Crestview Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Langhorne, Pennsylvania.
- Location
- 262 Toll Gate Road, Langhorne, Pennsylvania 19047
- CMS Provider Number
- 395459
- Inspections on file
- 29
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Crestview Center during CMS and state inspections, most recent first.
A resident with chronic respiratory failure, diabetes, vascular dementia, severe cognitive impairment, dependence for bed mobility and transfers, and incontinence was assessed as at moderate risk for pressure ulcer development. The care plan included barrier cream, observation for skin breakdown, evaluation of localized skin issues, and weekly skin checks, but did not include turning and repositioning interventions. Staff skin assessments initially documented no sacral breakdown, but later identified an unstageable sacral pressure injury that rapidly worsened, with additional foot wounds noted. A nurse aide reported discovering a hole on the resident’s bottom after the resident complained of pain, and an LPN reported not seeing any wound or repositioning devices the prior shift. The DON confirmed there were no turning/repositioning interventions in the care plan and that turning and repositioning were not consistently documented, and the record lacked evidence of such interventions, culminating in an unstageable sacral wound requiring hospitalization.
A resident with a left ankle surgical wound and documented risk for skin breakdown and MDRO infection had physician orders for dressing changes every three days, with care plan interventions to provide wound care as ordered. After a surgeon noted the wound was well-healed and without infection, nursing documentation later described the left foot surgical incision as swollen, inflamed, and with scant purulent drainage. The e-TAR showed wound treatments as completed on multiple dates, but an RN admitted to signing out the dressing changes without actually performing them, stating they intended to return but became too busy. The resident reported that it had been a while since the last dressing change and recalled a prior weekend nurse as the last to perform it. The attending physician subsequently assessed the wound, initiated Cephalexin for signs and symptoms of infection, and the infection control log recorded a facility-acquired left foot wound infection. The DON confirmed that the allegation of neglect for failure to provide wound treatment per MD orders was substantiated.
A resident with a left ankle surgical wound and intact cognition had physician orders for dressing changes every three days, supported by a care plan addressing skin breakdown and MDRO risk. Despite documentation on the ETAR that wound treatments were completed on multiple occasions, an RN later admitted to signing out the treatments before performing them and then failing to return to complete the dressing changes. The resident and the resident’s daughter reported that the dressing had not been changed for some time, and staff assessment noted the left foot surgical incision was swollen, inflamed, and draining purulent fluid. The physician subsequently ordered daily wound care and Cephalexin for a wound infection, and the infection control log recorded a facility-acquired left foot wound infection.
A resident with severe cognitive impairment and multiple neurologic conditions returned from a hospital stay and had weekly skin assessments documented, along with an order for a geri sleeve to the left arm to be removed for skin checks. A family member later reported an unexplained bruise on the resident’s right inner forearm. On observation, the resident was found wearing geri sleeves on both arms, and the DON identified a fading bruise on the right inner forearm. There was no documentation of this bruise or related change in condition in the clinical record, contrary to facility policy requiring evaluation and documentation of new skin changes.
A resident's assessment included an inaccurate diagnosis of anorexia, which was likely entered for billing purposes and subsequently transcribed into the clinical record, despite the care plan indicating the resident was nutritionally stable. The DON confirmed the diagnosis was not accurate, resulting in a deficiency related to accurate clinical documentation.
A resident with cognitive impairment and behavioral health diagnoses attempted to elope multiple times, escalating in agitation as staff intervened. The care plan lacked specific de-escalation interventions, and most staff were unaware of effective strategies, resulting in inconsistent responses. Only one staff member knew how to successfully calm the resident, but this was not documented in the care plan.
Two residents were not provided with adequate supervision or required assistive devices, resulting in one resident being transferred without a sit-to-stand lift and falling, and another resident left unsupervised on the porch during a scheduled break. These incidents occurred despite established care plans and facility policies mandating specific safety measures.
On one nursing unit, multiple rooms with enhanced barrier precaution signage lacked appropriate disposal containers for PPE both inside and outside the rooms, contrary to facility policy. An LPN confirmed the absence of proper PPE disposal containers in these areas.
The facility failed to provide necessary personal hygiene services to two residents due to a malfunctioning hot water heater, resulting in cold water temperatures during peak times. Despite the issue, no adjustments were made to shower schedules, leaving residents without showers for weeks. Both residents reported not having their hair washed and feeling unclean, highlighting a deficiency in maintaining personal hygiene.
A resident with severe cognitive impairment experienced an injury of unknown origin, which was not properly assessed or reported to a physician by the LTC facility staff. Despite observations of bruising and discoloration by multiple staff members, there was no documentation or notification of the injury, leading to a deficiency in care.
The facility did not ensure residents could hold private Resident Council meetings, as required by policy. Residents were unaware they could meet without staff present, leading to discomfort in voicing concerns. The DON confirmed that staff were always present at these meetings.
The facility did not ensure a homelike environment for two residents, as their room had a hole in the wall and bed sheets used as curtains. The residents felt uncomfortable, and the Maintenance Director acknowledged the need for repairs and proper curtains.
The facility failed to provide activities that enhanced resident interactions in the community, as identified for six residents. Residents expressed their desire to resume trips they previously enjoyed, but these outings were discontinued due to issues with the facility's new van service. The DON acknowledged the residents' dissatisfaction, explaining that the new van service does not offer the same services as the previous one, making it difficult to accommodate residents, especially those in wheelchairs.
The facility failed to adhere to physician orders for oxygen therapy management for several residents, including those with COPD and Alzheimer's. Observations revealed unlabeled and undated oxygen tubing, and a dusty oxygen concentrator, indicating a lack of compliance with prescribed respiratory care protocols.
The facility failed to maintain a safe and functional environment in the 100-unit Main Shower room, which has been out of order for an extended period. Residents expressed concerns about the persistent issue, unpleasant odors, and its impact on allergies. The Maintenance Director identified a cracked floor as the cause, with temporary epoxy seals applied while awaiting corporate approval for repairs.
The facility failed to maintain an effective pest control program, with flies observed in the kitchen and resident areas. Open windows without screens, gaps in doorways, and a nearby garbage area contributed to pest entry. Pest control reports confirmed ongoing issues with mice and flies, disrupting residents during meals.
The facility failed to assess two residents' ability to self-administer medications safely. One resident with COPD self-administered an Albuterol inhaler without an interdisciplinary assessment or care plan documentation. Another resident with multiple diagnoses, including diabetes, was allowed to keep and use a topical medication without proper documentation or a physician order. Staff confirmed the lack of necessary evaluations and documentation.
A resident with severe cognitive impairment and mobility issues had their bed placed against the wall, which was not identified as a restraint by the facility. The resident's care plan did not include an assessment for this setup, despite the resident being at risk for falls and having bruises from banging extremities on the wall. An employee confirmed the bed's position, indicating a failure to comply with restraint policies.
The facility failed to develop baseline care plans within 48 hours of admission for three residents, as required for effective and person-centered care. One resident dependent on TPN, another requiring continuous oxygen therapy, and a third with communication deficits due to aphasia did not have timely care plans addressing their specific needs. Observations and clinical records confirmed the absence of these plans, highlighting a lapse in adhering to facility policy.
A facility failed to create a person-centered care plan for a resident using a midline IV catheter and antibiotics. Despite physician orders for Heparin and antibiotics like Gentamicin and Ertapenem, no care plan was documented, violating the facility's policy for comprehensive care planning.
A resident with severe cognitive impairment and mobility issues fell from bed during a bed bath due to inadequate supervision. The care plan required two staff members for assistance, but only one was present, leading to the fall. The facility's protocols, including door tag coding for assistance needs, were not followed.
A resident with multiple health conditions fell from a wheelchair while being improperly transported down a ramp by a staff member. The staff member pushed the wheelchair forward instead of backward, and the leg rests were not used, leading to the resident's fall and subsequent injuries.
A resident was found calling for help with an odor of feces in the room, and the call bell was out of reach. A nursing assistant confirmed the resident needed care and the call bell was not accessible. Previous grievances about delayed call bell responses had been addressed through staff education and audits.
The facility failed to label and date an opened container of enteral feeding formula for a resident with severe protein-calorie malnutrition and dysphagia, as required by facility policy and manufacturer's instructions. An employee confirmed the oversight during an observation.
Failure to Implement and Document Pressure Ulcer Prevention for High-Risk Resident
Penalty
Summary
The facility failed to timely identify and implement interventions to prevent the development of pressure ulcers for one resident, resulting in an unstageable sacral pressure ulcer. Facility policy on Skin Integrity and Wound Management required comprehensive initial and ongoing skin assessments, development of care plans based on assessment findings, and implementation and revision of interventions to prevent skin breakdown. The policy also required staff to identify residents at risk and implement appropriate prevention and treatment interventions. For this resident, the comprehensive care plan initiated on February 19, 2026, identified risk for skin breakdown and included interventions such as application of barrier cream, observation of skin for signs of breakdown, evaluation of localized skin issues, and weekly skin checks, but did not include turning and repositioning interventions. The resident was admitted with chronic respiratory failure with hypoxia, type 2 diabetes mellitus, and vascular dementia, and was assessed with a Braden Scale score of 13, indicating moderate risk for pressure ulcer development. The MDS showed severe cognitive impairment (BIMS score of 5), dependence on staff for bed mobility and transfers, and bladder incontinence. Nursing skin assessments from February 19 through February 24, 2026, documented no skin breakdown to the sacral area. On February 25, 2026, a skin assessment documented development of an unstageable sacral pressure injury, covered with slough and/or eschar and identified as facility-acquired. A nursing progress note on February 26, 2026, documented that the sacral wound had deteriorated, measuring 7.15 cm by 8.96 cm by 0.1 cm, with slough and eschar present, seropurulent drainage, and odor after cleansing, and additional wounds were observed on the right foot. Witness statements and interviews further described the circumstances leading up to the identification of the wound. A nurse aide reported that on February 25, 2026, during the 3:00 p.m.–11:00 p.m. shift, the resident complained of bottom pain during a bed bath; upon turning the resident, the aide and nurse observed and removed “plaster” and then saw a hole on the resident’s bottom. Another LPN reported working the night shift on February 24, 2026, and not observing any skin injury or wound, nor any turning/repositioning devices in place. The DON confirmed there were no care plan interventions addressing turning and repositioning for this resident, that the resident was on a standard pressure-redistribution mattress, and that although staff do turn and reposition residents, it is not always documented. Review of the clinical record did not show documentation or tasks/interventions indicating the resident was turned or repositioned to prevent a sacral pressure ulcer. The resident’s condition progressed to an unstageable sacral wound requiring hospitalization, with hospital records describing an open sacral wound with purulent, foul-smelling drainage and toe discoloration.
Neglect of Surgical Wound Care Leading to Wound Infection
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered wound care to a resident’s left ankle surgical wound, resulting in neglect and an infected surgical site. The resident was admitted with an orthopedic aftercare diagnosis for a left fibula fracture and had a care plan identifying risk for skin breakdown and an actual left ankle surgical wound, with interventions including providing wound care as ordered. The resident was also care planned as being at risk for MDRO colonization/infection due to wounds, with enhanced barrier precautions in place. A physician order dated in December directed that the left ankle dressing be changed every three days using Xeroform, gauze, cling, and an ace bandage. On a late-January orthopedic follow-up, the surgeon documented that the wound looked "fantastic," with no open wounds, no evidence of infection, improved swelling, and well-healed incisions, and advised to continue local wound care per the facility’s wound care team. However, by mid-February, a nursing note documented a new skin issue: the left foot surgical incision was swollen and inflamed with a scant amount of purulent drainage. A skin assessment recorded measurements of a surgical wound on the left shin and reiterated that the left foot surgical incision was swollen and inflamed with scant purulent drainage. Around this time, the resident’s daughter reported concerns to the DON and Unit Manager that the dressing on the left foot surgical wound was not being changed and that treatments were not being done as ordered, and that the foot appeared swollen and inflamed. Facility documentation showed that on the date of the daughter’s complaint, the resident still had an active order for left ankle wound treatment every three days, but the dressing in place was dated from the beginning of the month. The e-TAR reflected that treatments were documented as completed on two specific dates and as refused on another, yet the nurse assigned on the two documented treatment days admitted to signing out the dressing changes without actually performing them. The nurse stated having a habit of signing treatments out with the intention to complete them later but becoming busy and failing to return, and confirmed this occurred on both dates in question. The resident reported that it had been a while since the last dressing change and believed the last one had been done by a male nurse on a weekend. The attending physician later assessed the wound and started the resident on Cephalexin for signs and symptoms of wound infection, and the facility’s infection control log recorded a facility-acquired left foot wound infection with onset in mid-February. The DON confirmed that the allegation of neglect related to failure to provide wound treatment per physician orders was substantiated and that the resident sustained a wound infection of the left foot.
Failure to Perform Ordered Surgical Wound Care Resulting in Wound Infection
Penalty
Summary
The deficiency involves the facility’s failure to provide wound treatment in accordance with physician orders for a resident with a left fibula fracture and a left ankle surgical wound. The resident was cognitively intact and had a care plan identifying risk for skin breakdown and MDRO colonization/infection, with interventions including providing wound care as ordered and using enhanced barrier precautions. A physician order dated in December directed that the left ankle surgical wound dressing be changed every three days using Xeroform, gauze, cling, and an ace bandage. An orthopedic surgery note from late January documented that the wound looked “fantastic,” with no open wounds or evidence of infection, and instructed to continue local wound care per the facility’s wound care team. On a date in February, the resident’s daughter reported to the DON and Unit Manager that she believed the surgical wound dressing was not being changed and treatments were not being done as ordered, and that the foot appeared swollen and inflamed. A nursing note that same day documented a new skin issue: the left foot surgical incision was swollen and inflamed with scant purulent drainage. A skin assessment recorded measurements of a left shin surgical wound and again noted the left foot surgical incision as swollen and inflamed with scant purulent drainage. The following day, a nurse documented a change of condition, physician notification, initiation of Cephalexin 500 mg, and a change in the wound care order to daily dressing changes. A physician order dated that day specified daily cleansing of the left ankle surgical wound with wound cleanser, patting dry, applying Xeroform, and wrapping with Kling, and an order for Cephalexin 500 mg every six hours for seven days for a wound infection. The facility’s infection control log recorded that the resident acquired a facility-onset left foot wound infection treated with Cephalexin. The facility’s internal investigation found that on the date of the daughter’s complaint, the active order remained for dressing changes every three days, but the dressing in place was dated from the first of the month. The ETAR showed the treatment as completed on two subsequent dates and refused on another, yet the nurse assigned on those two dates admitted to signing out the dressing changes before actually performing them and then failing to return to complete the treatments. The resident reported that it had been “a while” since the last dressing change and believed the last one had been done by a male nurse on a weekend. The DON confirmed these findings, and the deficiency was cited as past non-compliance resulting in actual harm when the resident developed a left foot surgical site wound infection due to wound treatment not being completed as ordered.
Failure to Assess and Document Resident Skin Bruise
Penalty
Summary
The facility failed to ensure timely assessment, identification, and documentation of a change in skin condition for one resident. Facility policy on Skin Integrity and Wound Management required nursing assistants to observe skin daily and report changes to a nurse, and required licensed nurses to evaluate reported or suspected skin changes, document newly identified skin impairments as a change in condition, record findings on the 24-hour report, and perform and document skin inspections on all newly admitted or readmitted residents and weekly thereafter or with any significant change. The resident involved had diagnoses including brain neoplasm, epilepsy, and cortical blindness, and a recent MDS showed a BIMS score of 3, indicating severe cognitive impairment. The resident was transferred to the hospital and then readmitted; the readmission skin assessment documented no bruise on the right inner forearm. The resident’s clinical record showed weekly skin assessments and wound care treatments on multiple dates, and a physician’s order directed application of a geri sleeve to the left arm with removal for skin checks, treatment, and hygiene. During an interview, a family member reported the resident had an unexplained bruise on the right inner forearm. On observation with the DON present, the resident was noted to be wearing geri sleeves on both arms, and the DON’s skin assessment at that time identified a fading bruise on the right lower inner forearm. The DON confirmed there was no documentation in the clinical record identifying this bruise, indicating that the change in skin condition had not been assessed and documented as required by facility policy and regulatory standards.
Inaccurate Resident Diagnosis Documented in Assessment
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected resident diagnoses for one of nine residents reviewed. Specifically, a review of the clinical record for a resident revealed that the diagnosis of anorexia was added on a specific date, but the care plan, last revised several months later, only noted a potential for nutrition and hydration risk due to advanced age, with the resident currently stable nutritionally. An interview with the Director of Nursing confirmed that the anorexia diagnosis was not accurate and was likely used for billing purposes during a practitioner visit, then transcribed into the resident's list of diagnoses in the clinical record. This discrepancy was identified through observation, policy review, clinical record review, and staff interviews.
Failure to Develop and Implement Person-Centered Elopement Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan addressing elopement risk for a resident with significant cognitive impairment and behavioral health diagnoses, including autistic disorder, anxiety, traumatic brain injury, and dementia with agitation. Despite the resident's history and a low BIMS score indicating cognitive impairment, the care plan did not include specific or practicable interventions for de-escalating behaviors related to elopement. During an observed incident, the resident, wearing a wanderguard, attempted to leave the facility multiple times, triggering door alarms and escalating in agitation when staff attempted to intervene. Staff responses varied, with some attempting to physically redirect the resident and others seeking assistance, but only one staff member was aware of effective de-escalation techniques tailored to the resident's needs. Interviews confirmed that the staff assigned to supervise the resident were not informed of the appropriate interventions, which were only known to a single employee. The resident's care plan had not been updated to reflect these effective strategies, despite their demonstrated success in calming the resident during the incident. Facility policy required comprehensive, individualized care plans to be developed and revised after each assessment, but this was not followed, resulting in a lack of consistent, person-centered interventions for the resident's elopement risk and behavioral needs.
Failure to Provide Required Supervision and Safe Transfer Practices
Penalty
Summary
The facility failed to provide adequate supervision and ensure the use of required assistive devices for two residents, resulting in deficiencies related to accident prevention. One resident, with diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, and polyneuropathy, was assessed as dependent for transfers and required the assistance of two staff members using a sit-to-stand lift with a full body sling. Despite this, two nurse aides transferred the resident from a wheelchair to bed without using the required lift, as confirmed by the resident, her roommate, and facility staff. The resident reported that all three individuals fell to the floor during the transfer, and she experienced back pain as a result. The resident had requested the use of the lift multiple times, but the aides did not comply with her care plan or facility policy. In a separate incident, another resident using an electronic wheelchair exited the building to the front porch for a scheduled break without staff supervision, contrary to the facility's porch supervision schedule. The staff member assigned to monitor the porch was not present, and the resident was left unsupervised until the issue was brought to the attention of facility staff by a surveyor. The resident confirmed that supervision was typically provided by activity staff or aides, but on this occasion, no chaperone was present. These incidents demonstrate lapses in following established safety protocols and supervision requirements for residents at risk of accidents.
Failure to Provide Proper PPE Disposal for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection control techniques on the East wing, as evidenced by observations and staff interviews. Seventeen resident rooms with enhanced barrier precaution (EBP) signage did not have appropriate disposal containers available inside the rooms for the removal of personal protective equipment (PPE), as required by facility policy. Additionally, ten of these rooms also lacked appropriate disposal containers outside the rooms. A Licensed Practical Nurse confirmed the absence of proper PPE disposal containers both inside and outside the affected rooms. These findings were based on direct observation and review of facility policy, which specifies that PPE should be removed and disposed of before exiting the room, with hand hygiene performed upon exit.
Failure to Provide Adequate Personal Hygiene Due to Hot Water Issues
Penalty
Summary
The facility failed to ensure that dependent residents received necessary services to maintain personal hygiene, as evidenced by the lack of hot water for showers. On January 18, 2025, it was reported that one of the two hot water heaters was not functioning, leading to an inability to maintain comfortable water temperatures during peak demand times. Despite the restoration of one heater, the facility continued to operate with only one functional heater, which was insufficient to meet the needs of all residents. No adjustments were made to the shower schedules to accommodate the residents' needs, resulting in residents not receiving showers. Resident R1, who is cognitively intact and dependent on assistance for activities of daily living, reported not having her hair washed for two weeks due to the cold-water temperatures and not being offered a shower. Similarly, Resident R2, who requires supervision for bathing, also reported not having a shower or hair washed in a couple of weeks due to the same issue. Both residents confirmed that their shower schedules were not adjusted to accommodate the lack of hot water, leading to a deficiency in maintaining personal hygiene.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. F-0677 SS-D ADL Care Provided for Dependent Residents Hot Water Heaters were repaired and serviced on 1/31/2025. Hot water was restored. Current residents will be offered showers and the normal shower schedule will resume. The Maintenance Director or Designee will monitor Water Temperatures 5 times a week for 4 weeks to ensure water temperatures remain in acceptable ranges. NPE or designee will re-educate staff on notifying maintenance on the need to report inappropriate water temperatures and if needed to modify shower schedules based on hot water availability. DON or designee will conduct random weekly audits of shower schedules (5 residents) x 4 weeks, then monthly x 2 for residents to verify showers are given. The Maintenance Director or Designee will take water temperatures 5x per week for 4 weeks. Results of the audits will be reported at the monthly Quality Assurance Performance Improvement Meetings for review and recommendations.
Failure to Notify Physician of Resident's Injury
Penalty
Summary
The facility failed to assess, monitor, and notify the physician regarding an injury of unknown origin for a resident with severe cognitive impairment. The resident, who had a history of cerebral infarction, aphasia, vascular dementia with behavioral disturbance, and anxiety disorder, was admitted to the facility in 2016. On January 8, 2025, a nurse's aide and a therapist observed discoloration and bruising around the resident's left eye and forehead, but there was no documentation of a fall or injury in the facility records. The resident was later transferred to a local hospital for a new onset of strabismus in the left eye, where it was reported that the resident had an unwitnessed fall with a head injury. Despite the observations made by the staff, there was no documented evidence that the physician was notified of the resident's condition. The facility's policy required that changes in a resident's condition be assessed and communicated to the physician, but this was not done. Interviews with staff confirmed that the discoloration was observed, but the necessary steps to document and report the injury were not followed, leading to a deficiency in the quality of care provided to the resident.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. F-0684 SS-D QUALITY OF CARE The facility can not retroactively correct the cited deficient practice for Resident R1. Initial audit to be conducted with 7 day look back of progress notes to identify residents with injuries of unknown origin were assessed, monitored and physicians notified. NPE or designee will educate licensed nursing staff on assessing, monitoring and notifying physicians with injuries of unknown origin. DON or designee will conduct random weekly audits of progress notes (5 residents) x 4, then monthly x 2 for residents with injuries of unknown origin to ensure they are assessed, monitored and physicians notified. Results of the audits will be reported at the monthly Quality Assurance Performance Improvement Meetings for review and recommendations.
Failure to Provide Private Resident Council Meetings
Penalty
Summary
The facility failed to honor the residents' right to organize and participate in resident/family groups without interference, as required by their own policy. The policy, revised on August 7, 2023, states that the facility should promote self-governing Resident Councils and provide a private meeting space. However, during a Resident Group meeting on September 4, 2024, it was revealed that residents were not aware they could hold private meetings without facility staff present. One resident expressed that some members were uncomfortable voicing concerns with staff present, and the Resident Council President confirmed that meetings were always conducted with staff present. The Director of Nursing acknowledged that the facility was always invited to these meetings, confirming the lack of privacy for the residents.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for two residents, as observed in their shared room. During an inspection, it was noted that the room had a hole in the wall and bed sheets were being used as makeshift curtains on the windows. Both residents expressed that these conditions did not contribute to a comfortable and homelike atmosphere. An interview with the Maintenance Director confirmed the need for repairs to the wall and the replacement of the bed sheets with proper curtains.
Deficiency in Providing Community Interaction Activities
Penalty
Summary
The facility failed to provide activities that enhanced resident interactions in the community based on their preferences and interests. This deficiency was identified for six residents who attended the resident council. During a resident group meeting, residents expressed their desire to resume trips that they previously enjoyed, such as attending a Christmas play and dining at a popular restaurant. However, these outings were discontinued due to issues with the facility's new van service. The Director of Nursing acknowledged the residents' dissatisfaction and explained that the new van service does not offer the same services as the previous one, making it difficult to accommodate residents, especially those in wheelchairs. A potential alternative van service was found, but it would require residents to pay $5.00 each, which may not be affordable for them, and it could only accommodate a few residents at a time.
Failure to Adhere to Oxygen Therapy Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents dependent on oxygen therapy, as observed during a survey. Specifically, the facility did not adhere to physician orders for labeling and dating oxygen tubing for three residents with oxygen therapy needs. Resident R25, who is cognitively intact and diagnosed with respiratory failure and COPD, had an order for continuous oxygen and weekly tubing changes with labeling, which was not followed. Similarly, Resident R118, with severe cognitive impairment and Alzheimer's disease, and Resident R127, with severe cognitive impairment and COPD, also had orders for continuous oxygen and weekly tubing changes with labeling that were not adhered to. Observations revealed that the oxygen tubing for these residents was not labeled and dated as required, and Resident R118's oxygen concentrator had a visible build-up of dust. Additional observations included Resident R143, who was admitted with a diagnosis of Adult Failure to Thrive and had orders for continuous oxygen therapy with specific instructions for weaning and tubing changes. However, the oxygen tubing was not dated as per the physician's orders. Similarly, Resident R364, who had orders for continuous oxygen therapy and weekly tubing changes, also had unlabeled and undated oxygen tubing. These deficiencies were confirmed during a tour with the Director of Nursing, indicating a systemic issue in the facility's adherence to physician orders for oxygen therapy management.
Prolonged Shower Room Deficiency in 100-Unit
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents in the 100-unit Main Shower room. Observations on September 3, 2024, revealed that the shower room was out of order. During a Resident Group meeting on September 4, 2024, three residents expressed concerns about the prolonged unavailability of the shower room, with one resident mentioning that the issue had persisted for a long time and another noting that the proximity of their room to the shower room exacerbated their allergies. The residents also reported unpleasant odors emanating from the area. An interview with the Maintenance Director on September 6, 2024, revealed that the problem began in mid-December and was initially thought to be a plumbing issue, but was later identified as a cracked floor causing leaks. A proposal for repairs was submitted on January 23, 2024, but the Director was still awaiting approval from corporate headquarters. In the interim, the Director applied temporary epoxy seals, which required drying time and needed reapplication every 2-3 months.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations and reports of pest activity. During an inspection of the main kitchen, flies were observed in the dish room, food preparation areas, and the hallway leading to the kitchen. The kitchen windows were open without screens, and a large window had a torn, ill-fitting screen, allowing pests easy access. Additionally, a gap at the bottom of a doorway leading outside and another gap at the entrance lobby doors provided further entry points for pests and rodents. The garbage storage area, located near the kitchen, contained a dumpster and soiled linen containers, potentially attracting pests. The pest control operator's reports from June to August 2024 documented ongoing issues with mice and flies in the kitchen and resident rooms. Observations on the 300 nursing unit revealed flies in resident rooms, dining areas, and hallways, disrupting residents during meals. Staff confirmed the presence of flies, as they were observed swatting at them while assisting residents. The director of maintenance confirmed the pest control treatments and reports, indicating persistent pest problems in the facility.
Failure to Assess Residents' Ability to Self-Administer Medications
Penalty
Summary
The facility failed to determine if residents were safe to self-administer medications for two residents, R25 and R61. Resident R25, who is cognitively intact and has a diagnosis of respiratory failure and COPD, was observed with an Albuterol inhaler on the overbed table, which they self-administered four times per day. However, there was no interdisciplinary assessment to evaluate Resident R25's ability to safely self-administer the medication, nor was there any documentation in the care plan related to self-administration of medications. Similarly, Resident R61, who has multiple diagnoses including chronic respiratory failure and diabetes, was found with a bottle of Klayesta powder on their overbed table, which they used for open wounds. The unit manager confirmed that Resident R61 was allowed to keep the medication due to being alert and oriented, but there was no documentation or physician order related to Resident R61's self-medication. The Director of Nursing confirmed the lack of documentation and revealed that documentation regarding Resident R61's self-medication had just been initiated.
Failure to Identify Bed Placement as Restraint
Penalty
Summary
The facility failed to recognize the placement of a bed against the wall as a form of restraint and did not assess the functional status of a resident to determine the necessity of this restraint. The facility's policy on restraints, revised in December 2022, states that patients have the right to be free from physical restraints unless required for medical treatment. However, the clinical record review and observations revealed that a resident, admitted with cerebral infarction, hemiplegia, hemiparesis, and hypertension, had their bed pushed against the wall without a proper assessment or care plan addressing this setup. The resident, who had a BIMS score indicating severe cognitive impairment, was observed with their bed against the wall on multiple occasions. The care plan noted the resident's risk for falls due to cognitive loss and impaired mobility but did not include any assessment for the safety of having the bed against the wall. Additionally, the resident was seen by a medical doctor for bruising on their fingers and forearms, with progress notes indicating resistance to care and banging extremities on the wall. An employee confirmed the bed's position against the wall, further highlighting the facility's oversight in identifying and assessing the use of restraints.
Failure to Develop Timely 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 R369, who was dependent on Total Parenteral Nutrition (TPN) due to adult failure to thrive and postprocedural complications, did not have a baseline care plan addressing the management and care needs of TPN. Similarly, Resident R143, admitted with multiple diagnoses including Failure to Thrive and requiring continuous oxygen therapy, did not have a baseline care plan for respiratory care within the required timeframe. Observations confirmed that Resident R143 was on oxygen therapy, but the care plan was only initiated several days after admission. Resident R150, diagnosed with cerebral infarction and aphasia, also lacked a baseline care plan addressing communication deficits due to aphasia. The resident had unclear speech and difficulty making themselves understood, as confirmed by both clinical records and direct observation. The unit manager acknowledged the resident's communication difficulties, yet no baseline care plan was developed within the 48-hour window to address these needs. These deficiencies highlight the facility's failure to adhere to its policy of developing timely baseline care plans for new admissions, which is crucial for meeting residents' immediate needs.
Failure to Develop Care Plan for IV Antibiotic Use
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident, specifically related to the use of a midline intravenous catheter and associated antibiotic treatments. The facility's policy requires a comprehensive individualized care plan to be developed within seven days after the completion of a comprehensive assessment. However, for this resident, who was admitted with multiple diagnoses including chronic respiratory failure, UTI, and a history of MRSA, there was no care plan addressing the use of a midline intravenous catheter, heparin, and intravenous antibiotics. The resident had physician orders for the use of a midline intravenous catheter and specific intravenous medications, including Heparin Lock Flush and antibiotics such as Gentamicin and Ertapenem Sodium. These orders were in place to manage the resident's medical conditions, yet the facility did not document a care plan that included these treatments. This oversight indicates a failure to adhere to the facility's policy on developing a comprehensive care plan, which is essential for ensuring that the resident's medical, nursing, and psychosocial needs are met.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision for Resident R157, who was identified as having severe cognitive impairment and was dependent on staff for activities such as showering, bathing, and bed mobility. The resident's care plan indicated a need for total assistance from two staff members for bed mobility due to impairments in range of motion and contractures in both knees. Despite these requirements, the resident experienced a fall from the bed while receiving a bed bath, as only one staff member, nurse aide Employee E16, was present to assist. The incident occurred when Employee E16 attempted to turn Resident R157 to the left side to wash the resident's back and bottom. During this process, the resident began to fall and ultimately fell to the floor. The facility's documentation and interviews confirmed that the resident's room had a door tag coded as TA2, indicating the need for more than one person and additional equipment for turning and repositioning. However, this protocol was not followed at the time of the incident. Interviews with the Director of Nursing, Employee E2, confirmed that the resident should have been assisted by two staff members during turning and repositioning in bed. The failure to adhere to the care plan and door tag coding resulted in the resident's fall, highlighting a lapse in the facility's supervision and adherence to established protocols for safe resident handling.
Failure to Prevent Resident Fall Due to Improper Wheelchair Handling
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice to prevent accidents and falls for Resident R6. Resident R6, who was admitted with a contractured right knee, chronic pain, major depression, anxiety, morbid obesity, mild cognitive impairment, and was dependent on a wheelchair for mobility, experienced a fall while being transported by a staff member. On May 13, 2024, a staff member was pushing Resident R6 down a ramp to participate in an outdoor activity when the resident fell out of the wheelchair, resulting in bilateral abrasions to the knees and lip. The resident was subsequently transferred to the hospital and returned to the facility on the same day. The incident occurred because the staff member, identified as the Recreational Director, pushed the wheelchair forward down the ramp instead of backward, as is the recommended practice for safety. Additionally, the leg rests were not in use, which contributed to the resident's feet getting caught under the seat of the wheelchair, leading to the fall. An interview with the Director of Rehabilitation confirmed that leg rests should always be used, and wheelchairs should be positioned backward when using a ramp to ensure safety.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call bell was within reach, as required by their policy. During an observation on April 18, 2024, Resident R2 was found calling for help, stating she did not feel well and needed a nurse. An odor of feces was detected in the room, and the resident's call bell was found behind the bed, out of reach. A nursing assistant confirmed that the resident needed care and that the call bell was not accessible. The facility had documented grievances over the past three months regarding delayed responses to call bells, which had been addressed through staff education and call bell audits.
Failure to Label and Date Enteral Feeding Formula
Penalty
Summary
The facility failed to ensure that an opened container of enteral feeding formula was labeled and dated for a resident receiving enteral feeding. The facility's policy on enteral management, revised on March 1, 2022, requires that enteral feeding be provided safely and effectively, including labeling and dating opened containers of formula. Resident R1, who has multiple medical conditions including severe protein-calorie malnutrition and dysphagia, had a physician order for enteral feeding with Two Cal HN formula to be administered via syringe bolus four times daily. The manufacturer's instructions for Two Cal HN specify that the formula must be used within 48 hours once opened. During an observation on April 18, 2024, it was noted that an opened container of Two Cal HN formula was present on Resident R1's bedside table without any label or date. Employee E3 confirmed at the time of observation that the container was not labeled or dated. This failure to follow proper labeling and dating procedures for enteral feeding formula constitutes a deficiency in the facility's care practices, as outlined in the facility's policy and the manufacturer's instructions.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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