Exton Post Acute

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

Surveyors identified a deficiency in the facility’s main kitchen related to improper storage and labeling of frozen food items in the walk-in freezer. On April 6, 2026, during observations conducted with the Food Service Director (Employee E7), surveyors noted multiple frozen food products stored in open cardboard boxes with the plastic inner bags unsealed, including a bag of frozen cookie dough, a bag of mixed frozen vegetables, a bag of frozen peas, a box of frozen hamburger patties, a box of frozen turkey burgers, and a bag of frozen French toast. The cardboard boxes containing these items were not closed, and the plastic bags inside were not sealed. Further observations on April 8, 2026, again in the presence of Employee E7, revealed additional improperly stored items, including an unsealed bag of frozen chicken nuggets, an open box of frozen hamburger patties, and an unsealed bag of cookie dough. In an interview on April 9, 2026, at 12:51 p.m., Employee E7 confirmed that these foods observed on April 7 and April 8 were not properly stored and labeled. These findings were communicated to the Nursing Home Administrator on April 9, 2026, and constituted a failure to ensure that food in the walk-in freezer was stored and labeled in accordance with professional food service safety standards, as required by 28 Pa. Code 211.6(f) Dietary services.

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 timely develop and implement comprehensive care plans for residents receiving dialysis. One resident was admitted with a diagnosis of end-stage renal disease (ESRD) and dependence on dialysis, with a physician’s order dated March 11, 2026, for dialysis every Tuesday, Thursday, and Saturday; however, review of the active care plan showed that a dialysis care plan was not developed until April 2, 2026. In an interview on April 9, 2026, an employee confirmed that this resident’s dialysis care plan was not developed until that date. Another resident was admitted on March 11, 2026, with ESRD and dependence on dialysis, and review of the active care plan revealed that the dialysis care plan for this resident was not developed until April 8, 2026. Staff interview on April 8, 2026, confirmed that the second resident’s comprehensive dialysis care plan was not developed until April 8, 2026. These findings showed that the facility did not ensure timely development of comprehensive dialysis care plans for two residents with ESRD and dependence on dialysis, as required by 28 Pa. Code 211.5(f) (Clinical records) and 28 Pa. Code 211.12(c) (Nursing services).

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’s care plan was updated and revised to reflect new care needs related to a C. difficile infection. Facility policy revised in March 2022 required that resident assessments be ongoing and that care plans be revised as information about the resident and changes in condition occur. One resident, who had no cognitive impairment, was dependent on staff for daily care needs, and had active diagnoses of cancer, heart failure, and diabetes, was transported to the hospital emergency room and subsequently tested positive for C. difficile. The hospital discharge summary documented that the resident was placed on special contact precautions and discharged with an order for oral vancomycin 125 mg four times daily for 10 days. Upon readmission, provider documentation on a later date recorded an assessment and plan for C. difficile infection, including discontinuation of systemic antibiotics in the absence of fever and leukocytosis and initiation of oral vancomycin. Despite these documented findings and treatment orders, the resident’s care plan initiated on readmission did not include a C. difficile care plan until several weeks later. The Infection Preventionist stated that when a resident develops or is admitted with an infection, nursing is to notify Infection Prevention so that the appropriate care plan can be initiated. The deficiency was identified when surveyors compared the clinical record, including MDS, progress notes, hospital discharge summary, and provider notes, with the timing of the care plan updates and found that the C. difficile care plan was not added in a timely manner.

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 follow physician orders for two residents with end stage renal disease (ESRD) who were dependent on dialysis. For one resident with ESRD, dependence on dialysis, and diabetes, physician orders dated March 11, 2026, included Sevelamer Carbonate 800 mg by mouth with meals at 8:00 a.m., 12:00 noon, and 5:00 p.m., and blood glucose checks with Insulin Lispro per sliding scale before meals and at bedtime. The resident’s dialysis schedule was ordered for Tuesdays, Thursdays, and Saturdays, with the resident typically leaving the facility around 7:30 a.m. and returning around 3:30 p.m. Review of the March 2026 MAR showed that the 12:00 noon Sevelamer dose was not administered on multiple dialysis days and was documented as “hold” or “absent from facility.” Additionally, the 11:30 a.m. blood sugar checks were not performed on several dates, also marked as “absent from facility” or “hold,” and there was no physician order to hold Sevelamer or to omit blood sugar checks and corresponding Lispro insulin on dialysis days. There was no documentation that the physician was notified of these missed medications or assessments. For another resident with ESRD, dependence on dialysis, hypertension, and depression, the resident reported a dialysis schedule of every Monday, Wednesday, and Friday, leaving around 6:30 a.m. and returning around 1:00 p.m. Physician orders dated March 11, 2026, included Amlodipine 10 mg by mouth once daily and Prozac 40 mg by mouth twice daily. Review of the April 2026 MAR revealed that the 9:00 a.m. doses of Amlodipine and Prozac were not administered on several dialysis days, with the MAR indicating “hold” or “absent from facility.” There was no physician order to hold these medications during dialysis times, and no documentation that the physician was notified of the missed doses. The DON confirmed that the medications were not administered because the residents were out for dialysis. These findings showed the facility did not ensure physician orders were followed for these residents, in violation of 28 Pa. Code 211.5(f) and 211.12(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

Surveyors found that the facility failed to follow a physician’s order for PICC line care for one resident. The resident was admitted with osteomyelitis of the lumbar vertebrae and had a right upper arm PICC line for IV ceftriaxone every 12 hours. The physician’s order directed that the PICC transparent dressing be changed on admission and then every seven days, with caps changed during the dressing change. The March and April medication administration records indicated that the dressing change order was signed off as completed every seven days. However, during observation, the resident was seen seated in his room with the right upper arm PICC transparent dressing halfway detached, and the date on the dressing was March 16, 2026, indicating it had not been changed as ordered. The resident reported that the transparent dressing had not been changed since that date. A subsequent observation in the presence of a staff member showed the dressing remained halfway detached and unchanged. Both the staff member and the Director of Nursing confirmed that the PICC line dressing should have been changed every seven days, demonstrating that the physician’s order for PICC line dressing changes was not followed.

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 follow and monitor ordered fluid restrictions for two dialysis residents with end stage renal disease (ESRD). Facility policies on ESRD care and on encouraging and restricting fluids required accurate recording of fluid intake in milliliters, removal of water pitchers and cups from the rooms of residents on fluid restrictions, and maintenance of intake and output records in the resident’s room and medical record. For one resident with ESRD and dependence on hemodialysis, a physician’s order dated April 2, 2026, specified a 1200 ml/day fluid restriction with defined amounts to be provided by dietary and nursing, and further broken down by nursing shift. Review of this resident’s April 2026 Medication Administration Record (MAR) showed no evidence that the amount of fluid received each shift was recorded, and the DON confirmed these findings. For another resident with ESRD and dependence on dialysis, a physician’s order dated April 1, 2026, specified a 1500 ml/day fluid restriction, with specific daily amounts to be provided by dietary and nursing and divided by shift. Review of this resident’s April 2026 MAR revealed that the fluid amount consumed each shift was not recorded. Multiple observations on different days and times showed a large white cup filled with water on the resident’s bedside table, despite the fluid restriction order and facility policy requiring removal of water pitchers and cups for residents on restricted fluids. In an interview, the resident reported that staff placed a big cup of water at the bedside and stated that it “just appears,” and the resident was unsure how much fluid they were allowed to consume each day. The DON confirmed that the fluid consumed by this resident each shift was not recorded, and the facility failed to ensure the ordered 1500 ml/day fluid restriction was properly monitored and followed.

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

Surveyors identified a deficiency in the facility’s failure to respond to and implement consultant pharmacist recommendations from monthly medication regimen reviews (MRRs) for multiple residents. Facility policy revised in July 2025 required a licensed consultant pharmacist to perform an MRR for every resident receiving medications, including review of the medical record to prevent, identify, report, and resolve medication-related problems or irregularities. For one resident with bipolar disorder, obesity, a right humerus fracture, a neurogenic bladder with Foley catheter, and multiple medications including antipsychotics, antidepressants, diuretics, opioids, and anticonvulsants, the pharmacist’s January 10, 2026 MRR recommended re-evaluating and reconciling prior orders for pantoprazole 40 mg, tamsulosin 0.4 mg, and zolpidem 10 mg. The provider checked “agree” with this recommendation, but review of physician orders and provider notes showed the facility did not address these recommendations. For another resident with significant cognitive impairment, heart failure, hypertension, non‑Alzheimer’s dementia, anxiety disorder, and multiple psychotropic and cardiac medications, the February 8, 2026 MRR recommended clarifying the indication for lorazepam and Seroquel due to lack of supporting diagnoses; as of early April, the facility had not addressed these recommendations, and the DON could not provide the pharmacist’s recommendations from a subsequent March 4, 2026 MRR. A third resident with mild cognitive impairment, cancer, heart failure, diabetes, and multiple medications including antidepressants, anticoagulants, antibiotics, diuretics, and insulin had a March 4, 2026 MRR recommendation to clarify the Voltaren gel order to include a dose, but the active order still lacked a dose. A March 18, 2026 MRR for this resident noted potassium chloride required a supporting diagnosis; although the physician documented agreement and wrote “hypokalemia,” the active potassium chloride order as of April 8, 2026 did not include a diagnosis. In an interview, the DON confirmed that the pharmacist’s recommendations had not been addressed for these three 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 deficiency involves the facility’s failure to implement transmission-based contact precautions for a resident with suspected Clostridioides difficile (C. diff) infection, contrary to its own infection control policy. The facility’s policy, last revised in December 2024, states that residents with diarrhea and suspected C. diff infection are to be placed on contact precautions while laboratory results are pending. Nurse Practitioner notes for the resident showed that the resident reported multiple liquid stools and a stool sample was ordered and collected to rule out C. diff. Subsequent nursing and health status notes documented that the resident continued to experience diarrhea, loose stools, chills, and aches over the following days. Review of the resident’s physician orders showed an existing order for Enhanced Barrier Precautions but no order for contact precautions. Observations of the resident’s room on multiple days revealed there was no signage indicating contact precautions and no personal protective equipment available in the room. At the time of the survey exit, the stool test results were still pending. The facility Infection Preventionist confirmed in an interview that the resident had been tested for C. diff and should have been on contact precautions while results were pending, consistent with facility policy.

Penalty

Inspection fine: $59,325

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 a resident’s code status was clearly documented and readily available in the clinical record, which delayed the decision to provide life-sustaining measures such as CPR. The American Heart Association (AHA) guidelines and the facility’s own CPR policy both state that CPR should be initiated for an unresponsive individual unless there is a valid DNR order or clear, irreversible signs of death. The facility’s policy further specifies that if a resident’s DNR status is unclear, CPR must be initiated and continued until a DNR or physician’s order not to administer CPR is confirmed. In this case, the resident’s hospital records and the attending physician’s encounter note documented the resident as “Full Code,” indicating the resident wished to receive all possible life-saving interventions. The resident, identified as CL1, had been admitted from the hospital with acute respiratory failure with hypoxia and atrial fibrillation, and the hospital emergency room record and physician encounter note both documented a Full Code status. However, the facility’s physician orders for the resident did not contain any order for code status, and the code status was not displayed where staff expected to find it in the EMR or on the nurse’s sheet. On the night of the incident, the resident was last known to be responsive around 2:30 a.m. when an aide reported the resident rolled over and drank water. The nurse assigned to the resident observed the resident at midnight with a BIPAP mask on and again around 3:30 a.m. sleeping with a nasal cannula, noting the resident had a habit of removing the BIPAP mask. Shortly before 5:00 a.m., an aide called the assigned nurse (Employee E4) to check on the resident. The nurse found the resident lying supine, appearing normally pale, and reported not feeling a pulse at the wrist or neck. Because the code status was not listed on the nurse’s sheet, the nurse and the nursing supervisor (Employee E3) spent approximately 10 minutes looking for the code status in the EMR, during which time an aide remained with the resident. The code status could not initially be found in the computer, and no CPR was started. The supervisor assessed the resident as gray, cool, with no breath sounds, no carotid or radial pulse, eyes closed, mouth open, and mottling on the legs, and later located documentation in the EMR under a miscellaneous section indicating the resident was Full Code. Despite this, CPR was not initiated. The DON confirmed that the resident’s code status should have been reflected in the EMR banner and on physician orders but was not, and also confirmed that staff did not initiate CPR, citing their belief that the resident showed irreversible signs of death. The surveyors concluded that the assessments described by staff did not meet the AHA or facility policy criteria for irreversible signs of death, and that the failure to document and locate the code status and to initiate CPR in accordance with the resident’s Full Code status constituted an Immediate Jeopardy situation.

Removal Plan

• Completed a full house audit of all residents to determine presence of code status and presence of a physician order.
• Reviewed CPR drills.
• Provided licensed staff education on CPR policy and procedures, including general guidelines with focus on assessment of unresponsive residents, when to initiate CPR, and identification of irreversible signs of death.
• Taught licensed staff that code status will be in PCC on the code status banner.
• Educated licensed staff on the Emergency Code documentation form, including the narrative of details during the code.
• Educated licensed staff on compliance with physician orders related to the provision of CPR when indicated.
• Updated licensed staff orientation to include CPR and procedures, Emergency Code Documentation, and compliance with physician order.
• Audited the order listing report and admission/readmission documentation for presence of code status and corresponding order in PCC.
• Audited effectiveness of licensed staff training via questionnaires and on-the-spot interviews.
• Presented and reviewed all ongoing compliance audits at the QAPI meeting.
• Completed a code drill to ensure licensed nurses were prepared to respond to situations that required CPR.
• Scheduled remaining staff to receive the education prior to the start of their next shift.

Penalty

Inspection fine: $59,325

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 follow a physiatrist’s recommendations for monitoring a resident’s urinary status. The resident, identified as CL2, was admitted with COVID, shingles, a recent fall requiring rehab, bowel and bladder incontinence, altered mental status, encephalopathy, and BPH. A Physical Medicine and Rehab note documented that, as part of the assessment and plan for BPH, the physiatrist recommended monitoring urine output and post-void residuals (PVRs). However, a review of the resident’s physician orders did not show any orders for urine output or PVR monitoring. During an interview, the DON stated that nursing staff were not aware of the physiatrist’s recommendations and, as a result, these recommendations were not communicated to the primary physician. The DON confirmed that the recommendations for urine output and PVR monitoring were not implemented. The surveyors determined that the facility failed to ensure that the physician’s recommendations for urine and PVR monitoring were followed for this resident, in violation of 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services and 28 Pa. Code 211.5(f) Clinical Records.

Penalty

Inspection fine: $59,325

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 carry out ordered laboratory tests (CBC and CMP) in a timely manner for one resident. The resident had a diagnosis of metabolic encephalopathy and behavioral disturbances. On February 4, 2026, the NP documented the resident’s condition, and a physician order was written the same day for a CBC and CMP to be completed on February 5, 2026. The February 2026 Treatment Administration Record indicated that the CBC and CMP order was entered as being done on February 4, 2026, even though the order specified testing on February 5, 2026. A review of the resident’s laboratory results showed that the CBC and CMP ordered for February 5, 2026, were not actually performed until February 11, 2026. The February 11 blood work revealed abnormal values, including an elevated WBC of 16.8, creatinine of 2.86, and BUN of 79. A physician order dated February 11, 2026, included an order for 0.45% sodium chloride IV hydration. During an interview, the DON stated that the February 5 blood work order had not been entered into the laboratory system and therefore was not completed as ordered, and that this missed blood work was not identified until an audit on February 10, 2026. The DON confirmed that the laboratory order for February 5, 2026, was not followed in a timely manner.

Penalty

Inspection fine: $59,325

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 facility leadership, specifically the Nursing Home Administrator (NHA) and the Director of Nursing (DON), to effectively manage and oversee care so that cardiopulmonary resuscitation (CPR) was provided in accordance with facility policy and procedures for a resident who was designated as FULL CODE. Review of the NHA job description showed that this role carries administrative authority, responsibility, and accountability for directing the activities and programs in the center, while the DON job description assigns responsibility for planning, developing, organizing, evaluating, and directing the nursing service department and its programs in accordance with current rules, regulations, and guidelines governing nursing care facilities. Survey findings determined that, despite these defined responsibilities, the facility did not ensure that CPR was carried out as required for a FULL CODE resident, resulting in noncompliance with facility policy and procedures. As a result, the NHA and DON were found to have failed to fulfill their essential job duties to ensure that federal and state guidelines and regulations related to CPR and nursing services were followed, as cited under F678 and multiple sections of 28 Pa. Code regarding licensee responsibility, management, administrator’s responsibility, and nursing services.

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 physician's order for Warfarin medication from the hospital was followed and accurately communicated to the facility's physician for a resident admitted with diagnoses including falls and atrial fibrillation. Upon admission, the resident had a hospital order to hold Warfarin due to a critically high INR level, with instructions for a repeat blood test on the following Monday. However, the facility administered a total of 9 mg of Warfarin to the resident on the evening of admission, based on an outdated order from March 2022, rather than following the most recent hospital instructions to hold the medication. Review of clinical records and staff interviews revealed that the admitting nurse did not communicate the hospital's hold order to the facility's NP, who then ordered the outdated Warfarin dose. As a result, the resident experienced an elevated INR and was subsequently sent to the emergency room, where further complications including multiple falls, possible rib fractures, and a hematoma were documented. The deficiency was attributed to the breakdown in communication and failure to verify and implement the current physician's orders from the hospital.

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 its policy regarding employee background checks as required by the Older Adults Protective Services Act. Specifically, one employee was hired without the completion of a federal criminal background check, despite not having been a resident of Pennsylvania for the two years prior to their application. Review of the personnel file and interviews with both the employee and another staff member confirmed that the federal background check application had not been completed. The facility's policy, revised in April 2021, required such checks to be performed, but there was no documented evidence that this was done for the employee in question.

Penalty

Inspection fine: $10,358

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

A deficiency occurred when a resident was not administered a prescribed anticoagulant medication, Apixaban, upon admission to the facility. The resident had a complex medical history, including a recent femur fracture, Type 2 Diabetes Mellitus, cerebral infarction, peripheral vascular disease, anemia, and atrial fibrillation. The hospital discharge summary listed Apixaban as one of the medications to be continued, but a review of the clinical record and medication administration record revealed that there was no physician's order or documentation of Apixaban being administered from the date of admission through several days after. The omission resulted from a transcription error during the medication reconciliation process. A registered nurse assisting with multiple admissions noted a confusing instruction on the hospital discharge summary regarding Apixaban, which stated to "resume" the medication on a specific date. The nurse communicated this concern to the LPN on duty and instructed them to follow up, but the LPN did not do so, and the medication was not entered into the system. As a result, the resident missed ten days of Apixaban therapy. The resident subsequently developed a cold, pulseless left foot and was evaluated by a physician, who recommended an immediate arterial doppler. Due to the unavailability of a technician, the resident was transferred to the hospital, where they were diagnosed with a popliteal artery embolism and underwent a thrombectomy. The omission of Apixaban was identified during a readmission review, confirming that the medication error had compromised the resident's clinical condition and resulted in actual harm requiring hospitalization.

Penalty

Inspection fine: $43,173

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 assist a resident, identified as Resident 43, in making transportation arrangements to attend multiple orthopedic surgery appointments. This resulted in the resident missing appointments due to the inability to cover the out-of-pocket expenses for the medical transportation service used by the facility. The resident's condition worsened, leading to a deterioration of a surgical wound and subsequent hospitalization for wound treatment. Interviews with the resident and staff revealed that alternative transportation options were not explored, and the resident expressed dissatisfaction with the facility's handling of the situation. Additionally, the facility did not follow a physician's medication order for another resident, identified as Resident 30. The resident, who had a history of acute respiratory failure and pulmonary embolism, was prescribed Enoxaparin Sodium Injection for DVT. However, the medication was not administered on several occasions despite being available in the facility for emergency use. The clinical records did not indicate that the physician was notified of the missed doses, and the Director of Nursing could not provide an explanation for the failure to administer the medication. These deficiencies highlight the facility's failure to provide appropriate treatment and care according to orders and the residents' needs. The lack of transportation arrangements for Resident 43 and the failure to administer prescribed medication to Resident 30 resulted in actual harm and potential risks to the residents' health and well-being.

Penalty

Inspection fine: $43,173

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 supervision and assistance to Resident 20, resulting in a fall that caused significant harm. Resident 20, who was admitted with a post-right below knee amputation and other medical conditions, required partial/moderate assistance with toilet transfers as per the Minimum Data Set assessment. The care plan developed for the resident specified that two persons were needed to assist with toilet transfers and toileting hygiene. However, on October 21, 2024, the resident was being transferred to the toilet by only one nurse assistant, contrary to the care plan's requirements. During this transfer, the resident attempted to use the right leg, leading to a fall that caused the surgical incision on the right leg to open, resulting in copious bleeding. Following the fall, Resident 20 was sent to the hospital where the right below knee amputation incision was found to be open and actively bleeding. The hospital records indicated that the resident usually had two staff members assisting with transfers, but only one was present at the time of the incident. The resident underwent additional surgical procedures, including a BKA washout and wound vac placement, and required blood transfusions due to a drop in hemoglobin levels. The incident was confirmed by the Director of Nursing, who acknowledged that only one person assisted the resident during the fall, leading to the resident's hospitalization and further surgical treatment.

Penalty

Inspection fine: $43,173

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 proper infection control practices for residents requiring Enhanced Barrier Precautions (EBP) and for a resident with COVID-19. Observations revealed that for seven residents reviewed, there was a lack of EBP signage and personal protective equipment (PPE) available outside their rooms. Specifically, Resident 8, who had a partial traumatic amputation and diabetic complications, and Resident 13, with a pressure ulcer, did not have EBP signage or PPE in place. Similarly, Resident 20, with a surgical wound, and Resident 21, with an arterial wound, also lacked EBP signage and PPE. Residents 30 and 46, both with gastrostomy tubes, were observed without EBP signage or PPE outside their rooms. Additionally, Resident 105, who was on transmission-based precautions for COVID-19, was found to have inadequate infection control measures in place. Observations in Resident 105's room revealed the absence of a bin for used PPE, and used gowns and gloves were found improperly disposed of on the bathroom floor and handrail. The Director of Nursing confirmed that the necessary precautions were not in place for these residents, despite meeting the criteria for EBP and transmission-based precautions.

Penalty

Inspection fine: $43,173

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 report a fall incident involving a resident to the state agency in a timely manner. The resident, who was cognitively intact and required partial/moderate assistance with toilet transfers, experienced a fall while being assisted by a nurse assistant. The fall resulted in the reopening of a surgical incision on the resident's right leg, leading to profuse bleeding and necessitating hospital admission for evaluation and repair. The facility's policy mandates immediate reporting of such incidents to the state agency and other relevant authorities, but the incident was not reported until nearly three months later, after a surveyor requested an investigation. The resident's care plan, developed prior to the incident, specified the need for two-person assistance during toilet transfers, but this protocol was not followed at the time of the fall. The resident reported that only one staff member assisted them, contrary to the care plan's requirements. The Director of Nursing confirmed that the incident was not reported to the state agency until prompted by the surveyor, indicating a failure to adhere to the facility's reporting policy and state regulations.

Penalty

Inspection fine: $43,173

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 investigate a fall incident involving Resident 20, who was admitted with a post-right below knee amputation and other medical conditions. The resident required partial/moderate assistance with toilet transfers, as documented in their care plan, which specified a two-person assist for such transfers. However, during an incident shortly after admission, a single male staff member attempted to assist the resident with a transfer, resulting in the resident losing balance and falling. This fall caused the resident's surgical incision to open, leading to hospitalization for wound dehiscence and bleeding. Despite the severity of the incident, the facility did not conduct a timely investigation. The Director of Nursing completed an incident report only after being prompted by a surveyor, and no further investigation documents were provided. The facility's policy requires all incidents to be thoroughly investigated and reported, but this protocol was not followed, and the responsible staff member was not identified. This lack of investigation and documentation represents a failure to ensure adequate assistance and supervision, which directly led to the resident's hospitalization.

Penalty

Inspection fine: $43,173

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 wound care for a resident with a Stage 3 pressure ulcer on the midback. The resident was admitted with this condition, and a physician's order was given to cleanse the wound with normal saline, apply Hydrogel, and cover with Optifoam dressing every other day. However, a wound physician later recommended daily treatment with a bordered dressing, which was not implemented until seven days later, resulting in missed treatments. The wound nurse, responsible for updating the treatment orders, admitted that the change was overlooked, and there was no documentation of the physician being notified about the missed treatments. Subsequently, the resident's condition worsened, with the pressure ulcer becoming unstageable and increasing in size. A new order for Santyl treatment was issued but was not implemented until ten days later. The wound nurse could not provide an explanation for this delay. The failure to implement timely wound care was communicated to the Director of Nursing, highlighting a pattern of non-compliance with wound treatment orders, as evidenced by previous citations.

Penalty

Inspection fine: $43,173

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 obtain baseline weight and re-weight for significant weight change for two residents, leading to delayed nutritional interventions. Resident 28 was admitted with acute respiratory failure, dysphagia, and moderate protein-calorie malnutrition. A discrepancy in the baseline weight was noted, but the re-weight was delayed by three days, resulting in a significant weight loss of 11.48% from the hospital weight. The dietitian, Employee E3, struck out the initial weight and failed to provide a reason for not conducting a timely re-weight, which delayed necessary interventions. Resident 105, admitted with a cerebral vascular accident, dysphagia, and a gastrostomy tube, did not have a baseline weight taken upon admission. The hospital weight was incorrectly used as the baseline, and the nutritional assessment noted severe underweight and muscle wasting. The facility also failed to document whether the resident received the prescribed total volume of enteral feeding, which was crucial for monitoring nutritional intake. Employee E3 confirmed these oversights, which hindered appropriate and timely nutritional interventions.

Penalty

Inspection fine: $43,173

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 annual performance reviews were completed for five staff members, identified as E8, E9, E10, E11, and E12. This deficiency was identified through a review of staffing records and performance reviews, which revealed that these staff members did not have their performance reviews conducted within the appropriate timeframe. The Director of Nursing (DON) confirmed during an interview that the performance reviews were not completed in a timely manner.

Penalty

Inspection fine: $43,173

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 appropriate indication and consistently attempt non-pharmacological interventions before administering anti-anxiety medication to a resident. The resident, who has a history of traumatic brain injury, anxiety disorder, and depression, was prescribed Clonazepam, an anti-anxiety medication, to be taken as needed for anxiety. However, the medication was administered 27 times within a 21-day period without appropriate indication beyond anxiety, and 19 of those times, no non-pharmacological interventions were attempted prior to administration. This deficiency was identified through a clinical record review and staff interview, revealing that the facility did not adhere to the requirement of attempting non-pharmacological interventions before resorting to medication. The issue was discussed with the Director of Nursing, highlighting the facility's failure to ensure that the resident received appropriate care in line with regulatory standards.

Penalty

Inspection fine: $43,173

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 storage and labeling of medications on two medication carts, 1 East medication cart 1 and 2. During an observation, it was found that several medications, including Tylenol, Mucinex, Simethicone, Imodium, and Bisacodyl suppositories, were not stored in their original containers on cart 1. Additionally, two Lispro insulin pens were opened and undated. Employee E4 confirmed that medications should be in their original containers and that insulin pens should be dated once opened. On cart 2, similar issues were observed, with loose Xarelto tablets, Mucinex, and Bisacodyl suppositories not in their original packaging. Furthermore, three Degludec insulin pens, one Lispro insulin pen, one Aspart insulin pen, and one Lispro insulin vial were opened and undated. Employee E5 confirmed that medications should be in their original containers and that insulins should be dated when opened. These findings were discussed with the Director of Nursing, highlighting the facility's failure to adhere to proper medication storage and labeling protocols.

Penalty

Inspection fine: $8,824

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 complete necessary skin assessments for a resident, leading to the development of a stage 3 pressure ulcer. The facility's policy on skin integrity and wound management requires risk evaluations and skin assessments at specific intervals, including upon admission, weekly for the first month, quarterly, and with significant changes in condition. Despite these requirements, the resident's clinical record showed that skin assessments were not conducted from May 11, 2024, to June 6, 2024. This lack of monitoring resulted in the resident developing a stage 3 pressure ulcer on the sacral region, as confirmed by a wound care consult on June 12, 2024. The resident, who was admitted with conditions including a fracture of the neck of the left femur, Lewy Bodies Dementia, and Parkinson's disease, was identified as being at high risk for pressure ulcers. The admission Braden Assessment and baseline care plan both highlighted the need for daily observation of skin conditions. However, the facility did not adhere to these protocols, as confirmed by interviews with the wound specialist and the Director of Nursing. The failure to conduct regular skin assessments and monitor the resident's skin condition directly contributed to the development of the pressure ulcer, causing actual harm to the resident.

Penalty

Inspection fine: $8,824

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 ordered by the physician were available and administered to Resident CL1. A review of Resident CL1's physician's order dated July 24, 2024, indicated that Alpha-Lipoic oral tablet was prescribed to be given once daily for neuropathy. However, the medication was not administered from July 24, 2024, until August 3, 2024, as it was awaiting delivery from the pharmacy. Additionally, a physician's order dated July 26, 2024, for Medrol oral tablet therapy pack was not administered on July 26 and 27, 2024, due to untimely delivery by the pharmacy. Interviews with the Director of Nursing on August 19, 2024, confirmed that the medications were not administered because the pharmacy did not deliver them in a timely manner. This resulted in the facility's failure to provide the necessary pharmaceutical services to meet the needs of Resident CL1, as required by the physician's orders.

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 accurate and timely weight monitoring for a resident receiving gastrostomy tube feeding, which is crucial for maintaining their health. The resident was admitted for skilled rehabilitation and had an initial weight recorded using a bed scale, which the facility later confirmed they did not possess. This discrepancy in equipment availability raises concerns about the accuracy of the initial weight measurements. Subsequent weights were taken using different methods, leading to a significant and questionable weight loss of 33.5 pounds in one day, which was not promptly re-evaluated. The dietitian identified the significant weight change and requested a reweight, suspecting an error in the initial measurement. However, the reweight was delayed by six days, contrary to the facility's protocol requiring reweighting within 24 hours of identifying a significant weight change. Interviews with the dietitian and a licensed nurse confirmed the procedural lapse, highlighting a failure in the facility's weight monitoring process. This deficiency was communicated to the Nursing Home Administrator, emphasizing the need for accurate and timely weight assessments to ensure resident health.

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 safe and sanitary food preparation and storage in the main kitchen, as evidenced by several observations and staff interviews. During an observation, kitchen Employee E4 was seen preparing food without wearing a hair and beard restraint, which is a violation of the facility's policy on food safety. Additionally, the walk-in refrigerator contained several items that were improperly labeled or lacked necessary dates. These items included a large container of barbeque sauce with an open date but no discard date, a container of picante sauce with a past discard date, grape jelly with a past use-by date, and a gallon of thousand island dressing with no open or discard date. Furthermore, marinated chicken and cut beans were stored without preparation or use-by dates. In an interview, the Food Service Director, Employee E5, confirmed that Employee E4 should have been wearing a hair and beard restraint while preparing food. Employee E5 also could not provide information on when the marinated chicken and beans were prepared, as they were off during the weekend. This lack of oversight and adherence to food safety protocols was discussed with the Nursing Home Administrator, highlighting the facility's failure to comply with its own food and nutrition services policies and procedures.

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 activities of daily living (ADL) care, specifically bathing, to two dependent residents. Resident 1's Power of Attorney reported that the resident had not received a shower since admission. A review of Resident 1's clinical record confirmed the absence of documented showers since admission. Similarly, Resident 5's clinical record indicated that the resident was only showered once during their stay at the facility, as reported by a family member. The Director of Nursing confirmed that each resident was assigned shower days and should be showered at least twice a week, but there was no documented evidence that this was done for Residents 1 and 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 provide pharmacy services for Resident 2, who was admitted with physician orders for Symbicort inhaler to be administered twice daily and Adderall to be administered three times daily. Upon review of Resident 2's Medication Administration Record (MAR) for March 2024, it was found that the resident did not receive the Symbicort from admission until discharge on March 24, 2024. Progress notes indicated that the Symbicort was not administered because it was on order from the hospital and awaiting delivery from the pharmacy. Additionally, the resident did not receive Adderall during the same period, with progress notes stating that the medication was not available in the facility's emergency medication storage system and was awaiting delivery from the pharmacy. An interview with the Director of Nursing on April 25, 2024, confirmed that the medications were not administered as ordered by the physician due to delays in delivery from the pharmacy. This failure to provide timely pharmacy services resulted in the resident not receiving essential medications as prescribed. The deficiency was cited under 28 Pa. Code 211.9(a)(1) Pharmacy Services, 28 Pa. Code 211.12(3)(5) Nursing Services, 28 Pa. Code 201.14(a)(b) Responsibility of licensee, and 28 Pa. Code 201.18 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 timely assess, monitor, and treat Resident 222 for suspected laundry detergent poisoning. The resident, diagnosed with dementia and unable to articulate due to cognitive impairment, was found with open laundry detergent pods in their room. Despite this, the staff did not immediately assess the resident or notify the physician. The resident was later found with vomiting and diarrhea, but the staff still did not contact Poison Control or research symptoms of laundry detergent poisoning at that time. The nursing progress notes and witness statements revealed that the resident was found with the pods at 3:30 p.m., but no vital signs were taken, and the physician was not notified. The resident began showing symptoms of distress around dinner time, but the staff's response was delayed. It was not until 8:30 p.m. that the resident was given a shower and assessed, and the on-call provider was contacted, who then ordered the resident to be sent to the hospital. Upon arrival at the hospital, the resident was admitted to the ICU with severe symptoms, including vomiting bright orange emesis with the odor of detergent, aspiration, and required high-flow nasal cannula oxygen, IV fluids, IV antibiotics, bronchodilators, and frequent suctioning. The facility's interim administrator and corporate nurse confirmed that the staff failed to timely assess, monitor, and treat the resident for the suspected poisoning.

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 cognitively impaired resident, resulting in actual harm. Resident 222, diagnosed with advanced dementia, was found with opened laundry detergent pods in their room. Despite the discovery, the resident was not immediately assessed, and vital signs were not documented. The resident later exhibited symptoms of poisoning, including vomiting and diarrhea, but staff did not contact Poison Control or the physician promptly. The resident was eventually hospitalized in the ICU with severe symptoms, including aspiration and respiratory distress. The incident began when a nurse aide found the resident with opened detergent pods and reported it to a nurse. However, the nurse did not take immediate action to assess the resident or notify the physician. Later, the resident showed signs of distress, including vomiting and diarrhea, but the staff still did not contact Poison Control. The resident's condition worsened, leading to hospitalization in the ICU, where they required intensive treatment, including high-flow nasal cannula oxygen, IV fluids, antibiotics, and frequent suctioning. The facility's documentation and clinical records failed to show timely assessment, monitoring, or treatment of the suspected poisoning. The staff did not follow the facility's policy on poisoning, which required immediate action and notification of emergency services. The failure to provide a safe environment and timely medical intervention resulted in significant harm to the resident.

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 performance reviews were completed for five staff members, identified as E6, E7, E8, E9, and E10. Upon review of staffing records and performance reviews, it was found that these staff members did not have their annual performance reviews performed within the appropriate timeframe. This deficiency was confirmed during an interview with the Corporate Nurse, who acknowledged that the performance reviews were not completed timely. The Corporate Nurse also mentioned that a performance plan has been made to catch up on the past due staff performance reviews.

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 residents were free from significant medication errors for three residents. Resident 3, diagnosed with a seizure disorder, missed multiple doses of Phenytoin due to awaiting pharmacy delivery, despite the medication being available in the facility's automated dispensing machine. The Director of Nursing confirmed that the resident should have received the missed doses. Resident 67, readmitted with osteomyelitis, missed seven doses of the prescribed antibiotic Piperacillin, which was also available in the facility's automated dispensing machine. The clinical record did not provide a reason for the missed doses, and an employee was unable to explain the omission during an interview. Resident 81, admitted with an infected surgical wound, had a critical Vancomycin trough result and was ordered to hold the medication and recheck the levels before the next dose. Despite this, the resident's IV Vancomycin was administered without checking the trough level, and the clinical record did not document the required laboratory check. An interview confirmed the medication was administered as documented, and no incident report was completed for the error. The nurse involved in the incident no longer works at the facility.

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 nurse aides received the minimal 12 hours of annual training required. This deficiency was identified through a review of staffing records and interviews with staff. Specifically, five staff members (Employees E6, E7, E8, E9, and E10) did not receive the mandated training. The Corporate Nurse (E3) confirmed during an interview that the staff did not complete the required training hours. This lapse in training was acknowledged by the Corporate Nurse, who also mentioned that a performance plan has been made to address the overdue training.

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 blood work ordered by the physician for Resident 257 was completed. Resident 257, who has diagnoses including Alzheimer's disease, Parkinson's disease, and weakness, was seen by the physician due to concerns about increased lethargy and inability to participate in therapy. The physician ordered a decrease in psychotropic medication, a Neurology consult, and blood work (CBC and BMP) to be completed on February 8, 2024. However, the clinical record did not show that the blood work was completed on the specified date, nor was there any documentation that the physician was notified of the missed blood work. An interview with the Corporate Nurse confirmed that the laboratory did not come to the facility to take the resident's blood, resulting in the blood work order not being completed. This failure to complete the physician-ordered laboratory blood work for Resident 257 constitutes a deficiency in providing timely and quality laboratory services to meet the needs of the resident, as required by the relevant 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 notify the physician of a significant weight change for a resident who was admitted after brain surgery for a tumor resection and had additional diagnoses of Diabetes and Chronic Kidney Disease. The resident's weight increased from 297.1 pounds to 362 pounds within five days, a 65.1-pound gain. Despite this significant change, the physician was not informed until the resident reported the concern on March 5, 2024. The dietitian noted the weight change but attributed it to scale variance and did not take further action. Interviews with the dietitian and another staff member confirmed that the physician was not notified of the significant weight change in a timely manner. The facility's failure to ensure timely notification of the physician about the resident's significant weight change constitutes a deficiency in compliance with the relevant health 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 ensure a baseline care plan was developed for a resident within 48 hours of readmission. The facility's policy requires a baseline person-centered care plan to be implemented within 48 hours of admission or readmission. Resident 67, who was readmitted with a diagnosis of Osteomyelitis to the sacrum, had a physician's order for intravenous antibiotics to treat a wound infection. However, a review of Resident 67's care plan revealed that no baseline care plan was developed for the administration of IV antibiotics. This deficiency was confirmed during an interview with Employee E3.

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' weights were appropriately monitored and significant weight loss was timely addressed for two residents. Resident 3's clinical record did not contain any weights from the time of admission through the duration of the survey. The dietitian confirmed that an admission weight and weekly weights should have been obtained, and using the hospital weight was not acceptable. This failure to monitor Resident 3's weight is a clear deviation from the facility's policy, which mandates weights upon admission and weekly for four weeks thereafter. Resident 67 experienced a significant weight loss of 40.4 pounds (17.91%) within eight days, but the weight was not re-checked, and the physician was not notified. The significant weight loss was identified on November 30, 2023, but it was not addressed by the dietitian until December 13, 2023. The dietary note indicated that the resident's intake was documented at 100%, but the resident stated he only ate about 50%. This delay in addressing the significant weight loss and the failure to notify the physician are clear deficiencies in the facility's care for Resident 67.