealed that the north side exit from the Basement was a communicating staircase with walls not sheathed on the room 2A side, lacking the required one-hour fire resistance rating. This issue was also confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
The facility will work with an outside consultant to complete an FSES to cover this deficiency. The Administrator or designee is responsible for monitoring this and, as part of the Quality Assurance Performance Improvement Program, will report on Life Safety requirements and plan of correction to the Committee. The facility will work with an outside consultant to complete an FSES to cover this deficiency. The Administrator or designee is responsible for monitoring this and, as part of the Quality Assurance Performance Improvement Program, will report on Life Safety requirements and plan of correction to the Committee.
Facility Lacks Two Acceptable Exits in Basement
Penalty
Summary
The facility failed to provide two acceptable exits, located remotely from one another, affecting one of two floors of the building. During a document review on March 17, 2025, it was revealed that the basement level of the facility lacked two acceptable emergency exits that are located remotely from each other. Specifically, the north exit from the basement is a communicating stair and does not lead to an exterior exit discharge. This deficiency was confirmed during an interview at the exit conference with the Administrator and Maintenance Director on the same day, where it was acknowledged that the basement level lacked two acceptable exits.
Plan Of Correction
The facility will work with an outside consultant to complete an FSES to cover this deficiency. The Administrator or designee is responsible for monitoring this and, as part of the Quality Assurance Performance Improvement Program, will report on Life Safety requirements and plan of correction to the Committee.
Exiting Deficiency Through Intervening Dining Room
Penalty
Summary
The facility failed to ensure compliance with the NFPA 101 Life Safety Code regarding the number of exits in corridors. Specifically, the deficiency was identified in the north exit from the second floor, which requires passage through an intervening dining room, contrary to the requirement that corridors provide access to at least two approved exits without passing through any intervening rooms or spaces other than corridors or lobbies. This issue was observed and documented during a survey on March 17, 2025, at 11:30 a.m. The deficiency was confirmed during an exit conference with the Administrator and Maintenance Director later that day.
Plan Of Correction
The facility will work with an outside consultant to complete an FSES to cover this deficiency. The Administrator or designee is responsible for monitoring this and, as part of the Quality Assurance Performance Improvement Program, will report on Life Safety requirements and plan of correction to the Committee.
Failure to Ensure Advance Directives for Residents
Penalty
Summary
Bryn Mawr Village was found to be non-compliant with the requirements of 42 CFR part 483, Subpart B, and the 28 PA Code related to the health portion of the survey process. The facility failed to ensure that advance directives were in place for two residents, Resident R149 and Resident R26, as evidenced by clinical record reviews and staff interviews. Resident R149, admitted with a diagnosis of Chronic Obstructive Pulmonary Disease, had no advance directives indicated on the face sheet, nor was there documented evidence of discussions regarding advance directives. Similarly, Resident R26, admitted with Acute Respiratory Failure with Hypoxia and Multiple Sclerosis, also lacked advance directives on the face sheet and documentation of related discussions. Interviews with Unit Manager Employee E3 confirmed the absence of advance directives for both residents. Additionally, there were no physician orders for advance directives for either resident. The facility's policy on advance directives, last revised in 2016, mandates that residents be provided with written information about their rights to accept or refuse treatment and to formulate an advance directive upon admission. The policy also requires that information about advance directives be prominently displayed in the medical record and that the plan of care aligns with the resident's documented treatment preferences.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Residents R26 and R149 are discharged from the facility. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of the clinical records of current residents will be conducted to ensure that a code status is included, a physician order for code status is included, and the resident's family member is given an advance directive or clarification of the hospital code status to implement the residents wishes after admission to the facility. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff and Social Services regarding the components of this regulation and how to properly document this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ or designee of five clinical records to ensure that they include a code status, a physician order for code status and that the family was involved in the wishes. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure to Identify Bed Placement as Restraint
Penalty
Summary
The facility failed to identify the placement of beds against the wall as a restraint for three residents, which is a violation of their right to be free from physical restraints not required to treat medical symptoms. The facility's policy defines physical restraints as any device that restricts freedom of movement and cannot be easily removed by the resident. Observations revealed that the beds of Residents R247, R248, and R249 were placed against the wall, which was not documented in their care plans or assessments as a safety measure or preference. Resident R247, diagnosed with Alzheimer's disease and at high risk for falls, had no care plan addressing the bed placement. Resident R248, with intact cognition and a history of respiratory failure and falls, also lacked documentation for the bed's position. Resident R249, with hypertensive urgency and intact cognition, confirmed that the bed's placement was not their preference. Interviews with staff, including an LPN and the Director of Nursing, confirmed the bed placements, indicating a failure to adhere to the facility's restraint policy.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Residents R247, R248, R249 were interviewed by DON and NHA to obtain preferences for the placement of the beds and adjusted as needed. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Residents with beds near the wall were interviewed by DON and NHA regarding their preferences and beds were adjusted and care plan updated to reflect their request. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five residents to ensure that bed placement preferences are in place and the care plan is being followed. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure to Develop Timely Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident, identified as R149, within the required 48-hour timeframe following admission. The resident was admitted with multiple diagnoses, including COPD, Centrilobular Emphysema, Generalized Anxiety Disorder, Alcohol Dependence, Depression, Acute Pancreatitis, and Anemia. Despite having physician orders for medications such as Lidocaine Patch, Eliquis, and Gabapentin, the facility did not create a baseline care plan that included these orders or any other necessary healthcare information to properly care for the resident. The only care plan in place for the resident addressed an ADL self-care performance deficit, which was initiated eight days after admission. This delay in developing a comprehensive person-centered care plan was confirmed by the Unit Manager, Employee E3, during an interview. The lack of a timely baseline care plan and comprehensive care plan for Resident R149 represents a failure to meet the regulatory requirements for comprehensive person-centered care planning.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The care plan for Resident R149 was updated to include goals and interventions for the residents specific goals and needs. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of current residents will be conducted to ensure that a baseline care plan was developed and implemented and that a written summary of the baseline care plan was provided to the resident and/or resident representative. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff and Interdisciplinary Team regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five clinical records to ensure that a baseline care plan was developed and that the resident/ resident representative received a copy of the baseline care plan. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure to Develop Comprehensive Care Plan for Weight Changes
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident R33, who experienced significant weight changes. The facility's policy requires that a comprehensive person-centered care plan be developed and implemented for each resident, including measurable objectives and timeframes to meet their physical, psychological, and functional needs. However, upon review of Resident R33's clinical record, it was found that there was no documented evidence of a care plan addressing the resident's weight loss. Resident R33 was admitted to the facility with diagnoses including pleural effusion, dysphagia, and cognitive communication deficit. The resident's weight records showed a significant decrease from 180 lbs at admission to 150.4 lbs over a period of approximately two months, indicating a weight loss of 16.4%. Despite this notable weight change, the facility did not develop a care plan to address the resident's nutritional needs, which is a requirement under the facility's policy and federal regulations.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The care plan for Resident R33 was updated to include goals and interventions for the residents specific goals and needs. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of current residents will be conducted to ensure that a comprehensive care plan was developed and implemented and that a written summary of the comprehensive care plan was provided to the resident and/or resident representative. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff and Interdisciplinary Team regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five clinical records to ensure that a comprehensive care plan was developed and that the resident/ resident representative received a copy of the baseline care plan. Audits will be conducted weekly for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure to Provide Grooming Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide necessary grooming services for two residents who required assistance with activities of daily living. Resident R243, admitted with conditions including chondrocalcinosis, lack of coordination, and severe cognitive impairment, was observed with an inadequately groomed beard. Interviews with the resident and a family member revealed that the facility had not provided grooming assistance since the resident's admission, necessitating family intervention for shaving. A licensed nurse confirmed the absence of documentation or evidence of grooming assistance for this resident. Similarly, Resident R244, who had diagnoses including cirrhosis of the liver, muscle weakness, and intact cognition, was observed with an overgrown beard and hair over the upper lip. The resident reported inadequate grooming since admission, which affected his ability to eat properly. The Director of Nursing confirmed the resident's need for grooming assistance and the overgrown state of his beard. These findings indicate a failure by the facility to maintain adequate grooming for residents requiring assistance.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident R243 and R244 facial hair were trimmed by licensed staff. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of current residents was conducted by the DON/Designee to ensure that facial hair is groomed based on residents' wishes. Any additional concerns identified during the audit will be corrected immediately. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: DON/Designee will re-educate facility clinical staff on the components of this regulation with an emphasis on ensuring that residents receive appropriate grooming of hair/facial hair and footcare/nail care. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: DON/Designee to conduct random visual audits of 10 residents 1x a week for 4 weeks, 2x a month for 3 months, then monthly for 2 months to ensure that residents are being groomed appropriately and that facial hair is trimmed. The findings of these quality monitoring activities will be reported to the Quality Assurance/Performance Improvement Committee monthly for 6 months.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent and heal pressure ulcers for a resident, as required by professional standards of practice. The resident, admitted with a fracture and muscle weakness, was dependent on staff for mobility and at risk for developing pressure ulcers. Despite this, the facility did not implement a turning and positioning program to prevent pressure ulcers, as confirmed by the absence of documented evidence in the resident's clinical record. The resident, who was at risk for skin breakdown due to immobility and bowel incontinence, developed deep tissue pressure injuries on the sacrum, left heel, and right heel, as well as a Stage 1 pressure injury on the right great toe while under the facility's care. The lack of a documented turning and positioning program was confirmed by the Unit Manager, indicating a failure to adhere to the necessary preventive measures for pressure ulcer development.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Treatment was provided to Residents R1 to address the pressure ulcer and prevent new ulcer from developing. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit will be conducted for all Residents at risk for pressure ulcers to ensure proper treatment is being provided. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five residents to ensure that treatment to prevent pressure ulcers is being provided and physician orders are followed. Audits will be conducted weekly for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure to Obtain and Document Weekly Weights
Penalty
Summary
The facility failed to ensure that weekly weights were obtained as ordered by the physician for two residents. Resident R1 was admitted with diagnoses including a fracture of the lower end of the left femur and muscle weakness. A physician's order dated February 12, 2025, required weekly weights for four weeks, then monthly. However, there was no documented evidence that Resident R1 was weighed weekly as ordered, nor was there any indication of refusal to be weighed. An interview with the Unit Manager confirmed the absence of documentation regarding attempts to obtain weights or any refusal by the resident. Similarly, Resident R33, admitted with conditions such as pleural effusion and dysphagia, had a physician's order for weekly weights. After being discharged to the hospital and readmitted, there was no documented evidence of a weight being taken at readmission. The resident's weight records showed gaps greater than seven days between weighings, contrary to the physician's orders. The Unit Manager confirmed the lack of documentation for attempts to weigh the resident or any refusal. These deficiencies indicate a failure to adhere to physician orders and maintain proper documentation.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The Resident immediately weighed per physicians' orders. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of current will be conducted to ensure physician orders for obtaining weights are followed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff and Interdisciplinary Team regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five clinical records to ensure that physician orders for weights are being followed. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure to Follow Nutritional Recommendations for Enteral Feeding
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident receiving enteral nutrition, as evidenced by a lack of adherence to the recommendations provided by the Registered Dietitian. Resident R33, who was admitted with conditions including pleural effusion, muscle weakness, dysphagia, and cognitive communication deficit, required tube feeding due to difficulty swallowing. The care plan indicated that the Registered Dietitian was to evaluate the resident's nutritional needs quarterly and as needed, making recommendations for changes to the tube feeding regimen. Despite the Registered Dietitian's recommendation on January 2, 2025, for the tube feed to run at 65 ml/hour over 22 hours for a total volume of 1430 ml daily, the facility did not follow this guidance promptly. The clinical record showed a series of physician orders adjusting the tube feed rate, but there was no documented rationale from the physician for the delay in meeting the resident's caloric needs as recommended. This oversight resulted in the facility's failure to ensure the resident received the appropriate treatment and services to maintain nutritional parameters.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident R148 tube feeding orders were reviewed with physician to updated to reflect current needs. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit will be conducted for current Residents to ensure that all tube feeding orders are current and are being followed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five residents to ensure that tube feeding orders updated and are being followed. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Inadequate Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care services for two residents, R146 and R149, as observed during a survey. Resident R146, who was admitted with diagnoses including Acute Respiratory Failure and COPD, had a physician's order for oxygen at 2 liters per minute via nasal cannula. However, during an observation, it was found that the oxygen flow meter was set at 5 liters per minute, contrary to the physician's order. This discrepancy was confirmed by the Director of Nursing, Employee E3, during a follow-up observation. Resident R149, admitted with diagnoses including COPD and Generalized Anxiety Disorder, was observed receiving oxygen therapy without a physician's order. The oxygen concentrator's flow meter was also set at 5 liters per minute, and the oxygen tubing and humidification bottle lacked proper labeling. The resident reported informing the staff about the issue, but no action was taken. The Director of Nursing and Unit Manager confirmed the absence of a physician's order for oxygen therapy for Resident R149.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Residents R146 and R149 were provided with respiratory care and supplemental oxygen as ordered by the physician. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Residents on oxygen will be audited to ensure they are MD orders are being followed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five clinical records to ensure that pain medications are in place and are being given as ordered. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure in Pain Management for a Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident R148, consistent with professional standards of practice. The resident, who was admitted with diagnoses including spinal stenosis, low back pain, and chronic pain syndrome, had documented severe pain levels of 10 and 8 on March 3 and March 4, 2025, respectively. Despite having physician orders for Oxycodone and Tramadol for severe and moderate pain, the resident did not receive the prescribed Oxycodone on these dates. Additionally, there was no documented rationale for not administering the medication, nor was there evidence that the physician was informed of the non-administration or that non-pharmacological pain management techniques were implemented. The facility's policy on pain management emphasizes the importance of assessing and addressing pain based on professional standards and the resident's care plan. However, the review of Resident R148's clinical records revealed a lack of adherence to these guidelines. The resident's allergies to several opioids, including Oxycodone, were noted, yet there was no documentation explaining the decision not to administer the prescribed medication or any alternative strategies employed. This oversight in pain management was further highlighted by the absence of documentation regarding the effectiveness of interventions or modifications to the care plan, as required by the facility's policy.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident R148's pain medication were delivered and she has been receiving it as per Physician orders. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit will be conducted of residents that have an order for pain medications to ensure that they are being given per physician order. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five clinical records to ensure that pain medications are in place and are being given as ordered. Audits will be conducted weekly x for four weeks and then monthly for two months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Failure to Manage Resident's Opioid Allergies
Penalty
Summary
The facility failed to ensure the safe and effective use of medications for a resident, identified as R148, who had documented allergies to several opioids. The resident was admitted with multiple diagnoses, including spinal stenosis and chronic pain syndrome, and had a known allergy to opioids such as fentanyl, hydrocodone, hydromorphone, morphine, oxycodone, and codeine. Despite these documented allergies, a physician's order included oxycodone, which the resident was allergic to, and tramadol, which the resident suspected might cause a milder allergic reaction. Interviews with the resident and facility staff confirmed the presence of documented opioid allergies in the resident's clinical records. The physician, identified as Employee E5, acknowledged the oversight and stated that oxycodone had been discontinued, leaving the resident on tramadol. Additionally, the facility administrator, identified as Employee E1, admitted that the facility lacked a policy addressing allergies, which contributed to the oversight in medication management for the resident.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident R148 medications were reviewed with physician to identify any allergies and adjusted as needed. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit will be conducted for current Residents to ensure that all medication allergies are being followed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five residents to ensure that medication allergy orders are followed. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.
Consistent Staffing Deficiencies Across All Shifts
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios across all shifts for 21 consecutive days. During the day shift, the facility consistently scheduled fewer NA hours than required, with discrepancies ranging from 4.8 to 17.6 hours short of the necessary staffing levels based on the resident census. For instance, on February 20, 2025, with a census of 45 residents, only 24 NA hours were scheduled when 36 hours were required. Similar shortfalls were observed on other days, indicating a pattern of understaffing during the day shift. The evening and overnight shifts also experienced significant staffing deficiencies. The evening shift required one NA per 11 residents, yet the facility consistently scheduled fewer hours than needed, with shortfalls ranging from 2.18 to 13.09 hours. On February 23, 2025, for example, 32 NA hours were scheduled for a census of 62 residents, while 45.09 hours were required. The overnight shift, which required one NA per 15 residents, also fell short, with discrepancies ranging from 3.2 to 9.53 hours. These consistent staffing inadequacies were confirmed by the facility's administrator, indicating a systemic issue in meeting the mandated staffing ratios.
Plan Of Correction
Nursing schedules were reviewed to ensure the proper Nurse's Aide ratio on the morning, evening, and overnight shifts. NHA/designee will reeducate the scheduler and Director of Nursing on the correct Nurse's Aide ratio. NHA/designee will audit the nursing schedules in advance daily x4 weeks to ensure Nurse Aids are being staffed at the proper ratio. Results will be shared at QA.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required minimum staffing levels for Licensed Practical Nurses (LPNs) during both day and evening shifts over a period of 9 out of 21 days reviewed. Specifically, the regulation mandates a minimum of one LPN per 25 residents during the day shift and one LPN per 30 residents during the evening shift. However, the facility's staffing records revealed that on several occasions, the number of LPN hours provided was insufficient to meet these requirements. For instance, on February 14, 2025, the day shift had only 8 LPN hours for a census of 37 residents, whereas 11.84 hours were required. Similarly, on February 23, 2025, the evening shift had 8.50 LPN hours for a census of 62 residents, requiring 16.53 hours. The deficiency was confirmed through a review of nursing staff care hours and an interview with the facility's administrator, who acknowledged the shortfall in meeting the LPN-to-resident ratios. This issue was consistent across multiple days, indicating a pattern of inadequate staffing levels that did not comply with the regulatory requirements. The administrator's confirmation further substantiates the facility's failure to adhere to the mandated staffing ratios, impacting the quality of care provided to the residents.
Plan Of Correction
Nursing schedules were reviewed to ensure the proper LPN ratios on the day and evening shifts. NHA/designee will reeducate the scheduler Director of Nursing on the correct LPN ratio. NHA/designee will audit the nursing schedules in advance daily x4 weeks to ensure LPN's are being staffed at the proper ratio. Results will be shared at QA.
Deficiency in Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period. This deficiency was identified during a review of the facility's nursing staffing sheets for the weeks spanning February 13, 2025, to March 5, 2025. On 12 out of 21 days reviewed, the facility's staffing hours fell below the required threshold. Specific days with insufficient staffing hours included February 13, 14, 15, 18, 19, 20, 21, 23, 25, 27, 28, and March 2, 2025, with the lowest recorded at 2.93 hours on February 20, 2025. The deficiency was confirmed by the facility's administrator, Employee E1, on March 6, 2025.
Plan Of Correction
Nursing schedules were reviewed to ensure the total hours of general nursing care for each 24-hour period meets the requirement. NHA/designee will reeducate the scheduler and the Director of Nursing on the total hours of general nursing care for each 24-hour period. NHA/designee will audit the nursing schedules in advance daily x4 weeks to ensure total hours of general nursing care for each 24-hour period are met. Results will be shared at QA.
Failure to Implement Nutritional Interventions Leads to Significant Weight Loss
Penalty
Summary
The facility failed to provide adequate nutritional interventions and timely assessments for Resident R20, who experienced significant unplanned weight loss over several months. The resident, who was on a vegetarian and cardiac diet, lost 33.03% of their body weight from November 2023 to April 2024. Despite the resident's severe weight loss, the facility did not implement necessary dietary recommendations or notify the physician of the resident's condition. The Registered Dietician made multiple recommendations to address the resident's weight loss, including liberalizing the diet, adding nutritional supplements, and conducting weekly weight monitoring. However, these recommendations were not implemented, and the physician was not notified of the resident's significant weight loss. Additionally, the facility failed to follow the approved vegetarian menu, and meal intake was not properly monitored or documented. Interviews with facility staff revealed a lack of communication and follow-through on dietary recommendations. The Food Service Director was unaware of the approved vegetarian menu, and the Registered Dietician, who worked only two days a week, could not track the resident's weight loss effectively. The physician confirmed they were not informed of the resident's weight loss, and there was no evidence of a physician assessment in response to the resident's condition.
Removal Plan
- The facility initiated a comprehensive Quality Assurance/Performance Improvement Plan to ensure that the residents in the facility with concerns regarding weight loss were addressed by the physician/dietician and that recommendations were implemented if applicable; resident food preferences were being honored, to ensure that meal consumption amounts are being properly monitored and documented and to ensure that current policies were reviewed with changes made as indicated.
- Resident 20 was reweighed, and the dietician and physician were notified to implement interventions as needed.
- The resident was reassessed by the physician.
- The resident was re-interviewed by the dietary manager to update preferences related to preferred vegetarian diet.
- Current facility residents were re-weighed. The physician and dietician were notified of any significant changes with interventions implemented if applicable.
- Currently facility residents were interviewed by the Certified Dietary Manager to ensure their diet preferences were up-to-date and to ensure their preferences were being honored. An additional audit of the meal tracker system was completed by the Certified Dietary Manager to ensure that orders accurately reflected residents' current preference.
- Dietary recommendations for the last 30 days were reviewed to ensure that any recommendations made were implemented.
- Facility Licensed Nurses received education from the Director of Nursing regarding the procedures for obtaining resident weights and notifying the physician and dietician of any significant changes, along with implementing dietary recommendations in a timely manner.
- Facility clinical staff received education from Director of Nursing on ensuring that resident meal intake is appropriately monitored and documented.
- Facility Dietary Staff will receive education from the CDM on ensuring that residents are receiving the appropriate diet based on their preferences.
- An Ad Hoc QAPI Meeting was held to discuss the events surrounding the resident's weight loss, to identify the root cause, and to initiate improvements to the facility's processes and procedures regarding obtaining weights, communication with the IDT team when significant changes occur, implementing physician/dietician recommendations in a timely manner and ensuring that resident meal preferences are honored.
- Any staff member that did not receive education related to the above mentioned was notified by the staffing coordinator verbally via phone indicating they may not return to work until the education is received.
- Newly hired staff will receive education in orientation.
- Education for respective facility staff as stated above, weekly weight meetings with the members of the interdisciplinary team to ensure that weights are being obtained and any significant changes are addressed immediately with the appropriate team members to include the physician, verbally while in the facility and via phone call when not present; the dietician will be present in the weekly weight meetings and will provide a paper copy of recommendations made; an additional copy of recommendations will be provided to the facility in the form of an electronic copy via email to the NHA, DON, and CDM; care plans are active and reflect appropriate interventions related to the residents' current nutrition and weight status.
- Audits will be conducted as follows: bi-monthly resident interviews by the CDM to ensure that resident food and diet preferences remain up to date; random audits of 5 residents weekly to ensure that food intake is being appropriately monitored and documented.
- The Quality Improvement Performance Committee will continue to hold weekly meetings to review and discuss the results of the ongoing quality monitoring. The findings of these quality reviews to be reported to the Quality Assurance/Performance Improvement Committee weekly. Quality Review schedule modified based on findings.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to ensure that food was stored in accordance with professional standards for food service safety. During an initial tour of the main kitchen, it was observed that the main cook was not wearing a hair net while cooking. In the main refrigerator, all items were dated with a single date, March 28, 2024, which included defrosted pork loins, cheddar cheese, mozzarella cheese, and yogurt. The kitchen supervisor confirmed that this date indicated the open date. Additionally, pulled ham was dated May 25, 2024, and cheese was dated April 1, 2024, with the assistant supervisor indicating these dates as the use-by dates. Interviews with the kitchen supervisor and the Administrator confirmed that the food items were not labeled according to professional standards and facility procedures.
Failure to Provide Required Annual Training for Nursing Assistants
Penalty
Summary
The facility failed to ensure that five nursing assistants received the required minimum of 12 hours of annual training to maintain their competence. This deficiency was identified during a review of facility documentation, personnel files, and staff interviews. On May 8, 2024, a request was made to the Nursing Home Administrator and Director of Nursing for the annual training records of five nursing assistants, identified as Employees E15, E16, E17, E18, and E19. The facility was unable to provide these records. An interview with the facility Administrator on the same day confirmed that the facility did not track or complete the annual in-service training as mandated by the training requirements for nursing assistants. This lack of compliance with the training requirements was in violation of 28 Pa. Code 201.18(b)(1)(3) Management and 28 Pa. 211.12(c) Nursing services.
Confidentiality Breach and Privacy Violation
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical records and provide privacy during incontinence care for two residents. An interview with the Power of Attorney (POA) for a resident revealed that she had requested her mother's medical records and received them with another resident's medical information included. This breach was confirmed by the Medical Records Staff, who admitted that the records were not reviewed properly before being released. Additionally, an observation on the nursing unit showed that a staff member provided incontinence care to a resident with the room door fully open, exposing the resident. This was immediately confirmed by the Director of Nursing.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to adhere to physician orders regarding the monitoring of a resident's weight. According to the facility's policy, weights should be measured weekly for two weeks upon admission to prevent and monitor undesirable weight loss. A physician's order for a resident, dated April 27, 2024, specified weekly weights for four weeks, to be taken every Friday morning. However, the clinical records showed that the last recorded weight for the resident was 170.5 pounds on April 26, 2024, and no subsequent weights were documented. An interview with the Registered Dietitian confirmed the absence of further documented weights. Upon reweighing the resident on May 7, 2024, the resident's weight was found to be 157 pounds, indicating a significant weight loss of 8% (13.5 pounds) over eleven days. This deficiency was identified under 28 Pa Code 211.12(d)(5) Nursing services.
Failure to Provide Timely Foot Care
Penalty
Summary
The facility failed to provide timely foot care for a resident, identified as Resident R38, who required assistance with Activities of Daily Living. On May 3, 2024, an observation revealed that the resident had long and thick toenails on both feet. The resident's representative reported having requested a podiatrist consultation at least five times without receiving a response. The Director of Nursing confirmed on May 7, 2024, that the resident's toenails were indeed long and that no appointment had been made with a podiatrist, despite the facility having a podiatry service available for emergencies. A progress note from the same day indicated that a request was finally sent to the podiatrist, and no injury or skin breakdown was observed.
Failure to Notify Physician of Severe Weight Loss
Penalty
Summary
The facility failed to ensure that a physician assessment was completed for a resident experiencing significant unplanned weight loss. The facility's policy required nursing staff to measure resident weights on admission, the next day, and weekly for two weeks thereafter, with specific thresholds for significant and severe weight loss. Despite these guidelines, a resident experienced severe weight loss over several months, with no evidence that the physician was notified or that an assessment was completed. The resident's weight decreased from 132.6 pounds to 88.8 pounds over a six-month period, representing a 33.03% weight loss, which is classified as severe. The dietician recommended changes to the resident's diet and suggested notifying the physician about the weight loss, but the clinical records revealed that the physician was not informed. Interviews confirmed that the physician was unaware of the resident's weight loss and that no assessment was conducted. This oversight violated several state codes related to nursing services, physician services, and clinical records, highlighting a deficiency in the facility's adherence to its own policies and regulatory requirements.
Medication Storage Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with professional standards. During an observation of the east medication storage room, it was found that the room was open despite having a lock, which was left unlocked. Inside the room, a medication refrigerator was observed to have medications stored within it, but the refrigerator's lock was missing, even though it had metal hooks for locks. This was confirmed by an interview with a Licensed Practical Nurse, who acknowledged that both the medication storage room and the refrigerator were unlocked.
Failure to Follow Approved Vegetarian Diet
Penalty
Summary
The facility failed to adhere to an approved vegetarian diet for a resident, leading to a deficiency in ensuring nutritional adequacy. The resident, who was on both a vegetarian and cardiac diet, had specific nutritional needs, including an estimated calorie requirement of 2000-2200 kcal and 63-83 grams of protein. Despite having a vegetarian extension of the cycle menu approved by a dietician, the facility did not follow this menu. The Food Service Director, Employee E13, was aware of the resident's dietary requirements but did not utilize the approved vegetarian menu extension, resulting in a lack of documentation regarding the resident's calorie intake and the specific foods provided over the past four months. Interviews with facility staff revealed a lack of awareness and understanding of the approved vegetarian menu extension. Employee E13 admitted to not knowing how to access the vegetarian extension electronically, which contributed to the failure to follow the approved menu. The Regional Food Service Staff, Employee E14, confirmed the existence of the approved vegetarian menu extension, highlighting a communication and training gap within the facility's dietary services. This deficiency was identified under the regulations 28 Pa. Code 211.6 (a) Dietary services and 28 Pa. Code 201.18 (e)(2)(3) Management.
Failure to Accommodate Resident's Lactose Allergy
Penalty
Summary
The facility failed to provide food that accommodates the allergies and intolerances of a resident, identified as Resident R37. The resident's admission nutrition assessment indicated a lactose allergy and intolerance, which was confirmed by physician orders specifying no milk due to lactose intolerance. Despite this, the resident was ordered fortified foods, including a nutritional supplement called Super Cereal, which contained dairy products such as dry milk, whole milk, and butter. Interviews with the resident and his wife revealed that the resident could not tolerate any dairy products and had requested a non-dairy nutritional supplement, Boost Breeze. However, the resident continued to receive and consume the fortified cereal containing dairy each morning, as confirmed by an interview with the resident and the Registered Dietitian.
Failure to Provide Prescribed Diets
Penalty
Summary
The facility failed to provide food items consistent with the prescribed diet orders for two residents during dining observations. For Resident R25, the physician's orders included a health shake three times a day and double portions, but during dining observations, the resident was not served a double portion lunch meal or the mighty shake supplement as indicated on the meal ticket. Similarly, Resident R14 had a physician's order for a health shake, but during dining, the meal ticket indicated a magic cup, which was not provided on the meal tray. These discrepancies were confirmed through interviews with a Licensed Practical Nurse and a Unit Manager.
Failure to Manage Nutritional Needs Leads to Immediate Jeopardy
Penalty
Summary
The Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility, resulting in a significant deficiency related to the care of a resident, identified as Resident R20. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, cognitive communication deficit, and dysphagia, experienced unplanned significant weight loss of 43 pounds over five months. The facility did not provide timely nutritional interventions, assessments, or notify the resident's physician about the weight loss. Additionally, the resident was not provided with an appropriate vegetarian diet, contributing to the Immediate Jeopardy situation. The clinical records revealed that the resident's weight decreased from 132.6 pounds in November 2023 to 88.8 pounds by April 2024, indicating severe weight loss. Despite the Registered Dietician's repeated recommendations for re-weights, nutritional supplements, and physician notifications, these interventions were not implemented. The facility failed to document meal intake consistently and did not follow through with the dietician's recommendations, such as liberalizing the diet and providing supplements like Vitamin C and protein shakes. The report highlights the lack of adherence to the facility's policies and procedures, as well as the failure to monitor and address the resident's nutritional needs adequately. The deficiencies identified in the report demonstrate a significant lapse in the responsibilities of the Nursing Home Administrator and the Director of Nursing, leading to the Immediate Jeopardy situation for Resident R20.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
