Embassy Of Hearthside
Inspection history, citations, penalties and survey trends for this long-term care facility in State College, Pennsylvania.
- Location
- 450 Waupelani Drive, State College, Pennsylvania 16801
- CMS Provider Number
- 395868
- Inspections on file
- 46
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 37
Citation history
Health deficiencies cited at Embassy Of Hearthside during CMS and state inspections, most recent first.
The facility failed to maintain sufficient dietary staffing, resulting in frequent use of Styrofoam containers for resident meals instead of regular dishware. Several residents reported that meals were sometimes or often served on Styrofoam, including all three meals in a day, and that hot meals were less hot and eating from Styrofoam made one resident feel sick. The dietary manager confirmed that Styrofoam was used at least once daily for about two weeks due to staffing shortages and continued less frequently afterward. Review of staffing schedules showed numerous unfilled morning and evening food service worker shifts that were required to meet departmental needs, and these concerns were brought to the NHA and cited under applicable state regulations.
The facility failed to maintain an adequate activity program for all residents after reducing activity department staffing, leading to frequent cancellations and days with no activities. Multiple residents reported that activities had declined, that there were times with no activities available, no alternatives if they did not like the scheduled activity, and weekends when they stayed in bed due to lack of programming. Review of activity calendars showed reduced activities, including no activities on certain Saturdays, only a single church service on some Sundays, and the elimination of evening activities compared to the prior month.
A resident with a history of refusing care and medications was physically restrained by multiple staff members, resulting in bruising and forced administration of Ativan against her will. Staff actions included holding the resident's limbs and mouth shut, with one nurse aide acting outside her scope of practice. The resident's care plan lacked recommended behavioral interventions, and the incident was not reported to the DON or authorities in a timely manner.
Surveyors found that food items in the main kitchen were stored without open or use by dates and many were not properly covered or sealed. These deficiencies were observed in dry storage, bread racks, walk-in freezer, walk-in refrigerator, and production areas, and confirmed with the dietary manager, NHA, and DON.
A resident reported being physically assaulted by another resident, including being struck and having a phone thrown at his face. The incident was reported to both an LPN and the RN in charge, but staff delayed action, telling the resident to wait for the Administrator. No investigation, interviews, or required notifications to authorities were completed, and the Administrator later confirmed the lack of action was due to no witnesses being present.
A resident suffered a leg fracture after an LPN pushed her in a wheelchair without leg rests, causing her foot to get caught. The incident was not reported immediately, and the resident experienced pain and swelling, leading to a hospital admission for surgical intervention.
The facility failed to maintain acceptable nutritional status for four residents, resulting in severe weight loss for one. A resident lost 31.6 pounds (15%) since admission without timely reassessment or intervention from a dietitian. Despite requests for additional nutritional shakes, the facility did not adjust the dietary plan or notify the physician of significant weight changes. Other residents also experienced severe weight loss with delayed assessments and inadequate follow-up.
The facility did not employ a full-time qualified director of food and nutrition services or a full-time qualified dietitian. A part-time registered dietitian worked remotely with some onsite visits during night shifts when no food service operations occurred. The full-time dietary manager lacked necessary certifications and qualifications.
The facility failed to maintain food storage and service equipment according to professional standards. Observations in the main kitchen revealed issues such as a large hole in the wall, debris on the dishwasher, and cracked tiles with pooling water. Dishwashing racks were worn, and the steam table and steamer had buildup. In the [NAME] unit's nourishment room, food items were improperly stored without labels or dates, and the microwave and refrigerator were dirty. These findings were reviewed with the Nursing Home Administrator and DON.
The facility failed to maintain a clean and safe environment, with multiple deficiencies observed across various rooms and units. Issues included an electrical outlet box on the floor, significant dirt buildup, stained privacy curtains, and damaged fixtures. These findings were reviewed with the Nursing Home Administrator and DON.
The facility failed to ensure that nursing staff had documented competencies for enteral tube feeding, catheter care, medication administration, and dressing changes. This deficiency was identified for two RNs and two LPNs, affecting residents with specific medical needs, including those with indwelling catheters, pressure ulcers, and enteral tube feedings.
The facility failed to document and address pharmacy recommendations for several residents. Pharmacy reviews were completed, and recommendations were made to physicians, but there was no evidence of the pharmacist's report or physician's response. This deficiency was confirmed by the Nursing Home Administrator and DON, indicating non-compliance with pharmacy and nursing service regulations.
The facility failed to implement appropriate enhanced barrier precautions for three residents and did not ensure an environment free from potential infection spread due to improper storage of equipment and supplies. Observations revealed unsanitary conditions in residents' bathrooms, the nourishment room, and the laundry area. Residents with wounds, nephrostomy tubes, and Foley catheters were not initially placed on EBP, lacking necessary signage and PPE. These deficiencies were reviewed with the Nursing Home Administrator and Director of Nursing.
A resident was observed with Fluticasone nasal spray on their bedside table, used for allergies, without a physician's order or facility assessment allowing self-administration. The facility did not document the resident's ability to safely self-administer the medication, as required.
A facility failed to establish clear advance directives for a resident, as there were no physician orders or care plans related to the resident's code status. A POLST form indicating DNR status was signed by the resident's responsible party but not by a medical provider. A second POLST form was later provided, signed by the medical provider but not by the resident or their responsible party, indicating confusion and improper documentation.
A facility failed to maintain a resident's ability to eat independently, as documented in MDS assessments. Initially requiring supervision, the resident later needed extensive assistance, with no documented assessment of this decline. The resident also experienced significant weight loss, and Speech Therapy was delayed. The facility lacked documentation of measures to address the decline.
The facility failed to implement physician orders for two residents, leading to deficiencies in care. One resident with a G-tube did not receive necessary water flushes due to a documentation error, while another resident did not have prescribed arm slings available for edema management. These issues were confirmed by the Nursing Home Administrator and Director of Nursing.
A resident with a pressure ulcer on the left foot was found to have neglected foot care, with yellow, thick, and curling toenails and peeling skin. Despite requesting podiatry services three times, the resident had not been scheduled for care due to their initial short-term status. The facility failed to offer or coordinate podiatry services until the resident's status changed to long-term.
The facility failed to maintain or improve the range of motion (ROM) for two residents, leading to deficiencies in their care. One resident, after exhausting therapy benefits, did not receive continued care to maintain ROM, and another resident, despite having a home exercise program, experienced a decline in condition due to lack of a restorative program. Staffing shortages were cited as a reason for not recommending restorative programs.
A facility failed to provide necessary emergency supplies for a resident receiving hemodialysis, who was at risk for bleeding due to anticoagulant medication. The resident, who attended dialysis outside the facility, did not have essential items like sterile gauze or a hemostat in her room, despite having a central line. The deficiency was identified during an observation and interview, and confirmed with facility management.
A facility failed to create and implement an individualized care plan for a resident with dementia. Despite the resident's diagnosis and assessment indicating the need for such a plan, the care plan lacked a personalized approach to address cognitive loss. This deficiency was confirmed with the facility's administration.
A resident experienced a significant delay in receiving medically related social services after the death of her spouse, leading to ongoing depressive symptoms and a decline in condition. Despite expressing feelings of sadness and a lack of appetite, the facility did not provide timely interventions or psychological support, as confirmed by the Nursing Home Administrator.
The facility did not ensure that nurse aides received the required 12 hours of annual in-service training. For two nurse aides, there was either no documented evidence of training completion or insufficient documentation to confirm the training was conducted, leading to a deficiency under personnel policies and procedures.
The facility did not notify the DOH about a dry sprinkler system failure that compromised safety. The issue was known before a repair quote was received, but it was not addressed, leading to a fire alarm activation. The Maintenance Manager confirmed the system was not repaired, although it was functional with a temporary air compressor.
A resident experienced severe health issues, including coughing episodes and unresponsiveness, but the RN failed to complete timely documentation and notify the physician as required. The RN documented the events the following day, despite prior issues with documentation duties.
The facility failed to obtain required Dermatology panel tests for Sarcoptes scabiei for five residents, despite physician orders. The contracted lab did not perform the tests, and the facility did not identify the omission until 14 days later.
The facility failed to maintain complete and accurate ADL documentation for five residents due to a recent switch to a new documentation system. The corporate office removed all portable electronic devices, leaving staff without the necessary tools to document care, resulting in missing records for various aspects of resident care.
The facility failed to obtain timely Pennsylvania State Police background checks and FBI background checks for newly hired employees, as well as ensure completion of abuse training. Employees 3, 4, 5, and 6 had significant delays and omissions in their personnel files, including missing attestations of Pennsylvania residency and incomplete criminal record checks.
The facility failed to identify triggers related to PTSD for two residents, leading to a deficiency in providing culturally competent, trauma-informed care. Clinical records and assessments confirmed PTSD as an active diagnosis, but care plans lacked identification of re-traumatization triggers. The Director of Nursing confirmed these findings.
The facility failed to store food items safely, maintain sanitary equipment, and record food temperatures as per policy. Observations included undated food items, dust and debris on equipment, and missing temperature logs. The Dietary Manager confirmed the deficiencies.
The facility failed to implement appropriate enhanced barrier precautions (EBP) for five residents with chronic wounds or indwelling medical devices. Observations and staff interviews confirmed the absence of EBP for these residents, despite the facility acknowledging the need for such precautions.
The facility failed to ensure resident and/or responsible party participation in comprehensive care plans for two residents. Both residents reported not being invited to participate in their care plan meetings, and their clinical records contained undated invitations without contact information. The facility did not take steps to identify and eliminate barriers to their participation.
The facility failed to provide the highest practicable care for a resident with a fluid restriction and another with a diabetic foot ulcer. The fluid restriction was not properly documented or monitored, and the wound care treatments were inconsistently administered, leading to lapses in care.
A resident with highly impaired hearing did not receive necessary audiology services despite being promised a visit from a hearing doctor. The care plan did not include the use of a hearing aid, and there was no follow-up on the audiology services that were supposed to be provided. Facility staff were unaware of the status of the resident's hearing aid, and her medical record did not incorporate its use into her plan of care.
The facility failed to implement timely and appropriate treatment for a resident's pressure ulcer, leading to the wound worsening and the resident's hospitalization with severe sepsis and osteomyelitis. Despite requests for an air mattress and prescribed treatments, the facility did not provide adequate care, resulting in the resident's death.
The facility failed to implement effective fall prevention interventions for two residents, resulting in repeated falls and injuries. One resident did not have the required bilateral fall mats, and another experienced multiple falls due to inadequate and inconsistently applied interventions.
The facility failed to administer supplemental oxygen as prescribed for two residents. One resident received 2.5 l/m instead of the prescribed 3 l/m, and another received 3.5 l/m instead of the prescribed 2 l/m. These discrepancies were confirmed by staff interviews.
The facility failed to assess the entrapment risk of assist bar use for two residents, leading to potential safety hazards. Maintenance evaluations only considered limited zones of entrapment risk, neglecting other potential areas. These findings were confirmed during staff interviews.
The facility failed to provide necessary behavioral health care for a resident with a history of alcohol abuse and psychotic disorder. Despite an initial psychiatric evaluation recommending follow-up, no further services were provided, leading to continued disruptive and aggressive behaviors. Interviews revealed that the facility had a new behavioral management contract, but it was unclear if the resident received any services.
The facility failed to develop and implement individualized person-centered care plans for a resident with dementia. Despite the assessment indicating the need for such a plan, no documentation was found to support its development or implementation, as confirmed by the DON.
The facility failed to ensure that the consultant pharmacist reported irregularities to the attending physician and that the physician appropriately responded for two residents. For one resident, the CRNP declined a medication reduction recommendation without evidence of a previous failed attempt, and there was no documentation of the pharmacist's recommendations being forwarded. For another resident, pharmacy recommendations were not available in the clinical record, and the Director of Nursing could not locate them.
The facility failed to ensure that two residents' medication regimes were free from potentially unnecessary medications. One resident was prescribed Trazodone without a diagnosis of insomnia and without attempts at gradual dose reduction. Another resident had their Risperdal dose increased based on a single episode of yelling, without addressing other potential causes for the behavior.
The facility failed to maintain a medication error rate below five percent, resulting in a 7.89 percent error rate. An LPN administered medications to two residents without following the instructions to give the medications with food, as required. Both residents were unable to be interviewed due to cognitive status, and no breakfast trays were present during the medication pass.
A resident's medications were found unsecured on an overbed table, leading to a deficiency. The resident accidentally knocked over the medication cup, spilling the pills. The LPN was unaware the medications were still in the cup. The facility's failure to secure the medications was noted as a deficiency.
The facility failed to provide adequate dental care services for two residents. One resident had not received any dental services since admission, despite having significant dental issues and consenting to services. Another resident received only preventative services and did not receive scheduled comprehensive dental care, despite complaints of pain.
The facility's arbitration agreement failed to ensure a neutral and fair arbitration process for a resident. The agreement did not allow for a choice of venue convenient to both parties and designated an entity to conduct the arbitration, rather than allowing for the selection of a neutral arbitrator. This was confirmed during an interview with the Director of Clinical Services.
Insufficient Dietary Staffing Leading to Frequent Use of Styrofoam for Meal Service
Penalty
Summary
The facility failed to provide sufficient staff in the food and nutrition services department, resulting in frequent use of Styrofoam containers for resident meals instead of regular dishware. Multiple residents reported that meals were sometimes or often served on Styrofoam, including for all three meals in a day. One resident stated that food on Styrofoam gets cold quickly, another reported that hot meals were less hot and that this occurred about once a week, and another resident stated that eating off Styrofoam made her feel sick and that she did not like Styrofoam. These resident interviews indicated an ongoing pattern of Styrofoam use for meal service. The dietary manager reported that beginning on December 19, 2025, and lasting for approximately two weeks, Styrofoam was used at least once a day due to frequent staffing shortages in the department, and that it continued to occur less frequently afterward. Review of the food service staff schedule from November 30, 2025, to February 1, 2026, showed numerous open morning and evening food service worker positions on multiple days, indicating that scheduled staffing levels were not met. These open positions were identified as required to meet the needs of the department. The concerns regarding the use of Styrofoam due to insufficient staffing were reviewed with the Nursing Home Administrator, and the deficiency was cited under 28 Pa. Code 201.14(a) Responsibility of licensee and 28 Pa. Code 201.18(b)(3) Management.
Failure to Maintain Adequate Activity Program for All Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the individual needs and interests of all residents, as evidenced by resident interviews and review of activity calendars. One resident reported that activities were often cancelled due to there being only two activity staff, resulting in days with no activities at all. Another resident stated that activities had declined in quality, that there were not always activities to attend, and that there were no alternative options if they did not like the scheduled activity. A third resident reported that activities had been cancelled and that there were now days without any activities, which bothered them. A fourth resident stated they stayed in bed over a recent weekend because there were no activities to attend and expressed that they liked having something to do on weekends. Review of the facility’s activity calendars for December 2025 and January 2026 showed that in January there were no activities scheduled on the first, third, and fifth Saturdays, and the corresponding Sundays listed only a single church service. Further review showed a reduction in the number of activities available in January compared to December, including the removal of evening activities during January. In an interview, the Nursing Home Administrator confirmed that the activity department had recently undergone staffing reductions, which caused the decrease in available activities. These findings were reviewed with the Nursing Home Administrator and the Director of Nursing, and the deficiency was cited under 28 Pa. Code 201.29(a) related to resident rights.
Failure to Prevent Physical Abuse and Forced Medication Administration
Penalty
Summary
A resident with a history of refusing care and medications, as well as exhibiting physical and verbal aggression toward staff, was found to have multiple bruises on her left upper arm. The bruises were discovered after the resident's son reported them to an LPN, who observed three oddly shaped bruises but was unable to measure them due to the resident's refusal. The incident that led to the bruises occurred when staff attempted to administer Ativan to the resident, who resisted and knocked the medication out of the nurse's hand. Multiple staff members were involved in restraining the resident, with one nurse aide placing the pills in the resident's mouth and holding her mouth closed until the medication dissolved, while others held her limbs during the process. Interviews with staff revealed that the nurse aide used excessive physical force, including grabbing the resident's arms and holding her mouth shut, which resulted in the bruising. Staff accounts also indicated that the resident was physically aggressive during the incident, striking and scratching staff members, but the response from staff involved actions outside their scope of practice and the use of physical restraint to administer medication against the resident's will. The nurse aide involved was later heard stating that she made the resident take the pills because she had been scratched. The facility's investigation found that the care plan for the resident did not include specific behavioral interventions suggested by the resident's son, despite her known history of non-compliance and aggressive behaviors. The incident was not reported to the Director of Nursing or other appropriate authorities in a timely manner, as the DON only became aware of the situation two days after it occurred, following the discovery of the bruises. The failure to implement appropriate care plan interventions, prevent physical abuse, and ensure timely reporting contributed to the deficiency.
Failure to Store Food According to Professional Standards
Penalty
Summary
Surveyors observed that the facility failed to store food in accordance with professional standards in the main kitchen. During an inspection, multiple food items in the dry storage area, bread racks, walk-in freezer, walk-in refrigerator, and production area were found opened without any open or use by dates. Additionally, several items such as mixed vegetables, mushrooms, lemons, and oranges were not covered or sealed. These findings were confirmed during an observation with the dietary manager and later reviewed with the Nursing Home Administrator and Director of Nursing. No information about specific residents or their medical conditions was included in the report.
Failure to Investigate and Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate and report an allegation of resident-to-resident physical abuse as required by its own policies and state regulations. A resident reported that another resident entered his room, rummaged through his belongings, physically struck him, and threw his cell phone, causing it to hit him in the face. The resident immediately informed both a licensed practical nurse and the registered nurse in charge, expressing a desire for the police to be called. Despite this, staff told the resident to wait until the Administrator could conduct her own investigation, and no investigation or interviews were conducted with the resident or other involved parties. Text message correspondence between the resident and the Nursing Home Administrator confirmed that, weeks after the incident, no one had spoken to the resident about the event. Interviews with the Administrator, assistant director of nursing, and social services staff confirmed that the facility did not investigate, obtain witness statements, or notify law enforcement or the Department of Health regarding the allegation. The Administrator stated that the lack of witnesses was the reason for not investigating or reporting the incident, which is contrary to facility policy and regulatory requirements.
Neglect Leads to Resident's Leg Fracture
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in a fracture of her right leg. The incident occurred when a licensed practical nurse (LPN) pushed the resident in a wheelchair without leg rests, causing her right foot to get caught under the wheelchair. This led to the resident experiencing pain and swelling in her right knee, which was later diagnosed as a fracture of the right femur. The resident was subsequently admitted to the hospital for surgical intervention. The LPN did not report the incident or the resident's change in condition immediately. The resident expressed pain and refused to get out of bed in the days following the incident, prompting a medical provider to be contacted. The LPN's involvement in the injury was only revealed during the facility's investigation, which took place several days after the incident. The lack of immediate reporting and failure to use leg rests contributed to the neglect and subsequent injury of the resident.
Failure to Maintain Nutritional Status Leads to Severe Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for four residents, leading to severe weight loss in one resident. Resident 81 experienced a significant weight loss of 31.6 pounds (15 percent) since admission, with no timely reassessment or intervention from a dietitian. Despite the resident's request for additional nutritional shakes, the facility did not adjust the resident's dietary plan or notify the physician of the significant weight changes. Resident 49 experienced a severe weight loss of 13.2 pounds (10.9 percent) over two months, with no intervention from a nutrition professional until three months later. The resident's provider or responsible party was not informed of the significant change in nutritional status. Similarly, Resident 105 experienced a severe weight loss of 26.7 pounds (15.4 percent) in one month, with delayed assessment by a dietitian and inadequate follow-up on weight monitoring. Resident 108 also experienced a severe weight loss of 13.2 pounds (9.4 percent) in one month, with no timely intervention from a dietitian or notification to the physician. The resident's weight stabilized eventually, but there was a lack of consistent dietary assessment and monitoring. The facility's failure to provide timely assessments and interventions from qualified nutrition professionals resulted in harm to the residents, as evidenced by the severe weight loss and lack of communication with medical providers.
Deficiency in Food and Nutrition Services Staffing
Penalty
Summary
The facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian. During an interview, the Administrator revealed that the facility was using a registered dietitian on a part-time basis, who primarily worked remotely with some onsite visits. However, these visits occurred during the night shift when no food service operations were taking place, and residents were likely sleeping. The facility employed a full-time dietary manager, but the Administrator was unsure of this employee's qualifications. A follow-up interview confirmed that the dietary manager was not a certified dietary manager, certified food service manager, did not have a national certification for food service management and safety, and did not hold a degree in food service management.
Deficiencies in Food Storage and Equipment Maintenance
Penalty
Summary
The facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety. During an observation in the main kitchen, several issues were identified, including a large hole in the wall, dried food splatter on ceiling tiles, and debris on the dishwasher. The dish room had cracked tiles with pooling water and food particles, and the dishwashing racks were worn and broken. Additionally, the steam table and steamer had brown buildup and water dripping onto clean dishes. The stove, plate warming unit, and tilt kettle were also found to be dirty and stained. Further observations revealed that the utensil rack above the cook's table exposed food contact surfaces to airborne particles, and the spatulas were stained. Cake pans had burnt-on buildup, and a garbage can was without a lid. Knife racks and shelves were dusty and dirty, and a portable air conditioning unit was covered in debris. Inside a cooler, containers with diced carrots and hot dogs were found with unclear expiration dates, and a food slicer was dirty. Resident meal service trays and cups were cracked, stained, and contained buildup. In the [NAME] nursing unit's nourishment room, multiple beverage cups and bowls of cereal were improperly stored without labels or dates. The microwave was rusted and had food splatter, and the countertop was stained and broken. The refrigerator was packed with food items without labels or dates, and the freezer contained uncovered items. The ice machine had a loose cover, and the dry storage area had dusty fans. These findings were reviewed with the Nursing Home Administrator and Director of Nursing.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations across various rooms and units. In Resident 64's room, an electrical outlet box was found lying on the floor with wires extending into a conduit hanging off the wall, and an oxygen concentrator was plugged into this outlet. Additionally, there was a significant buildup of dirt along the baseboard heater. Resident 8's room had marring on the wall behind the bed, and Resident 81's shared bathroom was found with staining, dirty caulking, and a screw preventing a cabinet door from opening. The bathroom also had a missing wall tile and an overflowing garbage can. Further observations revealed that Resident 15's room had privacy curtains with significant staining and brown smears. The [NAME] unit hallway and nourishment room were also in disrepair, with marred walls, dirty floors, rusted and chipped cabinets, and a broken countertop. The nourishment room had a light fixture hanging upside down with exposed wires, and the garbage can was soiled with dried substances. The Nittany Nursing Unit had dust buildup on vents, damaged ceiling areas, and an ice machine covered with a stained cloth pad. Additional deficiencies were noted in Resident 100's room, which had dirt and peeling paint, and Resident 43's room, which had dirt and smeared curtains. Resident 54's room had loose dirt and a tissue with a brown substance on the floor. Resident 82's room had soiled privacy curtains and black buildup on the floor, while Resident 91's room had discolored curtains and a dusty AC filter. These findings were reviewed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to provide adequate housekeeping and maintenance services.
Lack of Documented Nursing Competencies
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets necessary for the care and assessment of residents with specific medical needs. This deficiency was identified through a review of facility documentation and staff interviews, which revealed that the facility could not provide evidence of competencies for four employees, including two registered nurses and two licensed practical nurses. These competencies were related to enteral tube feeding, catheter care, medication administration, and dressing changes. The facility had a total of 118 residents receiving medications, eight residents with indwelling catheters, seven residents with pressure ulcers, and three residents with enteral tube feedings. The lack of documented competencies for these employees was confirmed during an interview with the Nursing Home Administrator and Director of Nursing.
Failure to Document and Address Pharmacy Recommendations
Penalty
Summary
The facility failed to maintain proper documentation and follow-up on pharmacy recommendations for five residents. Clinical record reviews revealed that pharmacy notes indicated completed reviews and recommendations made to physicians for Residents 8, 16, 101, and 108 on various dates. However, there was no evidence of the pharmacist's report of recommendations or a physician's response to these recommendations for the specified dates. This lack of documentation and follow-up was confirmed during an interview with the Nursing Home Administrator and Director of Nursing. The deficiency was identified under the regulation 483.45(c)(4) Pharmacy review, which had been previously cited on April 26, 2024. The facility's failure to maintain pharmacy recommendations or evidence of physician responses indicates a lapse in the required pharmacy services and nursing services as per the 28 Pa. Code 211.9 (d)(k) and 28 Pa. Code 211.12(d)(3)(5). This deficiency highlights the facility's non-compliance with established guidelines for drug regimen reviews and the necessary communication between pharmacists and physicians.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to implement appropriate enhanced barrier precautions (EBP) for three residents and did not ensure an environment free from potential infection spread due to improper storage of resident equipment and supplies. Observations revealed that raised toilet seats were placed directly on the floor in residents' bathrooms, and the nourishment room contained a rusted cabinet with various items, including protective gowns and personal hygiene items, stored in unsanitary conditions. Additionally, the facility's laundry area was found to have linens stacked directly on the ground, a broken window, and significant dust and debris accumulation, indicating poor infection control practices. Resident 72, who had wounds on the lower extremities and a history of MRSA, was not on EBP as required, with no PPE or signage indicating precautions in place. Similarly, Resident 40, with a nephrostomy tube, and Resident 325, with a Foley catheter, were not initially placed on EBP, lacking necessary signage and PPE. These residents' care plans included EBP interventions, but there was no evidence of implementation until after the survey observations. The facility's failure to adhere to infection prevention protocols was further highlighted by the condition of the laundry area, where linens were exposed to the environment, and equipment was covered in dust and debris. These deficiencies were reviewed with the Nursing Home Administrator and Director of Nursing, indicating a systemic issue in maintaining infection control standards across the facility.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to ensure that a resident's ability to self-administer medications was determined. During an observation, a resident was found in bed with Fluticasone nasal spray on the bedside table, which the resident used for allergies. A physician's order dated February 22, 2025, prescribed the nasal spray for allergic rhinitis, but there was no order or documentation indicating that the resident was assessed and approved to self-administer the medication. This deficiency was discussed with the Nursing Home Administrator and Director of Nursing.
Failure to Establish Clear Advance Directives for a Resident
Penalty
Summary
The facility failed to establish clear advance directives for a resident, identified as Resident 323. Upon review, it was found that there were no current physician orders or care plans related to the resident's code status, which indicates instructions for healthcare personnel in case of cardiac or respiratory arrest. A POLST form, which should direct medical staff on life-sustaining treatment, was located in the POLST binder but was only signed by the resident's responsible party and not by a medical provider, indicating a DNR status. This discrepancy was confirmed by a licensed practical nurse. Subsequently, a second POLST form was provided by the facility, signed by the medical provider but not by the resident or their responsible party, suggesting confusion and lack of proper documentation regarding the resident's advance directives.
Failure to Address Decline in Resident's Eating Ability
Penalty
Summary
The facility failed to maintain or improve a resident's ability to perform activities of daily living, specifically eating, without a documented medical reason for the decline. A clinical record review for a resident revealed that an MDS assessment initially indicated the resident required supervision with setup help only for eating. However, a subsequent MDS assessment showed the resident required extensive assistance from one staff member for eating. There was no documented evidence that the facility identified or assessed the resident's decline in eating ability. Additionally, the resident experienced a significant weight loss of 27.10 pounds, equating to a 15.65 percent severe weight loss over three months. Speech Therapy did not assess the resident until several months after the decline began. The facility was unable to provide documentation of any measures taken to address the resident's decline in eating ability.
Failure to Implement Physician Orders for Residents
Penalty
Summary
The facility failed to implement physician orders for two residents, leading to deficiencies in care. Resident 115, who was admitted with a gastrostomy tube (G-tube), reported that the tube had not been flushed since feedings were stopped, despite having an active physician's order for water flushes. The clinical record review confirmed that the order for water flushes was not documented in the resident's medication or treatment administration records, resulting in the resident not receiving the necessary flushes to maintain the tube's patency. Resident 104 had a physician's order for the use of arm slings to manage edema by keeping the arms elevated. However, during an interview, the resident reported not having a sling available in the room. The treatment administration record indicated that the sling was documented as applied on several dates, but there were notes indicating the sling was awaited on other dates. This discrepancy suggests a miscommunication between nursing staff and the physician, leading to the resident not receiving the prescribed treatment. The deficiencies were reviewed with the Nursing Home Administrator and Director of Nursing, who confirmed the issues with the orders for both residents. The failure to implement these physician orders resulted in a lack of appropriate care for the residents, as evidenced by the absence of necessary treatments and interventions.
Failure to Provide Proper Foot Care
Penalty
Summary
The facility failed to provide proper foot care for a resident, identified as Resident 81, who was observed with yellow, extremely thick toenails on the left foot during a pressure ulcer dressing change. The toenails were described as being one-half inch in depth, raised, and curling upward with a fungal appearance, while the skin on the toes was scaled and peeling. The resident reported having requested to see a podiatrist three times without success. The Director of Nursing explained that the resident was not scheduled for routine podiatry services because they were initially considered short-term, and only long-term residents were added for such services. The resident had recently changed to long-term status, which would now allow them to be added for routine services. A nursing note indicated that the resident's family wanted to schedule the podiatry appointment themselves to ensure transportation. However, there was no evidence that the facility offered or assisted in coordinating podiatry services prior to this note.
Failure to Maintain Residents' Range of Motion
Penalty
Summary
The facility failed to provide necessary services to maintain or improve the range of motion (ROM) for two residents, leading to deficiencies in their care. Resident 101, admitted in November 2023, was assessed with impaired ROM in his bilateral lower extremities. After exhausting his therapy benefits, Resident 101 was discharged from physical therapy in January 2025 with a positive response to passive techniques and a good prognosis for maintaining his function with staff assistance. However, there was no documentation of continued care from staff to maintain his ROM post-therapy. The physical therapist did not recommend a restorative nursing program due to reported staffing shortages, which contributed to the lack of follow-up care. Similarly, Resident 25, admitted in March 2019, was discharged from physical therapy in September 2024 with a home exercise program and an excellent prognosis with consistent staff support. Despite this, no restorative program was established, and the resident reported a decline in her condition, specifically in her left knee, since discontinuing therapy. The physical therapist again cited staffing shortages as the reason for not recommending a restorative program. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed these findings, indicating a failure to prevent further decline in the residents' ROM.
Failure to Provide Emergency Supplies for Dialysis Resident
Penalty
Summary
The facility failed to ensure the availability of necessary emergency supplies for a resident receiving hemodialysis. During an interview and observation, it was noted that the resident, who attended dialysis outside the facility three times a week, did not have any emergency supplies in her room. This included essential items such as sterile gauze, a hemostat, a needleless connector, or tape, which are crucial for managing potential bleeding from the resident's central line. The resident confirmed that she had an emergency kit at home but had not received one since her admission to the facility. The clinical record review revealed that the resident had a left chest tunnel catheter for dialysis and was at risk for bleeding due to anticoagulant medication. The care plan indicated that in the event of bleeding, pressure should be applied, and emergency services contacted if necessary. Despite these risks, the facility did not provide the necessary emergency supplies until after the deficiency was identified. This oversight was confirmed during a review with the Nursing Home Administrator and Director of Nursing.
Failure to Implement Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia. The clinical record review revealed that the resident was admitted with a diagnosis of dementia, which affects memory, language, problem-solving, and other cognitive abilities. Despite the facility's assessment indicating the need for a care plan to address dementia and cognitive loss, the review of the resident's care plan showed no evidence of an individualized approach to meet these needs. This deficiency was confirmed during a review with the Nursing Home Administrator and Director of Nursing.
Failure to Provide Timely Social Services for Grieving Resident
Penalty
Summary
The facility failed to provide medically related social services to a resident who was grieving the loss of her spouse. The clinical record review revealed that the resident was informed of her husband's death and exhibited signs of depression, such as crying and a lack of appetite. Despite these indicators, there was a significant delay in the provision of social services, with no documented interventions for 11 days following the notification of her spouse's death. During this period, the resident expressed feelings of sadness and a desire to die, although she later clarified that she did not want to die but was not feeling well. Interviews with the resident and her family indicated ongoing depressive symptoms and a decline in her condition, with family members expressing concern that she was giving up due to her grief. The facility's failure to provide timely and adequate social services support during the grieving process was acknowledged by the Nursing Home Administrator, who confirmed the lack of evidence for interventions to support the resident's emotional needs and offer psychological services. This deficiency highlights the facility's inability to meet the resident's needs during a critical time of emotional distress.
Failure to Ensure Required In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of in-service training annually, as mandated by regulations. During a meeting with the Nursing Home Administrator and Director of Nursing, the surveyor requested training records for two nurse aides, Employees 16 and 17. It was confirmed through an interview with the Director of Nursing that there was no documented evidence of Employee 16 receiving the necessary training hours in the past year. Although Employee 17's records indicated completion of 27.5 hours of training, the documentation only showed that a packet of information was given to Employee 17 for review, with no further evidence of actual training completion. This lack of proper documentation and assurance of training completion led to the deficiency. The deficiency was identified under 28 Pa. Code 201.19 (7) concerning personnel policies and procedures, highlighting the facility's failure to comply with the required in-service training for nurse aides.
Failure to Report Sprinkler System Failure to DOH
Penalty
Summary
The facility failed to notify the Department of Health (DOH) about an event that compromised quality assurance and patient safety. The issue involved the dry sprinkler system, which serves the entire facility. The problem was known before a repair quote was received on December 24, 2024, but the facility did not address the issue identified in the quote. This inaction led to the failure of the dry sprinkler system on January 27, 2025, which caused a fire alarm activation. As of February 6, 2025, these events had not been reported to the DOH. During an exit conference on February 5, 2025, the Maintenance Manager confirmed that the cause of the dry sprinkler system failure had not been repaired at the time of the survey. Although the dry system was operational with the use of a temporary air compressor, the failure to report the incident to the DOH was a significant oversight. This deficiency was noted under the NFPA 101 General Requirements, specifically referencing Title 28, Health and Safety, Part IV. Health Facilities § 51.3. Notification. (e)(f).
Plan Of Correction
The facility had identified an issue with the dry system prior to this event. Staff have been educated on events that need to be reported to the department of health and will do so in a timely manner. Two vendor quotes were obtained for the repairs. The dry system was functioning fully until the permanent repairs can be completed. The vendor is scheduled to be onsite March 3, 2025, to complete the permanent repairs to the dry system.
Failure to Ensure Timely and Accurate Documentation
Penalty
Summary
The facility failed to ensure complete and accurate clinical documentation for a resident who was admitted on June 12, 2024. On November 12, 2024, the resident experienced a series of health issues, including a mild coughing episode during lunch, a significant drop in oxygen saturation, and a severe coughing episode during dinner, which led to unresponsiveness and eventually cessation of breathing. Despite these critical events, the registered nurse did not complete the required Change in Condition Tool, and there was no documentation that the resident's physician was notified, although the CRNP later indicated that she was informed and had given instructions for monitoring and further actions. The registered nurse, identified as Employee 1, did not document her assessments and actions until the following day, November 13, 2024. Her documentation noted that she was informed of the resident's condition changes and had instructed the application of oxygen. However, her records were not completed in a timely manner, as expected by the facility's policy. Employee 1 had a prior record of failing to complete documentation and communication duties, as noted in her personnel file. The facility's administration confirmed these findings and acknowledged the expectation for timely documentation to ensure continuity of care.
Failure to Obtain Required Dermatology Panel Tests
Penalty
Summary
The facility failed to obtain laboratory work as ordered by the physician for five residents. A review of clinical records and staff interviews revealed that the facility's contracted laboratory did not perform the required Dermatology panel tests for Sarcoptes scabiei, which were ordered by a physician for five residents. Specifically, Resident 1 had a continuing itchy rash with raised areas, and a Dermatology panel was ordered on October 29, 2024. However, the results received on October 30, 2024, did not include testing for Sarcoptes scabiei. Similarly, Residents 3, 4, 6, and 7 also had orders for a Dermatology panel on the same date, but their results lacked the Sarcoptes scabiei test. The facility did not identify this omission until it was pointed out by the surveyor on November 13, 2024, indicating a lapse of 14 days without the required testing being completed.
Incomplete ADL Documentation Due to System Change
Penalty
Summary
The facility failed to ensure complete and accurate clinical documentation for five residents, as identified through clinical record reviews and staff interviews. The deficiency involved the lack of consistent documentation on the ADL Task Documentation forms, which are used to record residents' self-performance and staff support needed for activities of daily living. The missing documentation pertained to various aspects of care, including bed mobility, transfers, skin care, eating assistance, continence status and care, and resident behaviors. This issue was observed across multiple dates for each of the five residents reviewed. During an interview with the Nursing Home Administrator and the Director of Nursing (DON), it was confirmed that the residents did receive care, but the staff failed to document it properly. The DON explained that the facility had recently switched to a new ADL documentation system, and the corporate office had removed all portable electronic devices without providing replacements. This lack of electronic devices hindered the nurse aide staff's ability to document care effectively.
Failure to Obtain Timely Background Checks and Abuse Training
Penalty
Summary
The facility failed to comply with Pennsylvania state regulations regarding criminal background checks and abuse training for newly hired employees. Specifically, the facility did not obtain the required Pennsylvania State Police (PSP) background checks within 30 days of hire for four out of five reviewed employees. Additionally, the facility did not ensure that these employees attested to their Pennsylvania residency for the two years prior to their application, nor did it complete FBI background checks for those who did not meet the residency requirement. The personnel files of Employees 3, 4, 5, and 6 showed significant delays and omissions in obtaining and documenting these background checks and attestations. Employee 3, a nurse aide, was hired on December 11, 2023, but did not provide a signed attestation of Pennsylvania residency, nor did the facility obtain an FBI background check. The PSP criminal record check was only requested on April 24, 2024, more than four months after the hire date. Employee 4, a dietary aide, signed the Pennsylvania Resident Verification for Waiver of FBI Report 15 days after her hire date, and her PSP criminal record check was still pending beyond the 30-day requirement. Employee 5, a registered nurse, did not have a Pennsylvania Resident Verification form or an FBI background check in her file, and her PSP criminal record check was requested more than two months after her hire date. Additionally, Employee 5 worked paid hours before completing the required abuse training. Employee 6, an activities aide, signed the Pennsylvania Resident Verification form nearly two months after her hire date, and her PSP criminal record check was requested 12 days after hiring. The facility also failed to obtain any personal or professional references for Employee 6. These deficiencies were confirmed during an interview with the human resources director, who had no additional information to address the concerns raised by the surveyor.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to identify triggers related to the diagnosis of Post-Traumatic Stress Disorder (PTSD) for two residents, leading to a deficiency in providing culturally competent, trauma-informed care. Clinical record reviews for both residents revealed that they had been diagnosed with PTSD since their respective admission dates. However, due to their current cognitive status, neither resident could be interviewed about their PTSD. The facility's assessments confirmed that PTSD was an active diagnosis for both residents, yet their care plans did not identify any triggers that could cause re-traumatization. An interview with the Director of Nursing confirmed these findings, indicating that the facility did not adequately address the needs of these residents in their care plans. Specifically, the care plans lacked identification of everyday situations that could cause the residents to re-experience their traumatic events. This oversight was noted for both residents, who had been diagnosed with PTSD since their admission dates and continued to have PTSD as an active diagnosis in their most recent assessments.
Deficiencies in Food Storage, Equipment Sanitation, and Temperature Recording
Penalty
Summary
The facility failed to store food items in a safe and sanitary manner, maintain equipment in a sanitary condition, and prepare food items in accordance with professional standards in the main kitchen. During an initial tour of the main kitchen, several deficiencies were observed, including a white dry erase board falling off the wall, hoagie rolls in a walk-in cooler without a date or label, and a roll of thawed beef with an expired use-by date. Additionally, there was a significant amount of dust and debris on a window air conditioning unit in the dry goods storage area, and a build-up of a black substance on the air vents. Cobwebs were also noted on the ceiling border in the dry goods storage area. An air conditioning unit in the main kitchen had a significant build-up of dust, and the air filter and outlets were covered in dust and a black, sticky substance. A previously repaired section of the ceiling had a plastic-like sheet that was curling and exposing the hole, with screws only partially screwed in. An opened bag of sprinkles with no expiration date was found in a stainless-steel cabinet, and a metal wire storage rack had a build-up of dust and a white dust-like substance on the bottom shelf protective covering. Clean food trays in the dishwashing area were not protected from mop splash or wet floor splashes. Additionally, the ground behind the facility's main dumpsters had discarded items, including a stainless steel butter knife, a hairnet, and a used glove. The facility also failed to record food temperatures daily as per their policy. A review of the food temperature logs revealed missing temperature records for several dates. Employee 19, the Dietary Manager, confirmed the missing temperatures and could not provide further evidence that the food temperatures were taken on those dates. The findings were reviewed with the Regional Director of Clinical Services and the Director of Nursing, who acknowledged the deficiencies.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement appropriate enhanced barrier transmission-based precautions (EBP) for five residents who required them due to chronic wounds or indwelling medical devices. Resident 33, who had an indwelling foley catheter, was not placed on EBP despite having a urinalysis sent out due to infection concerns. Observations confirmed the absence of EBP, and interviews with staff revealed that the facility was still in the process of implementing these precautions for residents like Resident 33 who required them. Resident 6, who had an indwelling foley catheter and a Stage 4 pressure ulcer, was also not placed on EBP. Observations during a dressing change and interviews with staff confirmed the lack of EBP for this resident. Similarly, Resident 68, who received nutrition through a PEG tube, was not on EBP, as confirmed by observations and staff interviews. The facility acknowledged that these residents should have been on EBP but were not due to ongoing implementation processes. Resident 69, who had an indwelling urinary catheter and a recent history of a urinary tract infection, was not placed on EBP despite exhibiting non-compliance with good infection control behaviors. Observations and interviews confirmed the absence of EBP for this resident. Additionally, Resident 40, who had a Stage 4 pressure ulcer, was not on EBP, as confirmed by observations and staff interviews. The facility admitted that these residents should have been on EBP but were not due to the ongoing implementation of these precautions.
Failure to Ensure Resident Participation in Care Planning
Penalty
Summary
The facility failed to ensure resident and/or responsible party participation in comprehensive care plans for two residents. Resident 8 reported that she was not invited to participate in her care plan meetings. The clinical record for Resident 8 contained an undated invitation without a date, time, or contact information. Documentation indicated that neither Resident 8 nor her responsible party attended a care plan conference, and there was no explanation in her medical record regarding their participation. Additionally, there was no documentation to indicate that the facility took steps to identify and eliminate barriers to Resident 8's participation in her care planning. Similarly, Resident 69 was not familiar with care plan meetings and did not attend his scheduled care plan conferences. The clinical record for Resident 69 contained an undated invitation without a date, time, or contact information. Documentation indicated that neither Resident 69 nor his responsible party attended the care plan conference, and there was no explanation in his medical record regarding their participation. The facility did not take steps to identify and eliminate barriers to Resident 69's participation in his care planning. These deficiencies were discussed with the regional director of clinical services and the Director of Nursing during the survey.
Failure to Adhere to Physician Orders and Monitor Resident Care
Penalty
Summary
The facility failed to provide the highest practicable care regarding a fluid restriction for Resident 62 and physician-ordered treatments for Resident 2. Resident 62, who was readmitted after a hospital stay for congestive heart failure, had a fluid restriction order that was not properly documented or monitored. The clinical record showed inconsistencies and lack of documentation regarding her fluid intake, and the dietician's progress notes were based on observations rather than clinical documentation. The Director of Nursing confirmed that the fluid restriction was not correctly coded, leading to a lack of compliance monitoring. Resident 2, who had a diabetic foot ulcer, did not receive the prescribed treatments consistently. The clinical record revealed missed treatments on specific dates, with no documented evidence explaining the omissions or indicating that the resident refused the treatment. Observations and documentation from the wound care provider indicated that the ulcer was worsening at one point but later showed signs of improvement. The Director of Nursing acknowledged the missed treatments and suggested that staff might not have been waking the resident for the night shift treatment. These deficiencies highlight the facility's failure to adhere to physician orders and ensure proper documentation and monitoring of resident care. The lack of compliance with fluid restriction orders for Resident 62 and the inconsistent wound care for Resident 2 demonstrate significant lapses in the facility's care practices.
Failure to Obtain Necessary Audiology Services
Penalty
Summary
The facility failed to obtain necessary audiology services for a resident with highly impaired hearing. The resident, who required the use of a dry erase board for communication, reported that she had been promised a visit from a hearing doctor to clean her ears and provide hearing aids, but no one had come. The clinical record review revealed that the resident was assessed as having highly impaired hearing and that a care plan was developed to address her communication needs. However, the care plan did not include the use of a hearing aid, and there was no follow-up on the audiology services that were supposed to be provided. The resident had consented to audiology services, and documentation from the facility's contracted provider indicated that she was evaluated for a hearing aid check and that a replacement hearing aid was to be fitted. Despite this, the resident did not receive the necessary follow-up services, and the facility staff were unaware of the status of her hearing aid. Interviews with the Director of Nursing and the regional director of clinical services confirmed that the resident had not received professional audiology services after the initial evaluation, and her medical record did not incorporate the use of a hearing aid into her plan of care.
Failure to Implement Pressure Ulcer Treatment
Penalty
Summary
The facility failed to implement treatment and services to promote the healing of a pressure ulcer for Resident 40. Upon admission, Resident 40 was assessed with an unstageable pressure sore on the coccyx. Despite the care plan initiated, the facility did not start treatment until several days later. The wound worsened over time, and the treatment recommendations were not consistently followed due to delays in receiving necessary supplies from the pharmacy. Additionally, the facility did not provide an air mattress as requested by the resident's representative, which further contributed to the deterioration of the wound. The resident was eventually hospitalized with severe sepsis and osteomyelitis and returned to the facility before passing away. Interviews with staff and the resident's representative confirmed the lack of timely and appropriate care. The Director of Nursing acknowledged the failure to apply the prescribed treatments, and maintenance staff confirmed the delay in providing the air mattress. Documentation revealed that the wound continued to worsen, and there were multiple instances where the prescribed treatments were not administered due to unavailability of supplies. The facility's failure to implement the necessary treatments and services led to the progression of the pressure ulcer to a Stage 4 wound, ultimately contributing to the resident's severe health decline and death.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement interventions to deter resident falls and prevent potential injury for two residents. For Resident 20, the plan of care required bilateral fall mats at all times when she was in bed. However, observations on two separate occasions revealed that there was only one fall mat on the left side of her bed. This was confirmed by an LPN and the regional director of clinical services. The absence of the second fall mat indicated a failure to adhere to the prescribed fall prevention measures for Resident 20. Resident 48 experienced multiple falls due to the facility's failure to implement and follow through with appropriate interventions. After a fall that resulted in a head laceration, the plan included obtaining laboratory testing, which was not done. Subsequent falls were not met with effective new interventions, and the resident continued to fall despite being known for non-compliance with transfer and ambulation status. The facility's interventions, such as placing a sign to remind the resident to call for assistance, were ineffective and not consistently implemented. Additionally, the facility failed to install anti-rollback brakes on the resident's wheelchair as planned. The facility's documentation and interviews confirmed that the necessary interventions were either not implemented or not documented. This included the lack of a post void residual assessment, psychiatric evaluation, and the installation of anti-rollback devices. The repeated falls and injuries sustained by Resident 48 highlighted the facility's failure to provide adequate supervision and implement effective fall prevention strategies, despite the resident's known risks and behaviors.
Failure to Administer Supplemental Oxygen as Prescribed
Penalty
Summary
The facility failed to administer supplemental oxygen as prescribed by the physician for two residents. For Resident 8, the physician's order dated December 14, 2023, instructed staff to administer supplemental oxygen via a nasal cannula at 3 liters per minute (l/m) continuously. However, observations on April 23 and April 26, 2024, revealed that the oxygen was being administered at 2.5 l/m. This discrepancy was confirmed by the regional director of clinical services during an interview on April 26, 2024. Similarly, for Resident 62, the physician's order dated February 12, 2024, instructed staff to administer supplemental oxygen via a nasal cannula at 2 l/m continuously. Observations on April 24 and April 25, 2024, revealed that the oxygen was being administered at 3.5 l/m. This was confirmed by a Licensed Practical Nurse during an interview on April 25, 2024. The Director of Nursing was made aware of the concerns on the same day. The facility's failure to adhere to the prescribed oxygen administration rates for both residents constitutes a deficiency.
Failure to Assess Entrapment Risk for Bed Rails
Penalty
Summary
The facility failed to assess the entrapment risk of assist bar use for two residents, leading to potential safety hazards. For Resident 8, an active physician's order dated December 18, 2023, required the use of bilateral enabler bars to aid with turning and repositioning. However, a Maintenance Bed Rail Evaluation dated April 16, 2024, only evaluated Zone 1 and Zone 3 for entrapment risks, neglecting other potential zones of entrapment. Observation on April 23, 2024, revealed that Resident 8's bed was equipped with a footboard, making Zones 1, 2, 3, 4, 6, and 7 potential areas of entrapment risk. This concern was confirmed during a review with the regional director of clinical services on April 25, 2024. Similarly, for Resident 20, an active physician's order dated March 31, 2023, required the use of bilateral enabler bars, and another order dated November 13, 2019, required bilateral assist rails for bed mobility. Observation on April 23, 2024, revealed that Resident 20's bed was equipped with both a headboard and a footboard, making Zones 1, 2, 3, 4, 6, and 7 potential areas of entrapment risk. A Maintenance Bed Rail Evaluation dated April 16, 2024, also only evaluated Zone 1 and Zone 3 for Resident 20's entrapment risks. These findings were confirmed during an interview with the regional director of clinical services and the Director of Nursing on April 25, 2024.
Failure to Provide Necessary Behavioral Health Care and Services
Penalty
Summary
The facility failed to arrange for necessary behavioral health care and services for Resident 78, who had a history of alcohol abuse and was diagnosed with encephalopathy and alcohol dependence with alcohol-induced psychotic disorder. Despite an initial psychiatric evaluation recommending continued behavioral health follow-up, there was no evidence that Resident 78 received any further behavioral health services after the initial assessment in November 2023. The resident exhibited numerous behavioral issues, including combativeness, wandering into other residents' rooms, and physical aggression, which were documented multiple times by nursing staff and observed by surveyors. Resident 78's daughter expressed concerns about her father's behavior and the financial implications of sending him to an inpatient psychiatric facility. She was informed by the facility staff that Medicaid approval was necessary for a bed hold before he could be sent for inpatient services. Despite this, there was no follow-up on the initial psychiatric recommendations, and the resident continued to exhibit disruptive and aggressive behaviors, including urinating on the floor, throwing objects, and attempting to hit staff and other residents. Interviews with staff and the Director of Nursing revealed that the facility had recently signed a new contract with a behavioral management company, but it was unclear if Resident 78 had received any services from the psychologist. The facility's failure to provide ongoing behavioral health care and services as per the resident's plan of care resulted in the resident's continued behavioral issues, impacting his well-being and the safety of other residents.
Failure to Develop and Implement Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss for a resident. Clinical record review revealed that the resident was admitted with a diagnosis of dementia with other behavioral disturbances. Despite the facility's assessment indicating the need for a care plan for dementia, no such plan was developed or implemented. This deficiency was confirmed by the Director of Nursing during an interview, where it was acknowledged that there was no further documentation to support the development and implementation of the required care plan.
Failure to Ensure Proper Reporting and Response to Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the consultant pharmacist reported irregularities to the attending physician and that the physician appropriately responded to reported irregularities for two residents. For Resident 20, the consultant pharmacist recommended evaluating the use of Oxcarbazepine, but the CRNP declined the recommendation without evidence of a previous failed dose reduction attempt. Additionally, there was no documentation that the pharmacist's recommendations were forwarded to the physician or the Director of Nursing on multiple occasions. The Director of Nursing confirmed the absence of a separate, written report from the consultant pharmacist for the specified dates. For Resident 52, the clinical record review revealed that pharmacy medication regimen review assessments indicated new recommendations, but there was no evidence that these recommendations were forwarded to the Director of Nursing or the physician. The Director of Nursing confirmed that the pharmacy recommendations for the specified dates were not available in Resident 52's clinical record, and she could not locate the recommendations provided by the pharmacist. The facility's failure to ensure proper reporting and response to pharmacist recommendations led to deficiencies in managing potentially unnecessary medications for both residents.
Failure to Ensure Medication Regime Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident's medication regime was free from potentially unnecessary medications for two residents. Resident 56 was admitted without a diagnosis of insomnia but was prescribed Trazodone for insomnia shortly after admission. Despite multiple recommendations from the consultant pharmacist for a gradual dose reduction (GDR), the physician declined, citing mood instability. There was no evidence that the facility monitored Resident 56's insomnia or attempted a GDR, and the facility could not provide documentation of clinically significant symptoms requiring continued use of Trazodone. The Director of Nursing confirmed the lack of evidence for a failed GDR or the necessity of the medication. For Resident 20, the consultant pharmacist recommended evaluating the use of Oxcarbazepine, but the CRNP declined, fearing exacerbation of psychiatric disorders. Resident 20 had been on the same dose since 2019, with no evidence of a failed dose reduction attempt. The resident's Risperdal dose was increased following an episode of yelling at a new roommate, despite no documented adverse effects from previous dose reductions. The facility did not provide evidence that the resident's behavior was delusional or independent of the stimulus of the new roommate. The Director of Nursing and the activities director confirmed that the facility's justification for increasing the medication was based on a single episode of target behaviors during a time of medical treatment and a change in routine. The facility's documentation system deleted behavior tracking data after 30 days, making it difficult to assess the persistence of target behaviors. Behavior Summary Reports indicated minimal target behaviors in the months leading up to the medication increase. The facility failed to allow other causes for Resident 20's symptoms to be addressed before determining that the symptoms were significant enough to warrant an increase in medication therapy.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate below five percent, resulting in a medication error rate of 7.89 percent based on 38 medication opportunities with three medication errors. During a medication administration pass, an LPN administered medications to two residents without following the instructions on the pharmacy medication labels. Specifically, Resident 56's Metoprolol, which was to be given with food to avoid side effects like dizziness and drowsiness, was administered with water. Similarly, Resident 61's Aspirin and Multivitamin with minerals, which were also to be given with food, were administered with water. Both residents were unable to be interviewed due to their cognitive status. The surveyor noted that there were no breakfast trays on the Heirloom nursing unit at the time of the medication administration pass, and the facility's mealtimes indicated that breakfast trays were delivered at 6:45 AM. The findings were reviewed with the Nursing Home Administrator, highlighting the failure to adhere to medication administration protocols as outlined in the facility's policy. This deficiency was identified through observation, clinical record review, and staff interviews.
Failure to Secure Medications
Penalty
Summary
The facility failed to properly secure medications for Resident 23 on the [NAME] unit. During an observation on April 24, 2024, at 11:55 AM, Resident 23 was found in her bed with a small medicine cup containing four pills on her overbed table. The resident accidentally knocked over the cup, spilling the pills onto the floor. She indicated that these were her morning medications that she had forgotten to take. The surveyor immediately informed the medication nurse, Employee 16, who revealed that he was unaware the medications were still in the cup and thought the resident had already taken them. The medications identified were calcium acetate 667 mg, Simethicone 80 mg, Fish oil 1000 mg, and hydralazine hcl 25 mg. The Director of Nursing and the director of clinical services were informed of the unsecured medications on April 25, 2024. The facility's failure to secure Resident 23's medications was noted as a deficiency. This incident highlights a lapse in medication security protocols, as the medications were left unattended and accessible to the resident, contrary to the regulations requiring drugs and biologicals to be stored in locked compartments.
Failure to Provide Adequate Dental Care Services
Penalty
Summary
The facility failed to provide dental care services for two residents, Resident 8 and Resident 20, as required. Resident 8 had not received any dental services since her admission, despite having obvious dental issues such as broken and discolored teeth, and experiencing pain and difficulty chewing. The facility's plan of care for Resident 8 identified her risk for dental problems but did not include any interventions for arranging dental appointments. Although Resident 8 consented to dental services, there was no evidence that she received any professional dental care since her admission, including a scheduled visit on March 1, 2024, which did not occur as documented in her medical record. The Director of Nursing confirmed the lack of evidence for dental services provided to Resident 8 since her admission. Resident 20 also did not receive adequate dental care services. Her plan of care identified multiple missing and broken teeth, and she had received only preventative services from a dental hygienist, not comprehensive dental care. Despite being scheduled for a dental visit on April 12, 2024, there was no evidence in her clinical record that this visit occurred. Resident 20 had complained of mouth pain and toothache, and although she had received periodic exams, the facility failed to ensure she received professional dental services every six months as required. The Director of Nursing confirmed the lack of further evidence for professional dental services for Resident 20.
Arbitration Agreement Deficiency
Penalty
Summary
The facility's arbitration agreement failed to ensure a neutral and fair arbitration process for Resident 8. The agreement, signed on December 13, 2023, did not allow for a choice of venue convenient to both parties and designated an entity to conduct the arbitration, rather than allowing for the selection of a neutral arbitrator. This deficiency was confirmed during an interview with the Director of Clinical Services on April 26, 2024, at 9:03 AM. The facility's actions were found to be in violation of 28 Pa. Code 201.14(a), 28 Pa. Code 201.18(b)(2), and 28 Pa. Code 201.29(a)(j).
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
