Embassy Of Tunkhannock

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to implement effective procedures to accurately identify residents prior to medication administration. Facility policy required that medications be administered by licensed nurses in accordance with professional standards and that residents be identified by photograph in the electronic health record before medication administration. The admission policy also required that a resident photograph be obtained and uploaded to the electronic health record to ensure accurate identification. Despite these policies, the facility did not consistently maintain resident photographs in the electronic health record and did not have a reliable alternative identification process, particularly for cognitively impaired residents and for staff unfamiliar with the residents. One critical event involved two cognitively impaired residents who shared a room. One resident, admitted with senile degeneration of the brain and a BIMS score of 5 indicating severe cognitive impairment, had physician orders for morphine sulfate concentrate 20 mg/ml, 0.5 ml by mouth once daily, and levothyroxine sodium 25 mcg daily in the morning. The roommate, admitted with dementia and a BIMS score of 3 indicating severe cognitive impairment, did not have these medication orders. An agency RN, on her second shift in the facility and unfamiliar with the residents, entered the shared room to administer medications, called out the name of the resident for whom the morphine and levothyroxine were ordered, and the roommate responded "huh." Without verifying identity using a photograph or another reliable method, the nurse administered the morphine sulfate 0.5 ml and levothyroxine 25 mcg intended for the first resident to the roommate. After administering the medications, the agency RN realized at the computer that the medications had been given to the wrong resident. She immediately obtained the roommate’s vital signs, which showed blood pressure 90/50 mm Hg, heart rate 38 beats per minute, respirations 12, and oxygen saturation 98%, and contacted 911, the physician, and the resident representative. Emergency department documentation later confirmed that the resident arrived with accidental opiate poisoning and profound bradycardia, with reported heart rates as low as 29 beats per minute and low blood pressures, and required two doses of naloxone to stabilize heart rate and blood pressure before being discharged back to the facility the same day. Beyond this event, the facility’s systemic failure to maintain an effective resident identification system contributed to the deficiency. Observations showed that during medication administration, some residents did not have photographs in the electronic health record, even though the system had a designated location for such photos. Staff interviews confirmed that nurses relied primarily on electronic photographs to identify residents, but several residents lacked these photographs. Staff also reported using familiarity with residents, asking residents to state their names when cognitively intact, or relying on room nameplates, and they were unable to describe a consistent method for identifying cognitively impaired residents. Clinical record review identified multiple residents without photographs uploaded until surveyor inquiry, and staffing records showed that agency nurses comprised a portion of licensed staff, increasing the likelihood that unfamiliar staff would depend on incomplete identification tools. The DON confirmed the medication error, the reliance on photographs for identification, and that the admissions position previously responsible for uploading photographs had been eliminated, with no documented competency validation or specific training on resident identification procedures for the agency RN involved.

Plan Of Correction

Facility completed resident identification pictures in the electronic medical records for residents 48, 53, 65, 6, 7, 12, 59, 34, 23 on 4/9/2026. All resident photos uploaded and audited on same date. 2. Audit of all residents completed on 4/9/2026 to ensure photos of all residents were present in their medical chart for identification purposes. 3. Facility procedures for Medication Administration, Resident Admission Procedure and Orientation checklist for LPN/RN were reviewed and updated to reflect the taking of photographs of new residents upon admission and place in the electronic medical record for resident identification, completed on 4/9/2026. Residents received wrist bands on 4/13/2026 with exception of 5 residents who refused to have a wrist band as a secondary method of identification. Agency RN marked as a "do not return" to facility and agency was updated to mediation error on 4/7/2026. Education completed with facility licensed nurses on 4/9/2026 and ongoing on policies and procedures, resident identification, secondary identifications with use of wrist band, and 5 rights of medication administration. 4. New admission audits will be completed by the NHA/designee to ensure photo identification is uploaded to the EMR. QA committee notified of the IJ and abatement plan of correction. New admission audits for picture identification will continue daily X 2 months with results of audits to QA committee for review and alternative actions as required. DON/designee will audit nurses administering medications to ensure the 5 rights of medication pass are followed and all residents have accurate resident identification prior to medications administration is identified in 3 resident med passes, 3 X week for 4 weeks. 5. April 25, 2026

Removal Plan

• Identify residents who do not have photographs in the electronic health record.
• Take resident photographs and upload them to the electronic health record; photograph any residents not available immediately upon their return and upload promptly.
• Audit all residents’ electronic health records to verify photographs are present for identification purposes and review the system process for resident identification.
• Order wristbands for all residents containing the resident’s name and date of birth as a secondary identification method.
• Update resident photographs in the electronic health record as necessary and review them annually during resident care planning meetings by the Social Services Director or designee.
• Ensure resident photographs are taken on the day of admission and uploaded to the electronic health record, and apply a medical wristband with resident name and date of birth per the admission procedure.
• Provide education for LPNs and RNs on the five rights of medication administration and use of electronic health record photographs for resident identification, and make education on obtaining and uploading photographs available.
• Provide the agency staffing company a copy of the education materials to be completed by agency staff prior to accepting shifts and update the agency orientation packet to include the revised admission procedure and updated medication administration policy.
• Audit new admissions to ensure photographs are uploaded appropriately into the electronic health record.
• Conduct daily audits of photograph identification for new admissions for two months, and report results to the Quality Assurance Committee for review and alternative actions as required.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that nursing services and medication administration were provided in accordance with professional standards of practice and facility policy, specifically the verification of resident identity prior to administering medications. Facility policy on “Medication Administration” required licensed nurses to verify resident identity, including use of the resident’s photograph in the MAR, and to administer medications as ordered and in line with professional standards. State nursing standards cited in the report required RNs to exercise sound nursing judgment, administer drugs as ordered, and follow accepted codes of behavior to assure safe and effective practice, including adherence to the 5 Rights of Medication Administration. Resident 50 and Resident 51 were cognitively impaired roommates, each with severe cognitive impairment as evidenced by low BIMS scores on recent MDS assessments. Resident 50 had physician orders for morphine sulfate oral concentrate 20 mg/ml, 0.5 ml by mouth once daily, and levothyroxine sodium 25 mcg by mouth daily. Resident 51 had diagnoses including dementia with severe cognitive impairment. On the morning of the incident, an agency RN (Employee 1) entered the shared room, called out Resident 50’s name, and Resident 51 responded. The RN then approached Resident 51, identified the medications prepared for administration (morphine sulfate 0.5 ml and levothyroxine 25 mcg), received an “okay” response from Resident 51, and administered Resident 50’s medications to Resident 51. After leaving the room and returning to the computer to document, the RN realized the medications had been given to the wrong resident. The RN obtained Resident 51’s vital signs, which showed low blood pressure and bradycardia, and emergency services were contacted. Hospital records documented that Resident 51 arrived with abnormal vital signs, including a heart rate of 29 beats per minute and low blood pressure, was alert but disoriented, and was treated with two doses of naloxone for opioid poisoning and profound bradycardia. The resident was diagnosed with accidental opioid poisoning. In a subsequent interview, the RN acknowledged administering medication to the wrong resident and confirmed that she did not follow accepted medication administration practices or the 5 Rights of Medication Administration, leading to the resident receiving another resident’s opioid medication and experiencing adverse clinical effects requiring emergency medical treatment.

Plan Of Correction

1. Facility cannot retroactively correct deficiency as it relates to resident 51 on 4/6/2026 and a medication error. 2. Audited medication errors from 1/1/2026 to current to review root cause of errors. Results have been added to our education component for licensed nurses. 3. As outlined by the self-directed letter, AAE Consulting Services, approved by the Department of Health, will provide facility-wide education on the program called "Professional Standards and Significant medication error standards as well as federal regulations and accompanying guidelines. Education will be provided by AAE Consulting Services to conduct the directed in-service sessions on 4/23/26. Anyone that is unable to attend the 4/23/26 sessions will be required to be completed prior to their next scheduled working shift. A copy of the in-service will also be added to agency orientation documents for review prior to working a shift within the facility. All residents who did not refuse have been issued wrist bands for a secondary identification. Wrist band checks added to residents' TAR per shift to check for placement. All resident pictures for primary identification have been uploaded in their respective EMR's on 4/9/2026. 4. Facility education will be completed biannually with licensed nursing staff for the 5 rights of medication verification. Education will be included in all new licensed nursing staff education during the initial orientation process upon hire. Educations will be audited monthly by the DON/designee and forwarded to the QA committee to ensure compliance with resident identification during medication passes. 5. April 25, 2025

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the failure of the Nursing Home Administrator (NHA) and Director of Nursing (DON) to administer and oversee the facility in a manner that ensured effective systems for accurate resident identification prior to medication administration. The NHA’s job description required development, maintenance, and interpretation of policies and procedures, consultation with department directors to correct problem areas, and ensuring residents receive necessary services to attain and maintain their highest practicable functional status. The DON’s job description required planning, organizing, implementing, and evaluating nursing services, maintaining and updating nursing policies and procedures, and ensuring staff education and compliance with those policies. Despite these responsibilities, the facility did not ensure that established identification protocols were consistently implemented and enforced. The facility’s “Medication Administration” policy required licensed nurses to follow professional standards of practice and the five rights of medication administration, including verification of the right resident. The policy specifically required staff to use the resident’s photograph in the Medication Administration Record (MAR) as part of the identification process and to remain with the resident until medications were taken. The “Resident Admission Procedure” policy required staff to obtain and upload resident photographs to the electronic health record to support accurate identification. However, multiple residents did not have photographs available in the electronic health record until surveyor inquiry, demonstrating that the facility did not consistently implement its identification process or ensure an alternative reliable method for resident identification was consistently used. As cited under F760, an agency RN (Employee 1) administered morphine sulfate and levothyroxine that were ordered for one resident (Resident 50) to another resident (Resident 51). Although Resident 51 had a photograph available in the electronic health record, Employee 1 did not use the photograph or another reliable identifier to confirm identity. Instead, Employee 1 called out Resident 50’s name, and Resident 51 responded verbally, after which Employee 1 proceeded with medication administration without further verification. Resident 51 subsequently experienced bradycardia and required transfer to the emergency department, where naloxone was administered to reverse the opioid effects. The surveyors determined that the NHA and DON failed to ensure effective systems were implemented, monitored, and enforced to support staff compliance with facility policy and professional standards for resident identification prior to medication administration, resulting in Immediate Jeopardy.

Plan Of Correction

1. Facility cannot retroactively correct the deficient practice identified by the complaint survey on 4/9/2026. 2. Administrator and Director of Nursing audited all charts for resident identification and provided education to licensed nurses as part of the IJ abatement plan and continue to follow approved abatement plan enforcement actions. 3. Administrator and Director of Nursing will be educated by the Chief Nursing Officer, Corporate Operations Officer and Regional Director of Operations on job descriptions, expectations, and implementation of enforcement of effective systems to support accurate resident identification prior to medication administration. Corporate leadership will review current policies for resident identification and compliance monitoring. 4. DON/designee will audit nurses administering medications to ensure the 5 rights of medication pass are followed and all residents have accurate resident identification prior to medications administration is identified in 3 resident med passes, 3 X week for 4 weeks. Results from audits will be sent to the QA committee as part of the compliance program to ensure 100% correct resident identification for medication passes. 5. April 25, 2026

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that necessary resident-specific clinical information was communicated to the receiving health care provider during an emergent transfer. A resident, identified as Resident 51, was admitted to the facility on July 6, 2022, and had an advance directive indicating a no code status, meaning CPR was not to be initiated if the resident’s heart or breathing stopped. On April 6, 2026, at approximately 5:30 AM, the resident was accidentally administered another resident’s medication: morphine sulfate 0.5 ml. A progress note dated April 6, 2026, at 6:30 AM documented that Emergency Medical Services (EMS) were contacted and the resident was transferred to the emergency department for evaluation and treatment related to the medication error and accidental opioid exposure. However, review of the clinical record revealed no documented evidence that the facility communicated the details of this medication error to the receiving health care provider. Specifically, there was no documentation that the name of the medication, the dosage, the time it was administered, or the clinical circumstances surrounding the accidental administration were provided at the time of transfer. Further record review showed there was also no documented evidence that other essential information necessary for continuity of care was communicated to the receiving provider. This included the resident’s advance directive status, special instructions or precautions for ongoing care, baseline condition, or comprehensive care plan goals, as appropriate, to ensure a safe and effective transition of care. During an interview on April 9, 2026, the DON and NHA were unable to provide documentation that such necessary clinical information had been communicated at the time of the emergent transfer.

Plan Of Correction

1. Facility cannot retroactively correct deficiency as it relates to resident 51 on 4/6/2026. 2. Facility audit of last 10 resident transfers to hospital to ensure that e-interact UA (utilization assessment) and corresponding information on code status, MAR, face sheet and baseline condition were sent to hospital to ensure a safe and effective transition of care. 10/10 residents had corresponding documentation. 3. Licensed nursing staff educated on procedures for resident hospital transfers to include specific documentation to send with EMS to ensure an effective transition of care to include the PCC utilization assessment, baseline condition, code status, MAR, face sheet and reason for transfer. RN supervisor to verify proper information is collected and sent. 4. Audit of each hospital transfer will be completed by DON/designee X 2 months to ensure compliance with education. Results will be provided to the QA committee each month to verify compliance with regulatory requirements for hospital transfers. 5. April 25, 2026

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide adequate ADL care, specifically personal hygiene and nail care, to a dependent resident in accordance with facility policy. The facility’s "Personal Care Procedure" policy, last reviewed on January 23, 2026, required staff to provide needed assistance with bathing, showers, oral care, grooming, and nail care, including cleaning and trimming nails as needed during showers, and to document care or refusals. The resident involved was admitted with chronic atrial fibrillation and dementia and had an MDS dated February 11, 2026, indicating severe cognitive impairment (BIMS score of 3) and total dependence on staff for bathing and personal hygiene. The resident’s Kardex specified scheduled showers on Wednesday and Saturday evenings and a preference for showers over bed baths or baths. Facility documentation (Documentation Survey Report v2) for March and April 2026 showed that showers were recorded as completed as scheduled, including a shower documented the evening before the surveyor’s observation. However, during an observation at midday the following day, the resident was noted to have visible buildup and grime under all fingernails on both hands, with debris and grayish-black residue under the nail tips. The facility could not provide documentation that the resident had refused nail care or that fingernail cleaning had been performed as required by policy, despite the documented shower the previous day. When these findings were reviewed with the DON, the facility was unable to produce evidence that staff followed the facility’s personal care policy to ensure appropriate hygiene for the resident.

Plan Of Correction

Facility cannot retroactively correct deficiency as it relates to 51 on 4/6/2026 regarding ADL care. 2. Facility residents were reviewed by nursing and provided nail care on 4/13/26 and 4/14/26. 3. Facility personnel care procedures reviewed and updated. Education provided to facility nursing staff on the facility Personnel Care Procedure of nail care completion after showers and as needed during ADLs. 4. LPN charge nurse to complete random nail audits daily X 2 weeks, then weekly X 2 months with results sent to the QA committee to ensure compliance with resident grooming and personnel hygiene. 5. April 25, 2026

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to identify and report alleged resident-to-resident abuse to required external agencies within mandated timeframes. The facility’s Abuse, Neglect, and Exploitation policy, last reviewed on January 23, 2026, requires that all alleged violations that could indicate mistreatment, exploitation, neglect, or abuse be reported to the administrator, state agency, adult protective services, and other required agencies. The policy specifies that allegations involving abuse or serious bodily injury must be reported immediately, but no later than two hours after the allegation is made, and all other qualifying events within 24 hours. Despite this policy, the facility did not report two separate incidents involving interactions between two residents that met the definition of alleged resident-to-resident abuse. Resident 1 was cognitively intact with a BIMS score of 15 and had a care plan for behavioral concerns, including verbal agitation and aggression toward staff and the roommate and the roommate’s family, with interventions to avoid situations or people that upset him. Resident 2 had diagnoses including diabetes and intellectual disabilities, was rarely or never understood per the MDS, and was documented as moderately impaired in cognitive skills for daily decision making. On one occasion, investigative documentation and staff interview revealed that Resident 1 wheeled Resident 2 in her wheelchair into Resident 2’s room, shut the door, and made a statement to the effect that if Resident 2 acted up, she would stay in the room. Video review confirmed that Resident 1 wheeled Resident 2 into her room and shut the door before returning to his own room, and staff entered Resident 2’s room shortly afterward and remained with her for several minutes. On a separate date, investigative documentation and a progress note indicated that Resident 1 was observed ramming or intentionally striking Resident 2’s wheelchair multiple times with his own wheelchair. These incidents were investigated internally by the Nursing Home Administrator, who interviewed Resident 1 about the events. Resident 1 reported that he did not believe he harmed Resident 2 and that he sometimes assisted her to her room when she appeared upset. During an interview, the Nursing Home Administrator confirmed that he investigated the allegations of resident-to-resident abuse between these two residents but did not report the incidents to the state agency or adult protective services. The facility therefore failed to identify these events as allegations of resident-to-resident abuse that must be reported to required external agencies within required timeframes, regardless of the investigation outcome.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to timely identify and respond to significant weight loss and nutritional changes for one resident, in violation of its own weight policy. The facility’s policy required obtaining admission and follow-up weights, tracking significant weight losses of 5% in one month, 7.5% in three months, or 10% in six months, and ensuring that the MD and responsible party were notified of significant changes. For this resident, weights documented were 124 lbs on January 4, 120 lbs on February 1, 117 lbs on March 3, 118 lbs on March 15, and 114.5 lbs on March 22. The March 22 weight reflected approximately a 3% loss in one week and a 7.5% loss since January 4, but the record did not show that a reweight was obtained to verify this significant change as required when there was a notable variance. The resident had dementia, major depressive disorder, severe cognitive impairment (BIMS score of 1), and an existing care plan for nutritional problems related to advanced age, mechanically altered diet, and thickened liquids. The care plan set a goal to maintain weight within 3% of 124 lbs and to consume 75% of at least two meals daily, with interventions including fortified foods, a 4 oz nutritional shake with meals, a 4 oz frozen nutritional supplement daily, obtaining weights as ordered, and RD evaluation with recommendations. The remote RD responded to a weight alert on February 21 for the February 1 weight, noting an approximate 3% (4 lb) loss and recommending a 4 oz nutritional shake with meals three times daily. However, the corresponding physician order for the nutritional shake with meals was not entered until March 4, eleven days after the RD’s recommendation. A subsequent RD weight change note on March 9, in response to the March 3 weight, documented a 10% (14 lb) loss over 180 days and recommended a 4 oz frozen nutritional supplement with dinner and weekly weights. The physician order for weekly weights was entered on March 9, but the order for the 4 oz frozen nutritional supplement with dinner was not entered until March 17, eight days after the RD’s recommendation. The clinical record did not contain evidence that the recommended nutritional interventions (4 oz shakes with meals and 4 oz frozen supplement with dinner) were implemented in a timely manner following identification of weight loss. Additionally, the record lacked documentation that the attending physician and the resident’s responsible party were notified of the significant weight loss identified on March 22. During interview, the DON confirmed there was no additional documentation to show timely notification or timely implementation of the recommended interventions.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure its Quality Assurance Performance Improvement (QAPI) committee developed and implemented effective corrective action plans to prevent ongoing problems in the food and nutrition services department. The facility had a written QAPI policy stating it would maintain an effective, comprehensive, data‑driven program focused on care outcomes and quality of life, using evidence‑based indicators and goals predictive of desired resident outcomes. Despite this, during a survey ending in late January 2026, surveyors identified deficient practice related to timely identification of changes in nutritional parameters, implementation of appropriate nutritional interventions, and notification of the attending physician and responsible party when significant weight loss occurred. Following that survey, the facility created a plan of correction that included reviewing current residents for significant weight loss, completing nutritional assessments, implementing interventions, adjusting care plans, and notifying physicians and responsible parties as needed. The plan also called for education of the RD and licensed nursing staff on identifying significant weight loss and appropriate notifications, as well as ongoing audits of residents with significant weight loss. However, by the time of the subsequent survey ending in late March 2026, the same types of deficiencies were still present, demonstrating that the QAPI process had not effectively corrected or prevented recurrence of the identified issues. For one resident, weight records showed a decline from 124 pounds in early January 2026 to 114.5 pounds by late March 2026, including a 3 percent loss in one week and a 7.5 percent loss since early January. The record did not show that a re‑weight was obtained to verify this significant change. The remote RD documented weight alerts and recommended additional nutritional interventions, including increasing nutritional shakes with meals and adding a frozen nutritional treat with dinner, as well as weekly weights. There were delays of several days between the RD’s recommendations and the corresponding physician orders, and the clinical record did not show timely implementation of the recommended interventions. The record also lacked documentation that the attending physician and the resident’s responsible party were notified of the significant weight loss on the date it was identified, and the DON confirmed the failures in timely notification and implementation, indicating that the facility’s quality assurance monitoring did not detect or correct the ongoing deficient practice for this resident’s nutritional status.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to timely identify and respond to significant weight loss for one resident, contrary to its own Weight Policy. The policy required admission/readmission weights, weekly weights for three weeks, then monthly weights unless otherwise ordered, verification of any weight with significant variance, tracking of significant weight losses by the RD, and notification of the MD and responsible party of significant weight changes. Resident 5 had a care plan initiated for nutritional problems related to advanced age, mechanically altered diet texture, and mild protein store depletion, with goals to maintain weight and avoid significant weight changes, and interventions including weekly weights and RD evaluation with recommendations as needed. A physician order dated mid-December directed weekly weights. Weight records for Resident 5 showed weights of approximately 120.5–121.5 pounds over three consecutive weekly measurements, followed by a documented weight of 105 pounds on January 11, 2026, reflecting a loss of 16.5 pounds, or about 13.5% of body weight in one week. The clinical record did not contain documentation that this large change was rechecked promptly to verify accuracy, despite the facility’s policy that a nurse should verify weights showing significant variance. A remote RD note on January 15, 2026, identified the significant weight loss and recommended a reweight, but the resident was not reweighed until January 16, 2026, when the weight was recorded as 106 pounds, still reflecting a significant loss. A subsequent RD note documented a 12.4% weight loss in less than 30 days and 8.2% in three months, and recommended fortified foods with all meals and a 4 oz nutritional shake with lunch and dinner. Although the RD documented that the resident was to receive 4 oz nutritional shakes with lunch and dinner and that the resident was consuming about 75% of meals on a mechanical soft diet with thin liquids, the clinical record did not show that the recommended nutritional interventions, including the shakes, were implemented in a timely manner after the significant weight loss was identified. The record also lacked documentation that the attending MD and the resident’s responsible party were notified of the significant weight loss. Subsequent weights showed a further decline to 104 pounds. During an interview, the DON confirmed that there was no additional documentation to demonstrate timely MD and responsible party notification, timely implementation of nutritional interventions, or timely reweights, corroborating the identified deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Warfarin (Coumadin). The resident, who had diagnoses including dementia and muscle weakness, was prescribed alternating doses of Warfarin based on specific days of the week. On September 17, a new one-time order for 5 mg of Warfarin was received, with instructions to resume the prior alternating schedule afterward. However, when the nurse entered the new order, she also entered new standing orders for the alternating doses but did not discontinue the previous, duplicate orders. This resulted in the electronic medication record displaying multiple active Warfarin orders, leading to the resident receiving higher than prescribed doses on several consecutive days. Additionally, after the resident was hospitalized and returned with a new order to restart Warfarin on a specific future date, the medication was administered before the prescribed restart date. The medication cart was also found to have a prepared dose for administration on a day when the order specified the medication should be held. Staff interviews confirmed that nursing staff are responsible for reviewing and discontinuing outdated or duplicate orders in the MAR, but this was not done, resulting in the administration of incorrect doses and timing of Warfarin.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was free from chemical restraints, as evidenced by the administration of lorazepam gel without documented medical symptoms or behaviors that warranted its use. The resident, who was admitted with vascular dementia with behavioral disturbance and anxiety disorder, was prescribed lorazepam gel to be applied topically, despite having no contraindications for oral medications. The facility's policy required documentation of less restrictive alternatives and ongoing re-evaluation of the need for restraints, which was not provided in this case. The resident's clinical record showed multiple instances where the as-needed lorazepam gel was administered without supporting documentation of increased anxiety or behaviors. Observations revealed the resident was often groggy and not easily arousable, suggesting the medication was not used for a specific medical condition. Interviews with staff indicated the resident was usually groggy until midday, and the facility failed to provide evidence of attempts to address potential underlying causes of the resident's behavior. The facility's policy on medication regimen review required a prescriber to document the rationale for extending a PRN order past 14 days, which was not done. The Director of Nursing confirmed the lack of documentation for the resident's inability to tolerate oral medications and the absence of symptoms justifying the PRN medication. This lack of documentation and assessment led to the classification of the lorazepam gel as a chemical restraint, violating the resident's rights to be free from such restraints.

Plan Of Correction

Facility cannot retroactively correct deficiency. Resident 1's Ativan Gel was discontinued after review from the physician on 4/29/2025. PRN Ativan was ordered by physician beginning 4/30/2025 while facility completes a seven-day tracker of behaviors. Behavior monitoring ordered at the time of the new PRN medication. Care plan updated to reflect current orders. Current residents reviewed for PRN medications, behavioral monitoring and physician assessments with no corrections required. Education provided to physician assistant and medical director regarding PRN medication orders and required assessment of medication. Education provided to nursing staff on behavior documentation and use of non-pharmacological interventions prior to PRN usage. DON/designee will audit daily order summaries for PRN medications and examine use of PRN medications to ensure the regulations for PRN medications are followed X 2 weeks, then monthly X 2 months. Results to be forwarded to QAPI committee to ensure compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide timely and necessary foot care for a resident, as evidenced by observations and clinical record reviews. The resident, who was admitted with vascular dementia and anxiety disorder, was found to have long toenails with redness around the sides during an observation in April 2025. The resident's clinical records indicated that they had not received podiatry care since August 2024, despite previous diagnoses of onychomycosis and treatments of debridement. The facility's policy requires assistance in obtaining routine and emergency ancillary services, including podiatry. However, the Director of Nursing confirmed that the resident had not received routine podiatry care since the facility switched podiatry providers in September 2024. This lapse in care was identified during a survey, highlighting the facility's failure to adhere to its own policy and ensure proper foot care for the resident.

Plan Of Correction

Facility cannot retroactively correct deficiency for Resident 1. Investigation concluded that facility podiatry service vendor sent consent to treat to POA X 3 with unsuccessful return. Guardian contacted regarding podiatry service and consult. Facility successful on consent and physician orders. Podiatrist scheduled to provide service to Resident 1 on 5/13/2025. Current residents reviewed to ensure all residents and POAs have been educated to podiatry services and required documents have been obtained for service provider to ensure timely service. Education provided to admissions director, nursing staff and social worker for Podiatry service with provider. A revolving schedule of resident services has already been occurring, and new residents are being scheduled for examination and treatment. Nursing will report to SS director and nursing administration when a resident requires podiatry services outside of the scheduled time frame. SS/designee will audit podiatry services monthly x 4 months to ensure all residents who have signed consents have been seen by podiatry with facility service provider.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain its electrical systems, as evidenced by an unsecured junction box located above the suspended ceiling assembly in Room 104. This deficiency was observed on March 31, 2025, at 11:55 a.m. During an exit interview with the Facility Administrator and the Facilities Manager, the deficiency was confirmed, indicating a lapse in maintaining the electrical systems on the floor.

Plan Of Correction

Facility cannot retroactively correct deficiency. Facility audit of all junction boxes completed by maintenance director. All junction boxes were secured. Junction box cited during survey corrected at time of survey. Education provided to maintenance staff on security of junction boxes. Maintenance director/designee to audit junction boxes monthly X 3 months with results sent to the QA committee to ensure compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain its cooking facilities in compliance with NFPA 101 standards, specifically regarding the required inspections of the ansul system. During an observation on March 31, 2025, it was noted that the facility did not conduct one of the two required ansul system inspections within the preceding twelve-month period. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager, indicating a lapse in the facility's adherence to fire protection protocols for its cooking equipment.

Plan Of Correction

Facility cannot retroactively correct deficiency. Education provided to Maintenance Director on annual inspections for Ansul system. Maintenance Director scheduled inspection for 4/25/2025 of the automated fire suppression Ansul system. Vendor educated as to importance of timely inspections as scheduled each 6-month interval. NHA/designee will review inspection binder including Ansul system biannually to ensure all inspections are completed. Results to the QA committee to ensure compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the surety bond amount was sufficient to cover the total amount of resident funds held by the facility. A review of the Resident Fund Trust bank account revealed that the average daily balances frequently exceeded the surety bond coverage amount of $130,000.00. Specific dates showed balances ranging from approximately $130,801.51 to $159,603.09, indicating that the bond was inadequate on multiple occasions. During an interview, the Nursing Home Administrator confirmed that the surety bond coverage was insufficient to fully cover the resident funds, acknowledging the deficiency in financial management as per 28 Pa. Code: 201.18(1)(2)(3) Management.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to employ sufficient staff with the necessary competencies and skills to ensure appropriate nutritional oversight for residents. The Director of Food and Nutrition Services, who was not a qualified dietitian, did not receive frequent consultations from a qualified dietitian or other clinically qualified nutrition professional. The facility's assessment did not indicate the necessity of a qualified dietitian to meet the nutritional needs of the residents. The Registered Dietitian (RD) had not been on-site since October 8, 2024, and was working remotely, which limited her ability to provide direct oversight or consultation. The Full-Time Food Service Director (FSD), a Certified Dietary Manager, confirmed she did not meet the qualifications to be considered a qualified dietitian and primarily communicated with the part-time RD via email and telephone. The FSD's scope of practice did not include clinical assessment or evaluation for medically related nutritional therapy. The RD's remote status limited her ability to fulfill responsibilities such as conducting on-site consultations, observing residents eating, and assessing residents for nutritional or hydration deficiencies. The facility failed to ensure frequent consultation between the RD and the FSD, resulting in insufficient on-site nutritional oversight.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the menu was periodically reviewed and updated to reflect resident food preferences, resulting in a lack of meal variety for six out of 20 sampled residents. During a group meeting, residents expressed concerns about the repetitiveness of the menu, insufficient portion sizes, and the inconsistent availability of condiments. Despite raising these issues in multiple Food Committee meetings, no changes were made to the menu. The menu was developed by a corporate Registered Dietitian, and the Certified Dietary Manager lacked the authority to adjust it to accommodate resident preferences. A review of the facility's 4-week menu cycle confirmed a repetitive pattern in meal planning, with the same protein sources served consecutively over multiple meals. The facility's nurse consultant and Director of Nursing acknowledged that meal options were frequently repetitive and failed to provide adequate variety, and resident concerns had not been addressed. The facility's adopted Diet Manual indicated that older adults could improve their dietary patterns by choosing from a wider variety of protein sources, but the menu did not reflect this guidance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to routinely offer snacks to residents, as evidenced by interviews with six residents and a review of facility policy. The facility's Snack Policy stated that snacks should be provided between meals and in the evening for residents who desire them, with nursing staff responsible for offering and recording snack intake. However, residents reported not receiving snacks as desired, and grievances were filed indicating that snacks were either not readily available or placed in inaccessible locations. Observations confirmed that snacks were placed on top of unit refrigerators, making them difficult to reach. Despite grievances and a memorandum directing staff to offer snacks regularly, residents continued to report not being offered snacks. The Director of Nursing acknowledged the issue, confirming that each unit should have an ample supply of snacks to meet residents' preferences and dietary needs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to comprehensively review and update its facility-wide assessment to accurately reflect the specific needs of its resident population and the necessary personnel resources. The assessment, last reviewed on January 14, 2025, did not account for the actual care environment for 24 residents with dementia, as there was no locked Memory Care Unit in the facility. Additionally, the assessment lacked specific details regarding care needs, staffing requirements, and specialized activity programming for residents with dementia or Alzheimer's disease. The facility also did not update the assessment to address how available resources were being used to support staffing and operational decisions in compliance with regulatory requirements. During the survey, it was observed that 10 residents with advanced dementia were seated in an activity room with a television playing cartoons, despite scheduled activities like Trivia and Word Games or 1 to 1 visits not taking place. The Activity Director confirmed the lack of adequate activity staff to provide specialized dementia care activities and acknowledged minimal evening activity programming. The facility-wide assessment presented during the survey did not include comprehensive, current data regarding the resident population or the necessary resources to provide competent and safe care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a dignified dining experience for two residents, identified as Residents 52 and 6, who require assistance with feeding. On two separate occasions, these residents were observed in the dining/game room seated with another resident who was independent with eating. The independent resident received her meal promptly and began eating, while Residents 52 and 6 did not receive their meal trays or assistance until 20 to 30 minutes later. This delay in service was observed on March 18 and March 19, 2025. Resident 52 and Resident 6 both have severe cognitive impairments and were admitted to the facility with diagnoses including unspecified dementia. The Director of Nursing and the Nursing Home Administrator confirmed that the meal service was not conducted in a manner that promotes each resident's dignity, acknowledging the failure to serve and assist Residents 52 and 6 within the same timeframe as the independent resident. This deficiency was noted under 28 Pa. Code 201.29 (a) Resident rights.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that comprehensive care plans for three residents were reviewed and revised to accurately reflect their current medical needs and treatment interventions. Resident 25, who was admitted with acute and chronic respiratory failure and diabetes, had a physician's order for continuous oxygen administration at 2 liters via nasal cannula, but this was not updated in the care plan last revised in January 2025. Similarly, Resident 49, diagnosed with depression and cognitive-communication deficit, had new prescriptions for Trazodone and Lexapro for depression management, but these were not reflected in the care plan last revised in January 2025. Resident 64, admitted with atrial fibrillation and COPD, had physician's orders for continuous oxygen therapy and Eliquis for atrial fibrillation, with specific monitoring instructions for blood-thinning medication. However, these interventions were not included in the care plan last revised in February 2024. The Director of Nursing confirmed that the facility did not update the care plans to reflect the residents' current medical status and required interventions, leading to the identified deficiencies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide an ongoing program of activities designed to meet the needs, interests, preferences, and functional abilities of its residents, including those diagnosed with dementia. The review of the facility's March 2025 activity calendar revealed a lack of variety in scheduled activities, with only one dementia-specific activity scheduled three times during the month. Evening activities were limited to once per week, and weekend activities lacked variety. During a resident group interview, several residents expressed dissatisfaction with the activity programming, citing a lack of variety and insufficient evening activities. Observations on March 18, 2025, showed that residents in the Blue Unit activity room were not engaged in the scheduled activities, as the television was playing a cartoon program instead. The scheduled activities, such as Trivia and Word Games and 1 to 1 visits, were not conducted. The Activity Director confirmed the lack of adequate activity staff to provide specialized dementia care activities and acknowledged minimal evening programming. The facility did not offer individualized or customized activities based on residents' previous lifestyles, occupations, hobbies, preferences, and comfort needs, failing to ensure that scheduled activities were carried out as planned.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide nursing services consistent with professional standards of quality for four residents. Resident 12, diagnosed with atrial fibrillation and hypertension, did not have documented evidence that the physician or CRNP was informed of the method used to obtain PT/INR levels, as required by the facility's Coumadin Monitoring Procedure. The Director of Nursing confirmed the lack of clarity in the policy regarding the method of obtaining PT/INR levels. Resident 24, with diagnoses of dementia and congestive heart failure, did not receive daily weights on specific dates as ordered by the physician to monitor fluid retention. This was confirmed by a review of weight logs and the Treatment Administration Record, which showed missing entries for the required daily weights. Resident 42, diagnosed with diabetes and cardiomyopathy, was administered Metoprolol without documented evidence of blood pressure or heart rate measurements prior to administration, contrary to the physician's order. Additionally, Resident 64, with morbid obesity and COPD, did not have monthly weights documented for several months, despite a physician's order. The Director of Nursing confirmed these failures to follow physician orders for all four residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the timely receipt and administration of physician-prescribed medications for two residents, leading to deficiencies in pharmaceutical services. Resident 28, who was admitted with dementia and cerebral infarction with hemiplegia, had a physician order for Oxycodone 5 mg to be administered as needed for pain. However, there was no documentation on the medication administration record (MAR) that the medication was administered on specific dates, despite being signed out on the controlled drug record form. This indicates a lack of proper documentation and administration of prescribed medications. Resident 127, admitted with diagnoses including congestive heart failure, COPD, and diabetes, did not receive multiple essential medications on the day of admission due to a delay in delivery from the pharmacy. The Director of Nursing (DON) revealed that if orders are entered after certain times, the facility does not receive same-day medication delivery. Despite the facility's policy stating that emergency pharmaceutical services are available 24/7, the necessary steps to check the emergency supply or contact the physician for alternative orders were not taken for Resident 127. Additionally, the facility failed to maintain oversight of its medication dispensing system. Discrepancies were found between the recorded medication inventory and actual stock, with expired medications still available in the system. The pharmacy representative confirmed that routine audits were not conducted on individual medications in the emergency supply system. Furthermore, the facility did not have a backup emergency pharmacy, and nursing staff, rather than trained pharmacy personnel, were responsible for restocking the automated medication dispensing system. There was no documented evidence of formal training for staff on proper restocking procedures, nor was there documentation of pharmacy oversight or routine audits.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate dining space for dependent residents requiring staff assistance during meals in the Blue Unit. Observations on March 18 and March 19, 2025, revealed that the dining room was congested with residents in wheelchairs and Geri reclining chairs, making it difficult for staff to pass through, set up meal trays, and assist residents effectively. The limited space also restricted residents' ability to maneuver safely within the room. During an interview with the Director of Nursing (DON) and the clinical nurse consultant, it was acknowledged that the dining area was a tight fit during meals. The DON stated that due to staffing constraints, there was only one seating for each meal in the dependent resident dining rooms. This setup compromised the ability of staff to efficiently assist residents with meals and restricted residents' movement, creating an environment that did not support a dignified and comfortable dining experience.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from the misappropriation of property, specifically medications. Resident 28, who was moderately cognitively impaired and required assistance for daily activities, was prescribed Oxycodone for pain management. A review of the Medication Administration Record (MAR) revealed discrepancies, with 10 out of 30 doses of Oxycodone unaccounted for. Additionally, the narcotic sign-out record was missing, indicating a failure in the facility's medication management and safeguarding procedures. An investigation revealed that an agency LPN was observed on surveillance footage removing the Oxycodone blister pack from the medication cart, dispensing the pills into a medicine cup, and placing them into a glove box, which was then put into her backpack along with the narcotic sign-out record. This incident was reported by another LPN to the Director of Nursing, who confirmed the misappropriation. The facility's failure to ensure the security of the resident's medication led to this deficiency, as confirmed by the Nursing Home Administrator.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents who were dependent on staff for assistance with activities of daily living consistently received showers as planned. During a resident group meeting, two residents reported not receiving showers as scheduled. Resident 30, who was admitted with intrahepatic bile duct carcinoma and vascular dementia, required partial/moderate assistance for showering. The Documentation Survey Report indicated that Resident 30 missed scheduled showers on three occasions in March 2025, with no documentation of refusal or alternative care provided. Similarly, Resident 65, who was admitted with cerebral infarction and atherosclerotic heart disease, required substantial/maximal assistance for showering. The Documentation Survey Report showed that Resident 65 missed scheduled showers on three occasions in March 2025, with no evidence of refusal or alternative care. The Director of Nursing confirmed that the residents were not showered as scheduled, indicating a failure in providing necessary nursing services as per 28 Pa. Code 211.12 (d)(5).

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure documented evidence of clinical necessity for the administration of an antibiotic drug for a resident. The clinical record showed that a resident had a physician's order for Ciprofloxacin HCL to treat a urinary tract infection (UTI). However, a urine culture and sensitivity report revealed that the bacteria causing the infection, Escherichia coli, was resistant to Ciprofloxacin HCL. Despite this, the resident received two doses of the antibiotic before the resistance was identified. The facility's Infection Preventionist confirmed that several residents had received unnecessary antibiotic therapy before the facility reviewed the results of urine culture and sensitivity tests. The Infection Preventionist noted a pattern of antibiotic prescriptions being initiated before confirming bacterial susceptibility, which led to potential unnecessary medication use. This deficiency was identified during a staff interview and review of clinical records.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper coordination of care and services between the facility and the hospice agency for a resident. The facility's policy on Coordination of Hospice Services requires a coordinated plan of care that reflects the resident's needs and goals, developed in consultation with the resident's attending physician and representative. However, the care plan for a resident admitted to hospice services for peripheral vascular disease did not reflect this coordination. The care plan, initially dated February 15, 2024, and last revised March 18, 2025, lacked documentation of the necessary coordination between the facility and the hospice agency to meet the resident's daily and terminal care needs. An interview with the Director of Nursing (DON) confirmed the absence of documented evidence of interdisciplinary communication or coordination between the hospice and facility staff. This lack of coordination was identified during a review of the resident's clinical records and staff interviews, highlighting a deficiency in meeting the regulatory requirements for nursing services and the use of outside resources as per 28 Pa. Code 211.12 and 28 Pa. Code 201.21(c).

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement enhanced barrier infection control procedures for a resident, identified as Resident 12, who was part of a sample of 20 residents. The facility's policy on Enhanced Barrier Precautions, last reviewed on June 1, 2024, mandates the use of personal protective equipment (PPE) such as gowns and gloves during high-contact resident care activities, especially for residents with wounds, to prevent the transfer of multi-drug-resistant organisms (MDROs). However, during an observation on March 18, 2025, it was noted that there was no signage or postings indicating that Resident 12 required enhanced barrier precautions, nor were gowns or gloves readily available outside the resident's room for staff use. Resident 12 was admitted with diagnoses including atrial fibrillation and hypertension and was cognitively intact with a BIMS score of 14. A wound assessment on February 25, 2025, documented a left heel wound with serous drainage, requiring treatment with medical-grade honey and a bordered gauze dressing. Despite this, there were no physician orders for Enhanced Barrier Precautions at the time of the assessment. The Director of Nursing confirmed that the facility is responsible for ensuring the implementation of infection control procedures, including enhanced barrier precautions, in accordance with facility policy and nationally recognized guidelines. The deficiency was only addressed after surveyor inquiry, with physician orders for Enhanced Barrier Precautions initiated on March 20, 2025.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet the required nurse aide to resident ratios on 15 out of 21 shifts reviewed. The regulation mandates a minimum of 1 nurse aide per 10 residents during the day, 1 per 11 residents in the evening, and 1 per 15 residents overnight. However, the facility's staffing records showed consistent understaffing across multiple shifts. For instance, on February 4, 2025, the day shift had 7.13 nurse aides instead of the required 7.50 for a census of 75, and the evening shift had 5.23 nurse aides instead of the required 6.91 for a census of 76. Similar deficiencies were noted on subsequent days, with the facility failing to provide the necessary number of nurse aides based on the resident census. The deficiency was confirmed during an interview with the Nursing Home Administrator on February 11, 2025, who acknowledged that the facility did not meet the required nurse aide to resident ratios on the specified dates. Additionally, there were no higher-level staff available to compensate for the shortage of nurse aides during these shifts. This lack of adequate staffing was observed across various shifts, including day, evening, and night, indicating a systemic issue in maintaining the mandated staffing levels.

Plan Of Correction

Facility cannot retroactively correct past CNA to resident ratios. Facility is focusing on retention of existing nursing assistants and recruitment of new nursing assistants, through efforts of the Human Resources Manager and Nursing Administration. A corporate team has been identified to assist with recruiting efforts for nursing positions. Union SEIU has extended a free tuition for nurse aides as hired in ancillary positions. The scheduler has been educated regarding the CNA ratio regulatory requirements. Calculation of the daily CNA ratios will be completed and reviewed for accuracy by the scheduler/designee. Facility acquired OnShift platform for scheduling. Application alerts scheduler, DON, and Administrator when nursing ratios are not scheduled to be met so corrections, additions etc. can be made to meet minimum requirements. Daily ratios will be audited weekly X 4 weeks then monthly X 2 months. Audits will be reviewed at QAPI for compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to consistently provide the minimum required general nursing care hours of 3.2 hours per resident per day. A review of the facility's staffing levels revealed that on several dates in February 2025, the facility's direct care nursing hours per resident were below the required minimum. Specifically, on February 4, 5, 6, 7, 8, 9, and 10, the facility provided between 2.69 and 3.04 direct care nursing hours per resident, which did not meet the regulatory requirement. An interview with the Nursing Home Administrator on February 11, 2025, confirmed this deficiency in staffing levels.

Plan Of Correction

Facility cannot retroactively correct past nursing hours. The facility is focusing on retaining current nursing staff and recruitment using in-house recruitment resources and a company team to assist with recruitment, dedicated to only nursing applicants to correct nursing hours. The facility has contracted with 3 staffing agencies to augment facility employees for the nursing department. The facility is implementing staff incentives for current and new staff as well as reinforcing the facility call-off policy to deter unnecessary call-offs. NHA or designee will educate staff on incentives and the call-off policy. NHA/designee will audit nursing hours weekly for three weeks, then monthly for 3 months. Audits will be reviewed by QA monthly for 3 months to ensure compliance with POC.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a safe environment for a resident, leading to a fall and serious injuries. The resident, who was admitted with diagnoses including muscle weakness, congestive heart failure, and generalized anxiety disorder, was identified as being at high risk for falls. Despite this, the facility did not provide adequate supervision and assistance devices, such as leg rests on the resident's wheelchair, which were necessary to prevent accidents. On the day of the incident, the resident was being transported to the dining room by a nurse aide. During the transport, the resident leaned forward and fell out of the wheelchair, resulting in a 7 cm x 7 cm hematoma over the left eye, a laceration under the left eye, and a dislocated left shoulder. The resident was subsequently transferred to the hospital, where further examinations revealed a comminuted depressed fracture of the left orbital floor and a suspected nondisplaced fracture of the right orbital wall. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to implement effective safety measures, such as ensuring the use of leg rests during transport, which contributed to the resident's fall and subsequent injuries. This deficiency highlights the facility's failure to provide adequate supervision and assistance devices to prevent accidents, as required by regulations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet the required nurse aide to resident ratios on multiple occasions, as evidenced by a review of the facility's weekly staffing records. Specifically, the facility did not provide the minimum number of nurse aides per resident during the day, evening, and night shifts on 35 out of 42 shifts reviewed. For instance, on November 25, 2024, the day shift had only 5.20 nurse aides instead of the required 7.70 for a census of 77 residents. Similarly, on December 20, 2024, the night shift had only 3.13 nurse aides instead of the required 5.27 for a census of 79 residents. These deficiencies were consistent across several dates, indicating a pattern of inadequate staffing. The report highlights that no additional higher-level staff were available to compensate for the staffing deficiencies on the mentioned dates. An interview with the Nursing Home Administrator confirmed that the facility did not meet the required nurse aide to resident ratios on these occasions. The lack of sufficient nurse aide staffing could potentially impact the quality of care provided to the residents, although the report does not specify any direct consequences or risks resulting from this deficiency.

Plan Of Correction

Facility cannot retroactively correct past CNA to resident ratios. The facility is focusing on retention of existing nursing assistants and recruitment of new nursing assistants, through efforts of the Human Resources Manager and Nursing Administration. A corporate team has been identified to assist with recruiting efforts for nursing positions. The scheduler has been educated regarding the CNA ratio regulatory requirements. Calculation of the daily CNA ratios will be completed and reviewed for accuracy by the scheduler/designee. The facility acquired the OnShift platform for scheduling. The application alerts the scheduler, DON, and Administrator when nursing ratios are not scheduled to be met so corrections, additions, etc. can be made to meet minimum requirements. Daily ratios will be audited weekly for 4 weeks, then monthly for 2 months. Audits will be reviewed at QAPI for compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on 14 out of 42 reviewed shifts. The deficiency was identified through a review of the facility's weekly staffing records, which showed that on multiple dates, the number of LPNs on duty was below the required minimum for the facility's census. For instance, on November 28, 2024, there were only 2.19 LPNs on the evening shift, whereas 2.53 were required for a census of 76 residents. Similarly, on December 1, 2024, the evening shift had 2.16 LPNs instead of the required 2.53 for the same census. The deficiency was further confirmed through an interview with the Nursing Home Administrator on December 30, 2024, who acknowledged that the facility did not meet the required LPN to resident ratios on the specified dates. Additionally, there were no higher-level staff available to compensate for the shortage of LPNs during these shifts. This lack of adequate staffing was consistent across several dates in November and December 2024, affecting both day and night shifts.

Plan Of Correction

Facility cannot retroactively correct past LPN to resident ratios. The facility is focusing on retention of existing LPNs and recruitment of new LPNs, through efforts of the Human Resources Manager and Nursing Administration. An employer team has been established to assist the facility in recruitment and marketing for recruitment. LPN rates have been increased per new union contract with Embassy Healthcare, LLC. The scheduler has been educated regarding the LPN ratio regulatory requirements. Calculation of the daily LPN ratios will be completed and reviewed for accuracy by the scheduler/designee. Daily ratios will be audited weekly for 4 weeks, then monthly for 3 months. Audits will be reviewed at QAPI for compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to consistently provide the minimum required general nursing care hours of 3.2 hours per resident per day. A review of the facility's staffing levels revealed multiple instances where the nursing care hours fell short of this requirement. Specifically, on several dates in November and December 2024, the facility provided between 2.14 and 3.12 direct care nursing hours per resident, which is below the mandated minimum. This deficiency was confirmed during an interview with the Nursing Home Administrator on December 30, 2024.

Plan Of Correction

Facility cannot retroactively correct past nursing hours. The facility is focusing on retaining current nursing staff and recruitment using in-house recruitment resources and a company team to assist with recruitment, dedicated to only nursing applicants to correct nursing hours. The facility has contracted with 3 staffing agencies to augment facility employees for the nursing department. The facility is implementing staff incentives for current and new staff as well as reinforcing the facility call-off policy to deter unnecessary call-offs. NHA or designee will educate staff on incentives and the call-off policy. NHA/designee will audit nursing hours weekly for three weeks, then monthly for 3 months. Audits will be reviewed by QA monthly for 3 months to ensure compliance with POC.

Penalty

Fine: $92,49815 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to consistently provide individualized care to prevent the development of an avoidable mucosal membrane pressure injury for a resident. The resident, who was admitted with multiple diagnoses including cerebral infarction, protein-calorie malnutrition, and a stage 4 pressure ulcer on the left hip, was identified as being at mild risk for pressure sore development. Despite this, the facility did not adequately monitor and manage the resident's suprapubic catheter, which led to the development of a pressure sore on the underside of the resident's penis. The resident's care plan noted the use of a suprapubic catheter and the potential for pressure ulcers due to decreased mobility and catheter use. However, the facility failed to ensure proper positioning of the catheter tubing, which resulted in pressure on the resident's penis and the subsequent development of a mucosal membrane pressure injury. The injury was identified as pressure-related and was likely caused by the catheter use, as confirmed by a consultant wound specialist. Throughout the course of the resident's care, there were multiple instances where the facility did not document or address the resident's skin condition changes adequately. The facility's failure to provide appropriate catheter care and positioning led to the development of a pressure sore, causing the resident pain. The Director of Nursing confirmed that the facility did not ensure the catheter tubing was positioned to prevent pressure on the resident's penis, resulting in the pressure sore.

Penalty

Fine: $92,49815 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary supervision for a resident with known unsafe behaviors, resulting in a fall that caused serious injuries. The resident, who was admitted with vascular dementia, cognitive communication deficit, symbolic dysfunction, anxiety, and dysphasia, was assessed as a high fall risk. Despite being identified as requiring assistance with daily activities and transfers, the resident was non-compliant with safety devices and frequently attempted to ambulate independently, displaying confusion and unsafe behaviors. The resident's care plan included interventions such as ensuring the call light was within reach, encouraging its use, and using chair and bed alarms. However, the resident continued to exhibit behaviors like combativeness, non-compliance, and unsafe ambulation. On one occasion, the resident was found on the floor with injuries after attempting to ambulate without assistance, despite safety devices being in place. The incident report noted that the resident was non-compliant with safety instructions and was found barefoot, indicating a lack of adequate supervision. The Director of Nursing confirmed that the facility was aware of the resident's condition and behaviors but failed to provide the necessary level of supervision to prevent the fall and resulting injuries. The facility's policies on falls management and resident care were not effectively implemented, leading to the resident sustaining fractures to the left humeral head and nasal bone.

Penalty

Fine: $92,49815 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness. During an initial tour of the kitchen, several unsanitary practices were observed. These included a rack of clear plastic beverage pitchers with a white substance coating their surfaces, a ceiling tile with tan-colored circular staining above the beverage station, and an accumulation of dust on the coffee maker. Additionally, debris and dust were found behind the coffee maker and on the molding of a stainless-steel table. Another food/beverage preparation station had debris on the shelving, stained serving trays with dishes that were not covered, and thermal cups on a stained tray. The walk-in freezer had a broken door latch, an ill-fitting air curtain covered in frost with icicles dripping onto the floor, and cases of frozen food in direct contact with the floor. A fan pointed at the freezer door was covered with debris and dust, and ceiling tiles near the tray line area were splattered with a brown-colored substance. Further observations revealed a dirty broom leaning between the wall and kitchen preparation equipment, a microwave with food splattered on the handle, and two plastic containers of serving utensils with handles at the bottom and left uncovered. The cook's sink had a green cutting board with deep knife marks and was worn, and a black mobile cart had two unlabeled and undated clear plastic storage containers with cereal. The wall exiting the cook's area was peeling, and the tile baseboard was crumbling, leaving a gap. Ceiling tiles in the dish room area had a tannish-brown substance splattered on them. In the resident pantries, a ceiling tile near a vent had brown circular stains, and the top of a refrigerator had debris, dust, and food remnants. Another pantry had reddish stains on the floor around the refrigerator. These observations were confirmed by the Nursing Home Administrator, who acknowledged that the dietary department and equipment should be maintained in a sanitary manner to prevent foodborne illness.

Penalty

Fine: $92,49815 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. During the survey ending on May 21, 2024, the facility could not provide evidence of a developed assessment that addressed the specific and unique needs of its resident population and the available resources to meet these needs. Interviews with the Nursing Home Administrator (NHA) revealed that although the facility assessment was claimed to be included in the survey readiness binder, it was not presented to the survey team. Furthermore, despite the NHA's assertion that the assessment had been recently updated, the required document was still not provided by the conclusion of the survey.

Penalty

Fine: $92,49815 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain documentation and demonstrate evidence of its ongoing Quality Assurance Performance Improvement (QAPI) program. The facility's policy, last revised on August 29, 2022, outlines the commitment to a comprehensive, data-driven QAPI program focusing on care outcomes and quality of life. However, during the survey, it was found that the facility did not have documentation or evidence of an effective QAPI program. The policy requires maintaining documentation of systematic identification, reporting, investigation, analysis, and prevention of adverse events, as well as documentation of corrective actions or performance improvement activities. An interview with the Nursing Home Administrator (NHA) revealed that the facility had not conducted a QAPI meeting, and the NHA could not provide evidence of when the last meeting occurred. The NHA admitted to having other priorities, indicating a lack of focus on the QAPI program. The survey concluded with no evidence that the facility had developed, implemented, or maintained an effective QAPI program, violating the requirements outlined in 28 Pa. Code 201.14(a) and 28 Pa. Code 201.18 (b)(1)(e)(1).

Penalty

Fine: $92,49815 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement a quality assurance program to identify and address quality deficiencies, as required by federal regulations at 42 CFR S483.75 (g)(2). Specifically, the QAPI committee did not develop and implement appropriate plans of action to correct identified quality deficiencies, nor did it regularly review and analyze data, including data from drug regimen reviews, to make improvements. An interview with the Nursing Home Administrator on May 21, 2024, revealed that no actions aimed at performance improvement had been taken since the last annual survey completed on April 21, 2023.

Penalty

Fine: $92,49815 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a Quality Assurance Process Improvement (QAPI) Committee as required. During a review on May 21, 2024, the Nursing Home Administrator (NHA) was unable to provide evidence of attendance by staff, administration, or the Medical Director at QAPI Committee meetings. Additionally, the NHA could not produce sign-in sheets for meetings that should have occurred from April 2023 through April 2024. An interview with the NHA confirmed the absence of a functioning QAPI Committee during this period.

Penalty

Fine: $92,49815 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that essential equipment in the kitchen was in safe operating condition. During an observation of the dietary department, it was noted that the door latch of the walk-in freezer was broken, preventing it from securing properly and leaving a gap around the door's perimeter. Additionally, the seal around the freezer door was ill-fitting. Inside the freezer, the air curtain was also ill-fitting, covered in frost, and had icicles hanging from the plastic strips, which were dripping onto the floor, creating a slippery surface. The cases of frozen food and the wire metal shelves were encased in ice crystals. At the time of the survey, the Nursing Home Administrator could not provide documented evidence that the facility had addressed these ongoing issues to maintain resident food in a safe and sanitary manner.

Penalty

Fine: $92,49815 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to allow residents and their designated representatives to participate in the development and implementation of their person-centered care plans. This deficiency was identified during a resident group interview where five residents reported not being given the opportunity to participate in their care plan meetings. The residents involved were cognitively intact or had varying levels of cognitive impairment, as indicated by their BIMS scores, which ranged from 7 to 15. Clinical record reviews revealed that care plan meetings were held for each of the five residents, but there was no documentation indicating that the residents or their representatives were invited or participated in these meetings. The care conference forms lacked information on the residents' or their representatives' responses to the invitations, and there was no evidence that the care plans were provided to them for review after the meetings. Interviews with the Nursing Home Administrator (NHA) and residents confirmed the deficiency. The NHA stated that letters are typically provided to residents and their representatives to invite them to care plan meetings, but could not explain why the residents reported not receiving such invitations. Residents 19 and 30 specifically stated they were never provided with letters inviting them to participate in care plan meetings, highlighting a failure in the facility's responsibility to ensure resident participation in care planning.

Penalty

Fine: $92,49815 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to address and resolve resident grievances in a timely manner, as required by their Grievance Policy and Guidelines. The policy mandates that grievances should be resolved within ten working days, but the facility did not demonstrate timely action or keep residents informed about the status of their grievances. During a resident council meeting in February 2024, residents expressed concerns about cold food and coffee temperatures, and a grievance was filed. However, there was no documentation of actions taken to resolve this issue. By March 2024, the issue was reportedly resolved, but in April 2024, residents raised a new grievance about not being offered snacks, which was not documented in the grievance log. During a resident group interview in May 2024, residents reiterated ongoing concerns about food temperatures, snack availability, and long call bell wait times, indicating that these issues had not been resolved. The Nursing Home Administrator confirmed the facility's policy to resolve grievances promptly but could not provide evidence of efforts to address the residents' concerns. Residents reported that meals often sat in the hall for extended periods due to insufficient staff to distribute them, contributing to the cold food issue. Additionally, residents experienced delays in staff response to call bells, further exacerbating their dissatisfaction. The facility's failure to document and address these grievances, as well as the lack of communication with residents about the status of their concerns, highlights a significant deficiency in meeting resident rights and management standards.

Penalty

Fine: $92,49815 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a clean and safe environment for residents across two occupied care units. Observations revealed multiple deficiencies, including stained ceiling tiles, cracked floors, and exposed drywall in resident rooms. In the Nursing Hall shower room, a faucet was leaking, and the vent was covered in dust. Additionally, a toilet was missing a tank lid, and the shower stall had discoloration stains. Several resident rooms had broken or missing dresser drawers, and one dresser was heavily soiled with food and dried liquid. The medication/treatment supply room was found with a heavily soiled sink and a hole in the wall covered with plastic. Interviews with staff and the Nursing Home Administrator (NHA) confirmed the presence of dead animals in the walls, which contributed to the unsanitary conditions. The NHA acknowledged the need for repairs and replacements but was unable to provide evidence of purchase orders or prior identification of these issues. The facility's failure to address these maintenance and housekeeping deficiencies compromised the residents' right to a safe, clean, and homelike environment.

Penalty

Fine: $92,49815 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to consistently provide snacks as desired by residents, as evidenced by a review of resident council meeting minutes, facility policy, and interviews with residents and staff. The facility's policy indicated that nourishing snacks should be available for residents who need or desire additional food between meals, especially if the time span between the evening meal and the next day's breakfast exceeds fourteen hours. However, the scheduled mealtimes revealed that this time span was indeed exceeded, and residents reported not receiving snacks. During a resident council meeting, all attendees indicated they were not receiving snacks, and a grievance was filed on their behalf. Further investigation revealed that the facility's daily water and snack pass forms were often incomplete, with six out of thirteen forms lacking signatures and dates to confirm the task was completed. During a group interview, residents reported that snacks were only offered once or twice a month, and they often had to request assistance or obtain snacks themselves. The residents also mentioned that the facility frequently ran out of snacks and that staffing shortages might contribute to the issue. The Nursing Home Administrator was unable to explain why residents were not being offered snacks and admitted that the facility does not evaluate snack inventory levels to ensure consistent availability.

Penalty

Fine: $92,49815 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that medications were stored at the appropriate temperature according to the manufacturer's directions in one of the medication storage rooms, specifically the Blue Wing. During an observation, it was noted that the thermometer in the medication storage refrigerator read 26 degrees Fahrenheit, which is 6 degrees below freezing. This was in the presence of an LPN. The medications stored in this refrigerator included Lorazepam Intensol, Promethazine suppositories, and several types of insulin, such as Lantus Solostar, Novolog Flexpen, Victoza, Humalog Kwikpen, and Ozempic. The refrigerator temperature log for May 2024 indicated that the temperature should be maintained between 36 and 46 degrees Fahrenheit, and any malfunctions or fluctuations should be reported. However, the log showed a temperature of 36 degrees on the off-going shift prior to the observation. The Director of Nursing confirmed that the refrigerator was not at the correct temperature and informed the pharmacy about the issue. Manufacturer instructions for the medications indicated that they should be stored between 36 and 46 degrees Fahrenheit, and any frozen medications should be discarded. The Director of Nursing acknowledged that medications must be stored at the proper temperatures to maintain their integrity.

Penalty

Fine: $92,49815 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accommodate a resident's food preferences and provide planned oral gratification items, as observed during a survey. The resident, who has chronic obstructive pulmonary disease (COPD), diabetes, and gastroparesis, is dependent on tube feeding and is allowed specific items for oral gratification, such as lemon Italian ice and coffee. Despite these allowances being documented in the resident's care plan and meal tickets, the resident was not served the lemon Italian ice during observed lunch meals on two consecutive days. The resident expressed frustration over not receiving the lemon ice, stating that she is tired of repeatedly asking for it. During an interview, the Nursing Home Administrator (NHA) stated that the facility's policy requires the resident to purchase her own lemon Italian ice, despite the care plan and meal ticket indicating that it should be provided by the facility. The NHA could not provide a written policy supporting this requirement, instead stating it was their personal policy. This discrepancy between the care plan, meal ticket, and the NHA's statement highlights a failure in the facility's dietary services to meet the resident's documented needs and preferences.