Cliveden Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 6400 Greene Street, Philadelphia, Pennsylvania 19119
- CMS Provider Number
- 395852
- Inspections on file
- 34
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Cliveden Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that a resident with multiple chronic conditions, including seizures, anxiety, COPD, and multiple sclerosis, had extensive hoarding behaviors, with large piles of personal items occupying her side of a shared room and encroaching on her roommate’s space. The DON acknowledged the hoarding behavior, and observation confirmed compacted piles of belongings on furniture and the floor. Although the care plan identified hoarding as a behavior problem and set a goal to eliminate it, it lacked specific, measurable interventions such as behavioral health support, assistance with storage, or help organizing belongings, resulting in an incomplete person-centered care plan.
A resident with seizure disorder, anxiety, COPD, and multiple sclerosis, who was alert and oriented and dependent on staff for ADLs, did not receive showers according to her care plan and stated preferences. Facility policy required person-centered ADL care, and the resident’s plan specified assisted showers on two evenings per week. The resident reported she had not had a shower for an extended period because staff said there was no bariatric shower bed to fit her, and review of bathing records over a month showed only bed baths documented on scheduled shower days. Discussion with the DON confirmed that records completed by the assigned nurse aide did not show that showers were provided as planned, constituting a failure to honor the resident’s bathing preferences and follow care policies.
Two residents' narcotic medications were misappropriated when an agency nurse manipulated narcotic count sheets, resulting in missing doses of Suboxone and oxycodone. Despite policies requiring dual nurse verification of controlled substance counts, the discrepancies were discovered after a shift change, with a total of ten oxycodone tablets and nine Suboxone pills unaccounted for.
Two residents experienced misappropriation of controlled substances when a discrepancy in Suboxone and Oxycodone was identified. The facility's investigation was incomplete, lacking proper inventory reconciliation, documentation of medication counts, and comprehensive staff interviews. The missing medications were only referenced in interviews, and the audit did not include narcotic counts, resulting in a deficiency.
Surveyors found that two residents receiving specialized care—one with a colostomy and another with an IV for medication—did not have comprehensive care plans in place for these services. Interviews with the residents and the DON confirmed the lack of care plans addressing their specific needs.
A review of facility records and staff interviews found that several licensed nurses lacked documented competencies in IV and ostomy care, with no related policies or evidence of evaluation available. The DON confirmed the absence of required competency documentation for these skills.
Surveyors found that multiple window AC units throughout the facility were retrofitted by removing factory GFCI power cords and attaching extension cords, eliminating original electrical protections. One AC unit in the Dietary Director's office was also plugged into a power strip, contrary to regulations. Facility leadership confirmed these modifications, which violated electrical safety standards.
The facility did not notify the Department of Health before making changes to its HVAC systems, including installing window AC units and modifying electrical cords after P-Tec HVAC failures. This deficiency was confirmed through observation and staff interviews, and the issue remained unaddressed at the time of a follow-up visit.
A deficiency was identified when a group of residents, requiring supervision for fall risks, were found in a lounge with temperatures reaching 84°F, creating a hot and humid environment. While a nurse aide supervising the group had a cold beverage, most residents did not have access to water until it was belatedly provided. One resident appeared clammy and sweaty, and two others reported feeling hot and uncomfortable due to the room temperature.
The facility did not conduct complete investigations into allegations of abuse, neglect, and misappropriation of property for three residents. In one case, a resident reported money stolen by a nurse aide, but only the aide's denial was documented. Another resident with dementia was found on the floor after a fall, with no investigation into the circumstances. A third resident was injured during a mechanical lift transfer, but the facility could not provide evidence of interviews or confirm proper equipment use.
The facility did not maintain complete and accurate infection surveillance, with missing documentation of signs, symptoms, and antibiotic stop dates, and inconsistencies between infection tracking forms and pharmacy order reports. The DON confirmed incomplete infection tracking, and no surveillance documentation was available for one month.
The facility did not maintain an effective antibiotic stewardship program, failing to implement required protocols, conduct comprehensive reviews of antibiotic orders, or effectively monitor antibiotic usage. Discrepancies were found between pharmacy records and facility tracking, and staff confirmed the absence of key stewardship elements, resulting in noncompliance with regulatory requirements.
Several residents did not have documentation showing they were offered or received influenza and pneumococcal vaccines, as required. Clinical records and staff interviews confirmed that the facility failed to provide or offer these immunizations to eligible individuals, with no evidence of vaccine administration or offer found in the records.
A resident with multiple medical conditions was moved to a different floor without receiving advance notice or the opportunity to refuse the room change, contrary to facility policy and state regulations. Documentation showed the resident was notified on the same day as the move, and the DON confirmed there was no evidence of prior notification or the resident's right to refuse.
Staff failed to ensure a clean and homelike environment on the third floor, as evidenced by persistent strong urine odors in hallways and unclean conditions in the dining room, including trash, spills, and leftover trays, with both LPN and housekeeping staff confirming the ongoing issues.
The facility did not notify the Office of the State Long-Term Care Ombudsman when three residents were transferred to the hospital for emergency evaluation, including cases involving increased abdominal girth, abnormal labs, and a head injury from a fall.
A resident with dysphagia was left without upper dentures after staff reportedly discarded them, and despite repeated requests and dental consult recommendations for replacement, there was no evidence that the facility followed up or took action. Staff interviews and record reviews confirmed the absence of documentation or follow-up, leaving the resident unable to chew food properly.
A resident with hearing difficulties did not receive an audiology evaluation and hearing aid assessment as recommended by an ENT specialist. The resident reported ongoing hearing issues and had not received hearing aids, with staff confirming the recommended evaluation was not completed.
A resident with multiple medical conditions did not receive a physician-ordered right upper extremity splint and hand splint for contracture management. The splints were not applied as ordered, and documentation did not show evidence of their use. Staff confirmed the omission, and the resident reported no longer receiving the device without explanation.
A resident with a tracheostomy did not receive daily trach care as required by facility policy, and there was no documented physician order or care plan for daily trach care or cap management. Staff also identified a discrepancy between the physician order and the actual trach tube in use, and confirmed the lack of necessary documentation and orders for respiratory care.
The facility did not ensure that newly hired nurse aides and an LPN had documented skills competency evaluations to confirm their ability to provide required care, as confirmed by review of personnel files and by the DON.
The facility did not conduct required performance reviews for three nurse aides, as confirmed by personnel file review and staff interviews. The HR Director acknowledged that no staff performance reviews had been completed, resulting in noncompliance with personnel policy requirements.
Surveyors observed that two medication carts contained open and undated vials of various insulins, including Novolin, Lantus, lispro, and NovoLog, despite manufacturer guidelines requiring disposal 28 days after opening. Expired vials and numerous unidentified loose pills were also found, and these deficiencies were confirmed by the LPNs present.
A resident with dysphagia and no upper dentures, who reported difficulty eating and chewing, was not assessed for speech therapy services despite ongoing complaints and documentation of eating difficulties. The facility did not refer the resident for specialized rehabilitative services after dental consultations or staff reports.
The facility did not conduct or document a facility-wide assessment to determine the resources needed to care for residents with complex needs, such as dementia, pressure ulcers, dialysis, and tracheostomy care, during both daily operations and emergencies. When requested by surveyors, the assessment was not available, and the administrator confirmed its absence.
The facility did not ensure accurate completion of resident assessments and MDS documentation for four residents. Two residents did not receive required BIMS assessments, resulting in incomplete cognitive status sections. Another resident's MDS failed to reflect provided tracheostomy and suctioning care, and a separate resident's discharge status was incorrectly recorded as a hospital transfer instead of a home discharge.
The facility failed to maintain a safe, clean, and homelike environment in four rooms, with issues such as missing ceiling tiles and leaking stains. A resident reported a missing ceiling tile for about a week without replacement efforts, indicating non-compliance with facility policy.
A resident with hemiplegia and hemiparesis was unable to access the call bell due to its incorrect placement on the left side of the bed, despite being unable to use the left upper extremity. Staff interviews confirmed the oversight, as the call bell should have been placed on the right side to accommodate the resident's condition.
The facility failed to ensure compliance with identification badge requirements, as observed with two employees, a maintenance assistant and a licensed nurse, who were not wearing their badges during their shifts. This is contrary to the facility's policy that mandates employees to wear photo identification tags.
The facility failed to maintain resident dignity by not covering a urine collection bag and serving meals on disposable paperware. Additionally, meals were not served timely in one dining room, causing delays for some residents. A resident requiring feeding assistance had to wait for help, and clothing protectors were not offered, leading to food spills.
The facility failed to provide secure storage for residents' belongings, as several residents reported missing items and lacked keys to their locked drawers. Interviews revealed complaints about theft and unreturned laundry, with no grievances filed. A grievance about missing items showed no resolution, indicating a systemic issue.
The facility was unable to provide documentation of competency training for its licensed nursing staff in key areas such as medication administration and wound care. The Nursing Home Administrator acknowledged the absence of these records during a survey.
The facility did not conduct yearly performance reviews for nurse aides, as confirmed by the DON during an interview. Despite a request for documentation, no evidence of these reviews was provided.
The facility did not adhere to professional standards for food service safety. Observations revealed trash near the receiving area, a dark substance and dirt in the walk-in refrigerator, and a prep table with rust stains in the hot food production area. The convection oven and reach-in refrigerator were covered with grease and grime, with torn door gaskets. The dish machine had a build-up of a brownish substance. These issues were confirmed by the FSD.
A resident expressed concerns about seeing outside physicians and made multiple requests for medical appointments and updates, which were not addressed by the facility. Despite the resident's requests being documented during an IDT visit, the physician had not followed up on them, as confirmed by the DON.
The facility did not ensure that the State Department of Health contact information was visibly posted for residents in two out of three units. Only the first floor had signs, but they were not accessible to wheelchair-bound residents. The second and third floors lacked any signs. This was confirmed by a Social Worker, indicating a failure to comply with resident rights regulations.
A facility failed to maintain resident privacy during medication administration and tracheostomy care. An LPN left a laptop open in the hallway, exposing two residents' medical information. Additionally, a resident undergoing tracheostomy care was visible from the hallway due to an open door. The facility lacked a privacy policy.
The facility failed to provide accessible grievance forms and boxes for anonymous submissions on two nursing floors, and the existing grievance box was not accessible to wheelchair-bound residents. Residents were unaware of how to file grievances, and several reported unresolved issues related to missing clothing and stolen money, with no records in the facility's grievance log.
A facility failed to accurately document a resident's discharge status. The resident was discharged home with family, but the MDS incorrectly stated a discharge to a hospital. This error was confirmed by the RN Assessment Coordinator.
The facility failed to develop baseline care plans within 48 hours of admission for three residents, as required by policy. One resident with chronic kidney disease and a Foley catheter had no care plan for catheter management. Another resident with pain management needs had no care plan for pain management. A third resident with a pressure ulcer and tracheostomy had no care plan for wound care or skin breakdown. This deficiency highlights a failure to provide necessary and timely care planning for new admissions.
The facility failed to update care plans for three residents, leading to discrepancies between physician orders and care plans. A resident using oxygen therapy did not have it included in their care plan, another resident with dementia lacked a care plan focus for their condition, and a third resident's care plan contained outdated tube feeding instructions. The DON confirmed these oversights.
The facility failed to obtain a physician's order for tracheostomy care and suctioning for a resident and did not notify the physician after another resident missed several doses of prescribed medication due to pharmacy delays. The medication administration record indicated missed doses, but there was no evidence that the physician was informed, revealing a communication gap in medication management.
The facility failed to follow physician orders for oxygen administration for two residents. One resident received oxygen at 5 liters per minute instead of the ordered 2 liters, and another received 1 liter instead of the ordered 3 liters. These discrepancies were identified and corrected by licensed nurses.
The facility failed to maintain communication with a dialysis provider for residents requiring dialysis services. Despite a policy requiring the use of a Dialysis Communication form, there was no documented communication from the dialysis center on several occasions, and a nurse failed to document after a resident's return from dialysis. An LPN confirmed these findings, highlighting a lapse in adherence to the policy.
A resident with serious medical conditions did not receive prescribed Daptomycin on multiple occasions due to pharmacy delivery issues. Despite attempts to contact the pharmacy, the medication was unavailable, leading to missed doses as documented in the MAR and progress notes.
The facility failed to complete the drug regimen review process for two residents, as required by policy. A pharmacist's recommendations for a resident with anxiety and another with depression and PTSD were not documented or followed up on. The DON confirmed the absence of further documentation, indicating non-compliance with state regulations on pharmacy and nursing services.
The facility was found deficient for failing to employ a qualified director of food and nutrition services. The Food Service Director (FSD) lacked necessary certifications and qualifications, such as being a Certified Dietary Manager (CDM) or Certified Food Manager (CFM), and did not have a relevant degree or receive regular consultations from a qualified dietitian. The Nursing Home Administrator confirmed the FSD's lack of qualifications, violating specific dietary service and management regulations.
The facility failed to provide palatable food and drink at proper temperatures, as confirmed by resident interviews and test tray observations. Residents reported issues with food being cold, lacking variety, and not receiving items listed on meal tickets. A test tray revealed that food and beverages were below standard temperature ranges, and dietary staff confirmed these findings.
The facility failed to ensure that residents, including one with severe cognitive impairment, had the capacity to understand and sign binding arbitration agreements. Despite a resident's low BIMS score indicating severe cognitive impairment, the resident signed the agreement upon admission without proper assessment of their understanding.
The facility failed to ensure a safe, functional, and sanitary environment on three nursing units. Issues included detached heating baseboards, a strong urine odor, a hole in the wall, missing toilet paper roll cover, dirty and ripped floor mats, improperly stored basins, and unsanitary conditions. Residents reported inadequate cleaning, and staff confirmed the deficiencies.
Failure to Develop Person-Centered Care Plan for Resident With Hoarding Behaviors
Penalty
Summary
Surveyors identified a deficiency in the development of a person-centered care plan for a resident with documented hoarding behaviors. The resident, admitted in 2021, had physician orders in March 2026 reflecting diagnoses including seizures, anxiety, COPD, and multiple sclerosis. During an observation of the resident’s shared room, the resident was seen lying in bed surrounded by an abundance of personal items. These items, which included stuffed animals, papers, and pocketbooks, were piled on top of both her own and her roommate’s drawers, on the floor around her bed area, on the heating unit, bedside table, chair, and bedside dresser. The piles were so compacted that items in between could not be identified without lifting the piles. The resident stated that her room was “junky” and attributed this to having had items go missing since she had been at the facility. The DON acknowledged during interview that the resident had hoarding behaviors and that the condition of the room, which the resident shared with another female resident, was as described. Review of the resident’s current person-centered care plan showed that hoarding was identified as a behavior problem, with a goal that there be no evidence of hoarding behavior by the next care plan review date. However, the care plan did not include any specific interventions or measurable actions to address the hoarding behavior or to support the resident in managing her belongings. No strategies such as behavioral health treatment, assistance with storage, help prioritizing or sorting items, or involvement of family or friends were documented, resulting in a failure to develop and implement a complete, person-centered care plan to meet the resident’s identified needs.
Failure to Provide Scheduled Showers per Resident’s Care Plan and Preferences
Penalty
Summary
The facility failed to provide scheduled showers for a resident who was unable to perform activities of daily living independently. Facility policy on ADLs, last reviewed in December 2024, required staff across all shifts and departments to provide person-centered care that honors each resident’s preferences, including bathing preferences. One resident, diagnosed with seizure disorder, anxiety, COPD, and multiple sclerosis, had a significant change MDS dated January 21, 2026 documenting that she was awake, alert, and oriented. Her person-centered care plan for ADLs stated that she had a self-care performance deficit, required assistance of one person for bathing and showering, and preferred showers on Wednesday and Saturday evenings. During an interview, the resident reported she had not received a shower since May 5, 2025 because staff told her the facility no longer had a bariatric shower bed that could accommodate her. Review of her bathing record from early February through early March 2026 showed no documentation of showers on her scheduled shower days; instead, only bed baths were recorded on those days. When this was discussed with the DON, it was noted that the bathing records completed by the assigned nurse aide did not show evidence that the resident was provided showers as designated in her care plan, resulting in a failure to follow resident rights, resident care policies, and nursing services requirements under the cited Pennsylvania regulations.
Misappropriation of Controlled Substances Due to Inaccurate Narcotic Counts
Penalty
Summary
The facility failed to ensure that residents were free from misappropriation of personal property when narcotic medications were stolen or diverted for two residents. Facility policy defines misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident's belongings or money without consent. The policies also require that controlled substances be counted by two licensed nurses at each shift change, with both nurses verifying and signing off on the count. Despite these policies, a discrepancy was identified involving missing narcotic medications for two residents, with the loss discovered during a medication count by nursing staff. One resident, admitted with diagnoses including viral hepatitis, rhabdomyolysis, and pulmonary fibrosis, was prescribed Suboxone for opioid withdrawal and experienced frequent pain. The medication administration record showed that Suboxone was not available for a scheduled dose, and the medication was not administered as ordered. Another resident, admitted with an amputation and prescribed oxycodone for pain, was discharged from the facility, but a review of records revealed missing oxycodone tablets. The missing medications were identified after a shift change count, which initially appeared accurate but was later found to be manipulated. Interviews and documentation revealed that an agency nurse manipulated narcotic count sheets, resulting in inaccurate medication counts and the loss of controlled substances. The facility's investigation confirmed that a total of ten oxycodone tablets and nine Suboxone pills were missing. The incident involved the manipulation of records and failure to maintain accurate control and documentation of narcotic medications as required by facility policy.
Failure to Thoroughly Investigate Drug Misappropriation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of drug misappropriation involving two residents. A discrepancy was identified by a licensed nurse regarding missing controlled substances—specifically, Suboxone and Oxycodone—after one resident had been discharged and another remained admitted. The overnight nurse reported administering only one narcotic during her shift, and both the narcotic count book and electronic medication administration record reflected this. During the shift change, the narcotic count was reportedly accurate, but subsequent investigation revealed missing medications. The facility's investigation included obtaining three staff statements, a basic audit of medication carts, notification of the medical provider, ordering replacement medications, and notifying the police. However, the investigation lacked critical elements such as documented inventory reconciliation, actual medication counts, waste documentation, and comprehensive staff interviews. The missing medications were only referenced in interviews and not formally documented in the investigation report. Further review showed that the medication cart audit did not include narcotic counts, and not all staff with access to the medication cart were interviewed. The Director of Nursing determined that an agency nurse, who had worked at the facility twice, was responsible for the missing medications, based on manipulation of the narcotic book. The agency nurse was not charged but was placed on a do-not-return list. The investigation documentation was incomplete, with missing records of medication counts and incomplete audit documentation. The facility's failure to thoroughly investigate and document the incident resulted in a deficiency under state pharmacy services and management regulations.
Failure to Develop and Implement Care Plans for IV and Ostomy Care
Penalty
Summary
Surveyors identified that the facility failed to develop and implement comprehensive care plans for two residents who required specialized care. One resident was admitted with a colostomy and was receiving daily colostomy care, but there was no corresponding care plan documented in the medical record. Another resident was admitted with an intravenous (IV) line for medication administration to prevent wound infection, yet there was also no care plan addressing IV care in the medical record. Interviews with both residents confirmed the ongoing need for these specialized services, and an interview with the Director of Nursing verified that care plans for colostomy and IV care were not in place for these residents. The absence of these care plans was found during a review of clinical records and staff interviews, constituting a failure to meet federal and state requirements for comprehensive, person-centered care planning.
Plan Of Correction
Immediate Corrective Action: R7 care plan was reviewed and updated accordingly. R8 has been discharged from the facility. Housewide Corrective Action: Current residents with colostomy care and IV care were audited to ensure care plans were present. Policy/ Education: Licensed nurses will be re-educated on the facility's comprehensive care plan policy and ensuring specific care needs (IV and/or colostomy) are added to the care plan as applicable. Performance Monitoring: DON or designee will complete weekly audits x 4 weeks to ensure residents with colostomy care and IV care needs have care plans to reflect specific the same. Results will be reviewed during facility's monthly QAPI meeting. QA meeting will determine the need for continued auditing.
Lack of Documented Nursing Competencies in IV and Ostomy Care
Penalty
Summary
The facility failed to ensure that licensed nursing staff possessed the required competencies, specifically in intravenous (IV) care and ostomy care, for four licensed nurses whose training records were reviewed. Facility documentation and staff interviews revealed that there were no policies related to nursing competencies, and the training records did not show evidence of competency evaluations for IV care for two employees and ostomy care for all four employees reviewed. An interview with the Director of Nursing confirmed that there was no documentation available to demonstrate that the selected licensed nursing staff had been evaluated for competency in ostomy care, and that two of the employees had no documented IV competency. This lack of documentation and evaluation directly led to the deficiency cited under federal and state nursing service regulations.
Plan Of Correction
Immediate Corrective Action: IV care competencies were completed with E4 and E5. Ostomy care competencies were completed with E4, E5, E6, and E7. Housewide Corrective Action: Current licensed nursing staff to be audited to ensure IV care and ostomy care competencies have been completed. Policy/Education: Current licensed nurses will have IV care and ostomy care competencies completed. Performance Monitoring: DON or designee will complete weekly observations of 2 nurses performing ostomy care and IV care x 4 weeks to ensure staff are competent in performing both tasks. Results will be reviewed during facility’s monthly QAPI meeting. QA meeting will determine the need for continued auditing.
Improper Use of Extension Cords and Power Strips for Window AC Units
Penalty
Summary
Surveyors observed that throughout the facility, on each floor, multiple window air conditioning (AC) units were being used in place of the originally installed P-Tec units. These window AC units had been retrofitted by removing the factory-supplied GFCI power cords, then cutting, splicing, and attaching extension cords. This modification eliminated the AC units' original electrical protections. Additionally, one window AC unit in the Dietary Director's office was found plugged into a power strip, which is not permitted for this type of equipment. Interviews with the Administrator, Regional and local Maintenance Director, and the VP of Building Operations confirmed that power strips and extension cords were used to modify window AC units, resulting in the removal of the AC units' electrical protections and the attachment of heat-drawing equipment to power strips. These actions were found to be in violation of NFPA 101 and related standards, as extension cords and power strips were improperly used as substitutes for fixed wiring and permanent outlets.
Failure to Notify Department of Health of HVAC Modifications
Penalty
Summary
The facility failed to notify the Pennsylvania Department of Health prior to making modifications and changes to its heating, ventilating, and air conditioning (HVAC) systems. Specifically, when Packaged Terminal Air Conditioners (P-Tec HVAC) failed, the facility installed window air conditioning units and altered their electrical cords without first obtaining Department-approved plans or notifying the Department as required. This action was observed during a site visit, and the deficiency was confirmed through interviews with the Administrator, Regional and local Maintenance Director, and the VP of Building Operations. A subsequent onsite revisit determined that the facility had still not notified the Department of Health regarding the HVAC modifications. This ongoing failure to communicate planned changes affecting the facility's environment was confirmed in an exit interview with the Maintenance Director. The deficiency affected the entire facility, as it pertained to the systems responsible for maintaining safe and efficient environmental conditions for all residents.
Failure to Maintain Comfortable Environment in Resident Lounge
Penalty
Summary
The facility failed to maintain a comfortable environment in the 3rd floor multipurpose room, as evidenced by observations and interviews. During a tour with the Maintenance Director, the temperature in the room was recorded at 84 degrees, and the environment was described as hot, humid, and uncomfortable. Approximately 20 residents, who required supervision due to fall risks, were present in the room under the supervision of a nurse aide. It was observed that the nurse aide had a cold beverage, while 16 residents did not have any beverages available. The nurse aide confirmed that the residents did not have water and stated she would begin passing water and ice. Further observations revealed that one resident appeared clammy and sweaty and reported feeling uncomfortable due to the warm temperature. Two additional residents also reported feeling hot and uncomfortable. These findings indicate that the facility did not provide a safe, functional, sanitary, and comfortable environment for residents, as required.
Plan Of Correction
F 0921 Immediate Corrective Action: Residents were assisted out of the 3rd floor multipurpose room and into the 1st floor lounge area where room temperatures were more comfortable. Housewide corrective actions: All multipurpose rooms were audited to ensure comfortable temperatures were reached. Portable AC units were audited to ensure proper function. Education: Nursing staff were re-educated to ensure residents are frequently offered fluids through summer months. Performance Monitoring: Maintenance Director or designee will complete weekly audits x 8 weeks of all multipurpose rooms and portable AC units to ensure temperatures are at a comfortable and appropriate level and to ensure AC units are functioning properly. Results will be reviewed during the monthly QAPI meeting. QA meeting will determine the need for continued auditing.
Failure to Conduct Thorough Investigations of Abuse, Neglect, and Misappropriation Allegations
Penalty
Summary
The facility failed to conduct complete and thorough investigations into allegations of abuse, neglect, and misappropriation of resident property for three of four residents reviewed. In one case, a cognitively intact resident reported that a nurse aide allegedly stole $100 from her purse. Although the resident provided a receipt for the withdrawn money and the accused staff member was suspended, the facility did not conduct interviews with witnesses, search the resident's room, or interview the resident's roommate, family, or other relevant individuals. The only documentation available was a statement from the accused nurse aide denying the theft. Another incident involved a resident with severe cognitive impairment who was found on the floor after falling from her wheelchair in the hallway. The facility's fall report lacked evidence of a thorough investigation, as there were no interviews with staff or residents who may have been present, nor information on who found the resident. The Director of Nursing confirmed that no investigation was available for this incident. A third case involved a resident who fell while being transferred with a mechanical lift, resulting in a hospital visit for a thumb sprain. Although the reportable incident stated that staff and residents were interviewed and abuse was ruled out, the facility could not provide any documentation of these interviews or evidence that the correct sling size was used during the transfer. Again, the Director of Nursing confirmed that no investigation was available for this incident.
Failure to Implement Comprehensive Infection Surveillance and Tracking
Penalty
Summary
The facility failed to implement appropriate tracking and surveillance of infections over a five-month period, as required by its own infection prevention and control policy. The policy specified that the Infection Preventionist should systematically collect, analyze, and interpret health data, including detailed information such as signs and symptoms, antibiotic use, and infection onset dates. However, reviews of infection tracking forms from January through April revealed missing critical data, such as signs and symptoms and antibiotic stop dates. Additionally, the number of infections recorded on the tracking forms did not match the number of residents receiving antibiotics according to pharmacy order reports, indicating incomplete or inaccurate surveillance. For May, no infection tracking documentation was available at all. Interviews with the Director of Nursing confirmed that the facility did not have complete infection surveillance, including the tracking of signs and symptoms. The discrepancies between the infection tracking forms and pharmacy order reports, as well as the absence of required documentation, demonstrate a failure to follow established infection surveillance protocols. This deficiency was cited under 28 Pa. Code 211.10(d) Resident care policies and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Failure to Maintain Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program as required by both CDC guidelines and its own policies. Over a review period of ten months, the facility did not implement antibiotic use protocols, did not conduct complete reviews of antibiotic orders to determine appropriateness, and lacked a system to effectively monitor antibiotic usage and track symptoms. The facility's antimicrobial stewardship policy required documentation of dose, duration, route, and indication for every antimicrobial prescription, as well as monthly reviews for compliance and appropriateness, but these actions were not consistently performed. A review of facility documentation and pharmacy order reports revealed discrepancies between the number of antibiotic prescriptions recorded and those tracked by the facility. For each month reviewed, the number of residents receiving antibiotics according to pharmacy records exceeded the number tracked by the facility's stewardship program. For example, in January, pharmacy records showed 15 residents with antibiotic orders, but the facility only completed 10 infection reviews over a six-month period, indicating incomplete monitoring and tracking. Interviews with facility staff, including the Director of Nursing, confirmed that the antibiotic stewardship program did not include necessary protocols, comprehensive review of antibiotic orders, or effective monitoring systems. The lack of integration of dispensing and consultant pharmacists into the clinical care team further contributed to the deficiency, as did the absence of specific interventions to address inappropriate antibiotic use. These findings were cited as violations of state regulations regarding resident care policies and nursing services.
Failure to Offer or Provide Required Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to offer and/or provide influenza and pneumococcal immunizations to several residents as required. Clinical record reviews and staff interviews revealed that three out of five residents reviewed did not have evidence in their records of receiving or being offered the pneumococcal vaccine. Additionally, for some residents, there was no documentation that the influenza vaccine was offered or administered. The records for each affected resident showed either a lack of documentation of vaccine administration or any indication that the vaccines were offered, despite their eligibility and admission to the facility. These findings were based on direct review of clinical records and staff interviews, with no evidence provided to show compliance with immunization requirements.
Failure to Provide Advance Notice and Right to Refuse Room Change
Penalty
Summary
A deficiency occurred when a resident with diagnoses including epilepsy, hypertension, and muscle weakness was moved from the first floor to the third floor of the facility. The facility's policy required that residents or their representatives receive advance notice, either orally or in writing, before any room or roommate assignment changes, and that the reason for the change be provided. However, documentation in the clinical record showed that the resident was notified of the room change on the same day it occurred, rather than in advance. The Roommate Change-Advanced Notification form and nursing notes both indicated the move happened on the same day as the notification. Additionally, there was no evidence in the clinical record that the resident was given the opportunity to refuse the room change, despite the resident stating during an interview that he expressed a desire not to move. The Director of Nursing confirmed that there was no documentation showing the resident received prior notice or was allowed to refuse the transfer. This failure to provide advance notification and the opportunity to refuse the room change was found to be out of compliance with facility policy and state regulations regarding resident rights.
Failure to Maintain Clean and Homelike Environment on Third Floor
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment on one of three nursing units, specifically the third floor. Multiple observations on different days revealed a persistent strong odor of urine throughout the South and [NAME] unit hallways, even when no residents were receiving incontinence care at the time. The issue was confirmed by both nursing and housekeeping staff, who acknowledged the odor and noted that cleaning and spraying only temporarily masked it. Additionally, the third-floor dining room was observed to have trash and liquid spills on the floor and tables, with breakfast trays left out while residents were present. These conditions were directly observed and confirmed by staff interviews.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman regarding facility-initiated emergency transfers to the hospital for three residents. For one resident, clinical records showed increased abdominal girth and no bowel movement for three days, resulting in a physician-ordered hospital transfer. Another resident had abnormal laboratory results and was also transferred to a hospital for evaluation per physician orders. A third resident experienced an unwitnessed fall, sustained a hematoma to the head, and was subsequently transferred to the hospital. Review of documentation and staff interviews confirmed that the required notification to the Ombudsman was not made for these emergency transfers.
Failure to Follow Up on Dental Consults for Denture Replacement
Penalty
Summary
The facility failed to follow up on dental consult recommendations for a resident diagnosed with dysphagia who required new upper dentures. The resident reported difficulty chewing food due to the absence of upper dentures, which he stated were accidentally discarded by staff. Despite the resident's repeated requests for assistance in obtaining replacement dentures and the dentist's recommendations documented in two separate onsite dental consultations, there was no evidence in the clinical record that the facility took any action to address these recommendations. Interviews with staff confirmed that dental consults are provided to nursing staff, who are responsible for documenting and following up on recommendations. However, a review of the clinical record revealed no documentation or follow-up actions taken regarding the dental consults for this resident. The lack of follow-up resulted in the resident continuing to be without upper dentures, impacting his ability to eat properly.
Failure to Facilitate Audiology Evaluation for Hearing Loss
Penalty
Summary
A deficiency was identified when a resident with documented hearing difficulties did not receive an audiology evaluation and hearing aid assessment as recommended by an ENT specialist. The resident reported ongoing difficulty hearing and stated that, despite being evaluated by a doctor for hearing loss, he had not yet received hearing aids. Review of the clinical record confirmed the ENT consultation recommended further audiology and hearing aid evaluation, but there was no documentation to show these services were provided. This was further corroborated by staff, who confirmed the resident had not received the recommended evaluation.
Failure to Apply Physician-Ordered Splint for Contracture Management
Penalty
Summary
A deficiency was identified when a resident with diagnoses of heart failure, diabetes, and dysphagia did not receive a physician-ordered right upper extremity elbow extension splint and resting hand splint. The physician's order, in place since February 2023, specified that the splints should be applied in the morning and removed in the evening, with skin checks before and after use. The resident's care plan also included interventions for contracture management, including participation in restorative programs and use of a right wrist support brace. During the survey, the resident was observed without any splints and reported that he used to wear a device on his hand but it was taken away without explanation. The unit manager confirmed that the splint had not been applied, and a review of the Treatment Administration Record and Medication Administration Record showed no evidence of the splint being used as ordered during the review period. The occupational therapist also confirmed the resident's need for the splint to manage muscle tone. These findings indicate that the facility failed to implement the physician's order for contracture prevention devices.
Failure to Provide Required Tracheostomy Care and Documentation
Penalty
Summary
The facility failed to provide necessary respiratory care consistent with professional standards of practice for a resident with a tracheostomy. Facility policy required daily tracheostomy care and as-needed dressing changes, including removal of the drain/dressing sponge and cleaning around the stoma site and trach plate. Review of the resident's care plan indicated interventions such as ensuring trach ties were secured, suctioning as needed, monitoring for changes in status, and using universal precautions. However, the resident reported that tracheostomy care was not performed daily by nursing staff, and observations confirmed the presence of a tracheostomy with a cap in use. Further review of the clinical record revealed a physician order for a #8 shiley cuffless tracheostomy tube, but observation and staff interview identified the resident was actually using a #6 shiley cuffless tube, indicating a discrepancy in documentation. There was no documented evidence of physician orders or a comprehensive care plan for the daily care of the tracheostomy or for the management of the cap. Staff confirmed the lack of physician orders and documentation for daily tracheostomy care and cap management, constituting a failure to follow resident care policies and nursing service requirements.
Lack of Documented Skills Competency for Newly Hired Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff, specifically newly hired nurse aides and an LPN, possessed the necessary competencies and skill sets required to provide appropriate care to residents. Review of personnel files for three newly hired employees revealed there was no evidence of completed skills competency evaluations to confirm their ability to perform essential hands-on care and techniques as outlined in their job descriptions. These job descriptions included responsibilities such as providing direct personal care, restorative and rehabilitative procedures, medication administration, and other direct care tasks. During an interview, the Director of Nursing confirmed that no hands-on skills evaluations were available for these employees at the time of the survey. This lack of documented competency assessment was identified through review of facility documentation, personnel files, and staff interviews, and was found to be out of compliance with state regulations regarding personnel policies and staff development.
Failure to Complete Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete performance reviews for three nurse aides, as identified through a review of personnel files and staff interviews. Documentation showed that the nurse aides had been employed at the facility for several years, yet there was no evidence of any performance reviews being conducted for them. During an interview, the HR Director confirmed that no performance reviews had been completed for any staff, including the three nurse aides in question. This lack of performance evaluations was found to be noncompliant with the facility's personnel policies and procedures as required by regulation.
Improper Labeling and Storage of Insulin and Medications on Medication Carts
Penalty
Summary
Surveyors found that the facility failed to ensure all drugs and biologicals were labeled and stored according to professional standards on two of four medication carts observed. Specifically, open and undated vials of Novolin, Lantus, lispro, and NovoLog insulins were found on the second-floor south and east medication carts. Manufacturer guidelines for these insulins require that they be discarded 28 days after opening, but the vials observed were not dated, making it impossible to determine if they were still safe for use. Additionally, expired vials of Lispro and Novolin were present in the cart, and these findings were confirmed by the LPNs present during the observations. Further inspection of the medication carts revealed numerous unidentified loose pills behind medication containers in the top drawer of one cart. These issues were confirmed by the staff present at the time of observation. The failure to properly label, date, and store medications, as well as the presence of expired and unidentified medications, constituted noncompliance with pharmacy and nursing service regulations.
Failure to Assess Resident Without Dentures for Speech Therapy
Penalty
Summary
The facility failed to ensure that a resident without upper dentures, who had a diagnosis of dysphagia, was assessed for speech rehabilitation services. The resident reported difficulty chewing food due to the absence of upper dentures, which were reportedly discarded by staff. The resident also stated that he was informed by the facility that Medicaid would not pay for replacement dentures. During an interview, the resident was observed without upper dentures, and a dental consultation confirmed that the resident was unable to eat without his teeth and was still waiting for replacement dentures. A review of the clinical record showed no evidence that the facility referred the resident to speech therapy, despite the resident's ongoing difficulties with eating and communication of these issues to both staff and a dentist. The Director of Rehabilitation confirmed that there was no assessment by a speech therapist following the dental visits or at any time during the relevant period. This lack of referral and assessment constituted a failure to provide or obtain specialized rehabilitative services as required.
Failure to Conduct and Document Facility-Wide Resource Assessment
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. Review of facility documentation showed a census of 144 residents with diverse and complex care needs, including dementia care, pressure ulcers, indwelling catheter care, dialysis, hospice, intravenous therapy, feeding tube care, tracheostomy care, transmission-based precautions, and trauma-informed care. When requested by State Agents on two separate occasions, the Facility Assessment was not available for review. The Nursing Home Administrator confirmed in an interview that the assessment was not available at the time of the survey.
Failure to Accurately Complete Resident Assessments and MDS Documentation
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status for four out of 29 residents reviewed. Specifically, for two residents, the Brief Interview for Mental Status (BIMS) was not conducted as required, and Section C of the Minimum Data Set (MDS) was left incomplete. The Registered Nurse Assessment Coordinator confirmed that the BIMS assessments should have been completed but were not done in time for the MDS submission, resulting in missing information. Additionally, for another resident with a tracheostomy and a diagnosis of respiratory failure, the comprehensive MDS did not indicate that the resident received suctioning and tracheostomy care, despite these interventions being documented in the care plan. In a separate case, a resident's discharge status was incorrectly coded on the MDS as a discharge to a short-term hospital, when the clinical record showed the resident was discharged home with prescriptions and instructions. These findings were based on clinical record reviews and staff interviews.
Deficiency in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in four out of five rooms observed. Specifically, rooms 301, 302, 303, and 304 on the third floor unit exhibited issues such as missing ceiling tiles and leaking stains on ceiling tiles. In room 301, a missing ceiling tile and six leaking stains were observed in the restroom, along with a leaking stain down the wall. Room 302 had leaking stains on ceiling tiles above the resident's bed, while room 304 had a missing ceiling tile and three leaking stains. Room 303 also had leaking stains on two ceiling tiles. An interview with a resident in room 304 revealed that the missing ceiling tile between beds A and B had been absent for about a week, with no observed efforts to replace it. The facility's policy on maintaining a safe, clean, and homelike environment, revised in April 2022, was not adhered to, as evidenced by the lack of housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. These observations and resident feedback indicate a failure to meet the regulatory requirements for a homelike environment.
Plan Of Correction
1) Missing and stained ceiling tiles will be replaced in rooms 301, 302, 303, and 304. 2) House wide auditing will be conducted in resident care areas to ensure there are no missing or stained tiles. Tiles will be replaced as needed. 3) Current housekeeping staff will be re-educated on replacing stained and missing ceiling tiles and conducting routine auditing during daily cleaning routine. 4) Maint. Director or designee will do random audits weekly X4 and monthly X2 for missing and/or stained ceiling tiles and replace them as necessary. Results will be reviewed monthly in QAPI and determined if further auditing is necessary.
Resident Call System Deficiency
Penalty
Summary
The facility failed to ensure that a call device was accessible to a resident, identified as Resident R6, who was observed during a lunch meal service. Resident R6, who has a medical diagnosis of hemiplegia and hemiparesis affecting the left non-dominant side, was unable to reach the call bell placed on the left side of the bed due to their condition. This observation was made while Resident R6 was in bed with a lunch tray on the bedside table, and the resident was seen coughing continuously while consuming the meal and unable to verbalize the need for assistance. Interviews with facility staff confirmed the deficiency. A licensed nurse, Employee El, confirmed that Resident R6 was unable to use her left upper extremity due to hemiplegia and hemiparesis. Additionally, the facility's Director of Nursing, Employee E3, confirmed that the call bell for Resident R6 should have been placed on the right side of the bed, which was not done, leading to the resident's inability to call for assistance.
Plan Of Correction
1) Resident's care plan was updated to have call bell light on her stronger side. 2) Nursing will identify residents perceived to have a weakness or deficit on one side of the body. These residents will be referred to therapy for recommendations of care r/t the weak side regarding call bell placement and the resident's ability to use the call bell. 3) Nursing will be educated to ensure that residents call bell light is within reach of the resident and that resident can access and use. 4) Call bell audit will be completed by each unit manager weekly x 4 and monthly x 2 to ensure that call bells are always within reach of the residents and able to be accessed. Results will be reviewed monthly in QAPI and determined if further auditing is necessary.
Non-Compliance with Employee Identification Badge Requirements
Penalty
Summary
The facility was found to be non-compliant with the regulation requiring employees to wear identification badges. During an observation and interview with the facility's maintenance assistant, it was noted that Employee E2 did not have an identification badge while on a tour of the facility. This observation took place on January 31, 2025, at 10:00 a.m. Additionally, a licensed nurse, Employee E1, was observed on the third-floor unit without an identification badge on the same day at 1:00 p.m. The facility's policy, revised on January 3, 2022, mandates that employees must wear photo identification tags containing a recent photograph, the employee's first name, title, and the name of the health care facility or employment agency. The absence of identification badges for these employees indicates a failure to adhere to the established standards for identification badges as per Act 110.
Plan Of Correction
1) E1 and E2 will be provided with ID badges. 2) Current employees will be audited to ensure they have an ID badge available to them. 3) Current employees will be re-educated on ensuring they are wearing their name badge at all times and how to obtain one if they don't have one. 4) HR director will do random audits weekly X4 and monthly X2 to ensure staff are wearing their ID badge as necessary. Results will be reviewed monthly in QAPI and determined if further auditing is necessary.
Failure to Maintain Resident Dignity and Timely Meal Service
Penalty
Summary
The facility failed to uphold residents' dignity by not providing appropriate care and services. During an initial tour, it was observed that a resident with an indwelling Foley catheter had their urine collection bag visibly exposed without a dignity bag, which was confirmed by a licensed nurse. The nurse acknowledged that the urine collection bag should have been covered or the privacy curtain drawn to maintain the resident's dignity. Additionally, the facility did not serve meals in a timely manner in one of the dining rooms. Observations revealed that only a portion of the residents received their meals promptly, while others had to wait until the second food truck arrived, causing delays. Some residents were not served simultaneously, and a resident requiring feeding assistance had to wait for help. Furthermore, meals were served on disposable paperware, and residents were not offered clothing protectors, resulting in food spills on their clothing.
Failure to Provide Secure Storage for Resident Belongings
Penalty
Summary
The facility failed to provide a secure environment for residents' personal belongings, as evidenced by the lack of lockable storage in residents' rooms. Observations and interviews revealed that two residents did not have keys to their locked drawers, preventing them from securing their valuables. One resident reported missing clothing items that were supposed to be locked in her wardrobe, which lacked a lock. Another resident also reported missing clothing and personal items, and confirmed she did not have a key to her locked drawer. The Unit Manager confirmed these residents did not have keys to their locked drawers. Further interviews during a Resident Council meeting revealed multiple complaints about theft and missing items, including money and clothing. One resident reported money stolen during the night shift and missing socks after laundry, with no grievances filed. Another resident reported clothing theft and had to rely on family for laundry to prevent further loss. A third resident mentioned labeled clothing not returned from laundry, with no grievances filed. Additionally, a grievance filed by a resident's family regarding missing clothing and a virtual assistance device showed no resolution or inventory update, indicating a systemic issue with securing and tracking residents' belongings.
Lack of Competency Training Documentation for Nursing Staff
Penalty
Summary
The facility failed to provide evidence of competency training for its licensed nursing staff, as required by regulations. During a survey, the surveyor requested skills competency evaluations for four licensed nurses, specifically related to medication administration, oxygen administration, care of gastrostomies and administration of nutrition, tracheostomy care, wound care, and abuse prevention and reporting. However, the facility was unable to supply the requested documentation for these competencies. In an interview, the Nursing Home Administrator admitted that the facility did not have the necessary competency records for the nurses in question.
Lack of Yearly Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to provide evidence of yearly performance reviews for nurse aides. This deficiency was identified through a clinical record review and staff interviews. On August 29, 2024, an email was sent to the Nursing Home Administrator requesting documentation of these reviews. However, during an interview on August 30, 2024, the Director of Nursing confirmed that no such yearly reviews were conducted for the nurse aides.
Food Service Safety Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial tour of the Food Service Department, several deficiencies were observed. In the receiving area, trash including paper and plastic was found on the ground near the door and dumpster. The walk-in refrigerator had a dark substance on the walls and an accumulation of dirt and dust on the floor, particularly in the corners. In the hot food production area, a prep table with an undershelf was directly on the ground, pitted with rust-colored stains, and could not be cleaned without moving it. Additionally, the outsides of the convection oven and reach-in refrigerator were covered with grease and grime, and the door gaskets on the right door of the reach-in refrigerator were torn. The interior of the convection ovens had a build-up of dark-colored baked-on coating of burned food. The dish machine had a build-up of a light brownish substance in the corners of the top of the machine. These findings were confirmed by the Food Service Director during an interview.
Failure to Facilitate Resident's Medical Appointment Requests
Penalty
Summary
The facility failed to ensure that a resident was allowed to participate in decisions regarding medical appointment requests. Resident 135 expressed concerns about seeing outside physicians, which she had mentioned multiple times without receiving a response or having appointments scheduled. A review of the resident's clinical record showed that during an Interdisciplinary Team (IDT) visit on August 1, 2024, the resident expressed several concerns, including wanting vitamin D-3 supplements, a printout of her medications, a cardiologist appointment, an MRI to check leg usage, and updates on a past virus. Despite these requests being documented, an interview with the Director of Nursing revealed that the physician was aware of the requests but had not yet followed up on them.
Failure to Post State Department of Health Information
Penalty
Summary
The facility failed to ensure that the State Department of Health contact information was posted visibly in a prominent place for residents in two out of three units. During a tour conducted on August 28, 2024, with a Social Worker, it was observed that only the first floor had the State Department of Health signs posted. However, these signs were printed on paper with small print and placed high in a glass case, making them non-visible for residents who were wheelchair-bound. The second and third floors lacked any printed State Department of Health signs. This deficiency was confirmed by Social Worker Employee E14, who acknowledged the facility's failure to post the process for filing a complaint and the State Department of Health Hotline number as required by 28 Pa. Code 201.20(a) regarding resident rights.
Privacy Breach During Care Procedures
Penalty
Summary
The facility failed to maintain privacy for residents during medication administration and tracheostomy care. During medication administration for two residents, a licensed nurse left her laptop open and unattended in the hallway, exposing sensitive medical information. This occurred while the nurse was inside the residents' rooms administering medications, leaving the residents' personal health information visible to anyone passing by. Additionally, during tracheostomy care for another resident, the licensed nurse performed the procedure with the door to the resident's room left open, making the resident visible from the hallway. The facility did not have a policy in place to ensure privacy during such procedures, as confirmed by an interview with a staff member.
Inaccessible Grievance Process and Unresolved Resident Complaints
Penalty
Summary
The facility failed to ensure that grievance forms were accessible for residents wishing to file grievances anonymously, as there were no grievance boxes available on two of the three nursing floors. The grievance box on the second floor was not accessible to wheelchair-bound residents. Additionally, the facility's Resident Concern Report did not have an option for anonymous submissions. Interviews with staff revealed that residents had to obtain grievance forms from social workers or nurses, and these forms were located in an area where residents were not welcome to enter. Furthermore, the facility did not maintain a grievance log prior to June 2024, and there were missing grievance forms from January to May 2024 due to a lack of a proper filing process. Interviews with residents during a resident council meeting revealed that several residents were unaware of how to file a grievance. Residents reported unresolved grievances related to missing clothing items and stolen money, with no records of these grievances in the facility's log. One resident reported having money stolen and socks missing, while another mentioned clothing being stolen and having to rely on a family member to do laundry to prevent further losses. A third resident reported missing labeled clothing items that were not returned from the laundry. These incidents highlight the facility's failure to address and document resident grievances adequately.
Inaccurate Resident Discharge Assessment
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the resident's discharge status. Resident R141 was admitted to the facility and later discharged on June 11, 2024. Clinical documentation indicated that the resident was discharged to their home with family via medical transport, with all necessary scripts and personal belongings taken by the family, and a referral for home care services was in place. However, the discharge Minimum Data Set (MDS) completed on June 14, 2024, incorrectly stated that the resident was discharged to a short-term general hospital. This error was confirmed during an interview with the Registered Nurse Assessment Coordinator, Employee E16, who acknowledged the coding mistake.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for three residents, which is a requirement to ensure effective and person-centered care. Resident R130, who was admitted with chronic kidney disease, severe protein-calorie malnutrition, and sepsis, had a physician's order for a Foley catheter to promote sacrum wound healing. However, no baseline care plan for the urinary catheter was developed within the required timeframe. Resident R138, admitted with extradural and subdural abscess, dorsalgia, and opioid abuse, had multiple physician's orders for pain management medications, but a baseline care plan for pain management was not developed within 48 hours of admission. Resident R444, admitted with anoxic brain damage, type 2 diabetes mellitus, and a pressure ulcer, had physician's orders for wound care and tracheostomy management. Despite these needs, there was no baseline care plan developed for wound care, pressure ulcer, or skin breakdown within the required 48-hour period. The facility's policy mandates the development of a baseline care plan within 48 hours of admission, including necessary health care information and initial goals based on admission orders, but this was not adhered to for these residents.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that the care plans for three residents were updated to reflect their current care needs. Resident R31 was observed using oxygen therapy, but their care plan did not include this treatment, despite a physician's order for oxygen therapy being initiated nearly a year prior. The Director of Nursing confirmed that the care plan for oxygen therapy was marked as resolved or canceled, indicating a lack of proper updating. Resident R55, diagnosed with dementia, did not have a care plan focus addressing this condition, which was confirmed by the Director of Nursing. Resident R97's care plan included outdated instructions for a discontinued tube feeding formula, Isosource, which had been replaced by Jevity. The care plan was not revised to remove the Isosource instructions, even though the physician's orders had been updated. The Director of Nursing acknowledged that the care plan should have been revised to reflect the current orders. These deficiencies indicate a failure to maintain accurate and up-to-date care plans for residents, as required by facility policy and regulations.
Failure to Obtain Physician Orders and Notify Missed Medication Doses
Penalty
Summary
The facility failed to obtain a physician's order for tracheostomy care and suctioning for one resident, identified as Resident R97. During an observation, an employee performed tracheostomy care, including suctioning, without a documented physician's order. This was confirmed by the Director of Nursing, who acknowledged the absence of the necessary order for suctioning. Additionally, the facility did not notify the physician after another resident, identified as Resident R138, missed several doses of prescribed medication. Resident R138, who was admitted with multiple diagnoses including extradural and subdural abscess, dorsalgia, osteomyelitis of the vertebra, infective myositis, and opioid abuse, had a physician's order for Daptomycin-Sodium Chloride Intravenous Solution. However, the medication was not administered on multiple occasions due to unavailability from the pharmacy, and there was no documented evidence that the physician was informed of these missed doses. The medication administration record (MAR) for Resident R138 showed several instances where the medication was not given, coded as either 'Hold/see progress note' or 'Other/see progress notes.' Despite these codes, the progress notes did not indicate that the physician was made aware of the missed doses, highlighting a communication gap in the facility's medication management process.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to ensure that physician orders were followed regarding oxygen administration for two residents. Resident R4 was observed to have their oxygen administered at a rate of 5 liters per minute, contrary to the physician's order of 2 liters per minute. This discrepancy was identified during an observation on August 27, 2024, and was later corrected by a licensed nurse. Resident R4 had been readmitted to the facility with diagnoses including cerebral palsy, pneumonia, and asthma, which necessitated careful management of their oxygen levels. Similarly, Resident R31 was observed to have their oxygen administered at a rate of 1 liter per minute, while the physician's order specified a rate of 3 liters per minute. This error was also identified on the same day and corrected by a licensed nurse. The facility's policy on oxygen administration, dated December 4, 2023, outlines the need to verify physician orders and ensure proper oxygen flow rates, which was not adhered to in these instances.
Failure in Dialysis Communication
Penalty
Summary
The facility failed to maintain ongoing communication between the facility and a dialysis provider for three residents who required dialysis services. The facility's Dialysis Policy, dated April 1, 2022, mandates the use of a Dialysis Communication form each time a resident attends dialysis to relay pertinent information regarding the resident's condition and coordinate care with the dialysis provider. However, a review of Resident R33's clinical record revealed that there was no documented communication from the dialysis center on four specific dates. Additionally, there was no documentation from the facility nurse after the resident returned from dialysis on one occasion. An interview with a Licensed Nurse, Employee E9, confirmed these findings, acknowledging that the log sheets should be completed each time the resident goes to dialysis. The dialysis center is responsible for completing the middle section of the report, while the nurse on duty when the resident returns should complete the bottom section. This lack of documentation and communication indicates a failure to adhere to the established policy, potentially impacting the coordination of care for residents requiring dialysis.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident, identified as Resident R138, who was admitted with serious medical conditions including extradural and subdural abscess, dorsalgia, osteomyelitis of the lumbar vertebra, infective myositis of the left leg, and opioid abuse. The resident had a physician's order for Daptomycin, an intravenous antibiotic, to be administered daily for 32 days. However, the medication was not administered on multiple occasions due to unavailability, as documented in the medication administration record (MAR) and progress notes. The MAR indicated that the medication was not given on several dates, with codes indicating the need to see progress notes for further information. The progress notes revealed repeated instances where the medication was not delivered by the pharmacy, despite attempts to contact them. The notes documented that the pharmacy was informed of the issue, but the medication was still not available, leading to missed doses on multiple days. This deficiency highlights a failure in the facility's pharmaceutical services to ensure timely acquisition and administration of necessary medications for the resident.
Incomplete Drug Regimen Review Process
Penalty
Summary
The facility failed to implement a complete drug regimen review process for two residents, as identified during a review of clinical records and facility documentation, and through staff interviews. The facility's policy requires a licensed pharmacist to perform a monthly drug regimen review and report any irregularities to the attending physician, medical director, and director of nursing. However, for Resident R18, who was admitted with a diagnosis of anxiety, there was a lack of follow-up documentation after a medication regimen review was conducted on August 6, 2024. The Director of Nursing confirmed that no further documentation was available regarding the recommendations made on that date. Similarly, for Resident R35, who was admitted with diagnoses including depression and post-traumatic stress disorder, there was no follow-up documentation after a medication regimen review on July 16, 2024. The Director of Nursing also confirmed the absence of further documentation related to the recommendations made on that date. These deficiencies indicate a failure to adhere to the facility's policy and state regulations, specifically 28 Pa. Code 211.9 (k) and 28 Pa. Code 211.12 (d)(1)(3)(5), which pertain to pharmacy and nursing services.
Unqualified Food Service Director
Penalty
Summary
The facility failed to employ a qualified director of food and nutrition services, as evidenced by the findings from staff interviews and a review of employee credentials. Employee E4, the Food Service Director (FSD), was responsible for overseeing the ordering, receiving, storing, preparation, and service of food. However, during an interview, the FSD confirmed that she did not hold a certification as a Certified Dietary Manager (CDM) or Certified Food Manager (CFM), nor did she have a national certification for food service management and safety from a national certifying body. Additionally, she lacked an associate's or higher degree in food service management or hospitality from an accredited institution and had not received frequent consultations from a qualified dietitian. A review of the FSD's credentials corroborated that she did not meet the statutory qualifications required for her role. The Nursing Home Administrator, during an interview, was unable to provide evidence of the FSD's certification, confirming her lack of qualifications to direct the dietary department. This deficiency was identified under the regulations 28 Pa. Code 211.6(c)(d) Dietary services and 28 Pa Code 201.18(e)(1)(6) Management.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide food and drink that was palatable and served at the proper temperature for several residents. Interviews with residents revealed consistent complaints about the quality and temperature of the food. Resident R52 reported that the food was not always warm enough and that she was not receiving her milk. Resident R136 mentioned not receiving coffee, milk, or ice cream as listed on his meal ticket, and that the food was not always hot. Resident R77 expressed dissatisfaction with the food quality, noting that the vegetables were overcooked and mushy, and the food was not warm enough. Resident R132 also reported issues with meal temperature and portion size. Observations during a test tray conducted with the Food Service Director confirmed that the food and beverages were not at the appropriate temperatures. The chicken, potatoes, broccoli, milk, and hot tea were all below the standard temperature range, making them unpalatable. The Dietary Staff confirmed these findings, acknowledging that the hot foods and hot water were too cool. Additional interviews during a Resident Council meeting revealed further complaints about the food's palatability, with residents describing it as cold, having a bad texture, and lacking alternatives.
Failure to Ensure Residents' Capacity to Sign Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement. This deficiency was identified for three out of nine residents reviewed, including a resident with severe cognitive impairment. The facility's Admission Agreement included a Binding Arbitration Agreement, which was supposed to be explained to residents or their representatives in a manner they could understand. However, it was found that the agreements were routinely signed as part of the admission process without ensuring the residents' capacity to comprehend the terms. One resident, who was admitted with a diagnosis of stroke and dementia, had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Despite this, the resident signed the Binding Arbitration Agreement upon admission. An interview with the Nursing Home Administrator confirmed that the resident's low BIMS score should have precluded them from signing such documents, as they lacked the capacity to understand the agreement's terms.
Failure to Maintain a Safe and Sanitary Environment
Penalty
Summary
The facility failed to ensure a safe, functional, and sanitary environment on three of its nursing units. During an observation tour, it was found that the first-floor nursing unit had several issues, including a detached heating baseboard in multiple rooms, a missing baseboard behind a bed, and a strong urine odor in one room. The second-floor nursing unit had a hole in the wall above a bed in one room. The third-floor nursing unit had a missing cover for a toilet paper roll, a dirty and ripped floor mat, and a broken dresser shelf. Additionally, there were basins improperly stored on top of dressers and sinks, and a C-Pap machine was found to be dusty and unsanitary. Residents reported that their rooms were not being cleaned properly, and the housekeeping staff confirmed that basins were not being stored correctly. Interviews with the Housekeeping Director and the Director of Nursing revealed that the housekeeping staff were responsible for cleaning various parts of the rooms, but the observed deficiencies indicated that these tasks were not being performed adequately. The Housekeeping Director confirmed the presence of dust and unsanitary conditions in several rooms, while the Director of Nursing acknowledged that basins were not being stored as required. These findings highlight a failure in maintaining a clean and safe environment for residents, staff, and the public, as required by the facility's regulations.
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A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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