Forest Park Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Carlisle, Pennsylvania.
- Location
- 700 Walnut Bottom Road, Carlisle, Pennsylvania 17013
- CMS Provider Number
- 395270
- Inspections on file
- 44
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Forest Park Nursing And Rehabilitation during CMS and state inspections, most recent first.
A dependent resident with hemiplegia, dementia, and a history of CVA, care planned for Hoyer lift with two-person assist, a scoop mattress, a body pillow on the right side at all times in bed, and a low bed position, was found prone on the floor between the bed and the wall with a frontal scalp laceration requiring sutures. Documentation showed the resident was totally dependent for bed mobility and did not move or roll without maximal assistance, yet earlier that day the body pillow was documented as not in place. Staff reported the bed was at waist level and in a tilted position, the resident was leaning off the bed, there was no body pillow on the right side, and a clean brief was on the bed as if care was being provided. The NHA confirmed the bed was tilted and that staff attempted to grab the resident but could not explain how a non-mobile resident came to be leaning off the bed, demonstrating a failure to implement care-planned safety interventions and provide adequate supervision to prevent the accident.
A resident with dysphagia, GERD, and a BIMS score indicating normal cognition was moved from a prior room to a locked dementia unit after staff and the social worker, in consultation with the resident’s POA, determined the resident was an elopement risk despite already wearing a wander guard. The resident reported not consenting to the move and not receiving written notice, and clinical notes documented that the resident was upset and disagreed with the room change. The NHA confirmed the decision to move the resident was made when the resident expressed a desire to leave, and the facility could not produce any written room change notification provided to the resident prior to the move.
A resident with paraplegia and multiple pressure injuries, including a sacral stage 4 ulcer and heel wounds, did not receive properly documented wound assessments as required by facility policy and professional standards. Although there were physician orders for specific wound care and weekly body audits, staff-completed audit forms failed to note existing pressure ulcers, and the clinical record lacked wound descriptions and measurements over extended periods. After a hospitalization and readmission, a skin evaluation listed pressure ulcers on the coccyx and both heels but left measurement and staging fields blank, and no subsequent detailed wound assessments were documented. The DON acknowledged that, despite the resident refusing the in-house wound consultant but accepting routine wound care from staff, nursing staff should have completed and recorded full weekly wound assessments with measurements.
A resident with neuromuscular bladder dysfunction, urinary retention, and a cognitive communication deficit had an indwelling Foley catheter in place, but the facility failed to implement and document catheter care as required by its catheter care policy. Policy called for specific perineal and catheter cleansing steps and documentation of the date and time of care, the staff member providing care, and assessment findings. Review of the clinical record over an extended period showed no orders for catheter care and no documentation of catheter care or drainage bag emptying, and the NHA later confirmed that catheter care orders had not been in place despite the ongoing Foley catheter order.
The facility failed to implement physician orders and care plan interventions requiring hipster use for three residents with dementia, depressive disorders, fall histories, and documented cognitive impairment. Orders directed staff to encourage hipster use every shift or at all times and to document refusals, yet each resident was observed in a lounge/dining area without hipsters. A CNA reported that residents had no hipsters in their rooms and that none had refused them, while a laundry worker stated there were no hipsters available for these residents. Central supply staff later revealed multiple new hipsters locked in an office cabinet, and the DON confirmed that no hipsters were present in the residents’ rooms despite the expectation that each should have two pairs.
Surveyors found that all 46 semi-private rooms had only one shared closet without partitions, causing roommates’ clothing and personal items to touch and become intermingled on shelves and floors. A tour confirmed that no semi-private room closets had partitions to separate belongings, and the DON acknowledged that none of the closets provided private closet space for individual residents.
Three residents did not have required treatments and monitoring tasks documented as completed, including wound care, catheter care, enhanced barrier precautions, and security bracelet checks. The TARs lacked signatures on multiple shifts, and the administrator could not confirm if the care was provided due to lack of staff response.
A certified nursing assistant (CNA) worked 98 shifts after her nurse aide certification expired, as the facility failed to maintain updated verification of her certification status. The lapse was discovered during a review of employee records and the state nurse aide registry.
Two spa areas were found to have ambient temperatures above regulatory limits, with a resident reporting discomfort due to excessive heat and staff confirming the conditions. Observations also noted loud fan noise and dry spa showers, and the issue was reported to the administrator without further response.
The facility did not meet the required minimum NA staffing ratios on several shifts, as staffing records showed fewer NAs than mandated for the resident census. The shortfall was confirmed by the administrator, who cited numerous call offs as the reason for not meeting the required staffing levels.
The facility did not provide the required minimum of 3.2 hours of direct nursing care per resident per day on two reviewed days, as confirmed by staffing records and the Nursing Home Administrator.
The facility did not ensure timely reporting of an alleged resident-to-resident abuse incident, as required by policy. Two residents were involved in an incident observed by staff, but confusion among staff regarding reporting responsibilities led to a delay in notifying the administrator and proper authorities. The incident was not reported within the required timeframe, resulting in a deficiency.
The facility failed to maintain resident dignity and confidentiality by not ensuring staff assisted residents at eye-level during meals and by posting clinical information openly in rooms. Additionally, a resident's urinary catheter bag was visible from the hallway without a dignity cover.
The facility failed to adhere to care plans and document treatments for several residents. A resident with dysphagia did not receive recommended follow-up care, while another with wound care needs had treatments undocumented. A diabetic resident's insulin administration was inconsistent, lacking physician notification for withheld doses. Additionally, a resident's refusal of compression stockings was not properly documented, leading to inaccurate records.
A facility failed to monitor a resident's nutritional status, who had significant weight loss and required weekly weight checks. Despite orders for weekly weights, they were not obtained on specified dates. The DON was unsure why this occurred, and the NHA expected the weights to have been taken.
The facility failed to monitor side effects and target behaviors for two residents on psychotropic medications. One resident received lorazepam without documented non-pharmacological interventions or behavior monitoring, while another had missing documentation for side effect and behavior monitoring despite orders for such. The DON confirmed the lack of documentation and acknowledged an error in order entry.
The facility failed to adhere to professional standards for food storage and labeling, as observed in the main kitchen and three nourishment areas. Open food items lacked open dates or use by dates, and some food appeared old or improperly stored. The Foodservice Director and Nursing Home Administrator acknowledged the issues, emphasizing the need for proper labeling and dating according to facility policy.
The facility did not implement an antibiotic stewardship program as required by their policy, which was last revised in December 2016. The program was intended to monitor antibiotic use in residents, but as of a recent survey, the facility could not provide evidence of its implementation, including tracking antibiotics, duration of use, and monitoring culture and sensitivity. The Nursing Home Administrator confirmed the expectation for such a program to be in place.
The facility failed to provide complete and timely written notifications to residents and their representatives regarding hospital transfers, omitting necessary details such as reasons for transfer, appeal rights, and contact information for advocacy agencies. Additionally, the facility did not report the transfers to the Ombudsman, as confirmed by the NHA.
The facility failed to provide required bed-hold notifications to two residents upon hospital transfer. One resident's notifications lacked the bed-hold reserve payment rate, while another resident did not receive any notification. The facility's policy mandates such notifications, but the oversight was confirmed by the NHA and DON.
The facility failed to ensure accurate assessments for two residents, leading to documentation deficiencies. One resident's pain management and repositioning program were not correctly documented in the MDS assessments, while another resident's fall was not initially recorded. These errors were later corrected by staff.
The facility failed to update care plans for two residents. One resident, with congestive heart failure and difficulty walking, used a rolling walker not documented in her care plan. Another resident, with anxiety disorder and psoriasis, had a fall mat intervention in her care plan, but it was not present during observations. The NHA confirmed the walker was previously included and the fall mat was being removed as the resident transferred independently.
The facility failed to adhere to professional standards during medication and treatment administration. An LPN did not cleanse insulin pens before use and administered insulin without gloves to two residents. Additionally, another LPN used a Santyl tube labeled for a different resident during a dressing change. These actions were confirmed by staff and management.
A facility failed to follow its pressure ulcer care protocol for a resident with multiple ulcers. An LPN did not change gloves between cleansing and applying treatment to the wounds, contrary to the facility's policy. The resident had a history of cerebral infarction, type 2 diabetes, and a liver transplant, with ulcers on the buttocks and sacrum. The DON confirmed the lapse in procedure.
A facility failed to provide respiratory care consistent with professional standards for a resident using oxygen. The resident, with diagnoses including hypertension and atrial fibrillation, was observed receiving oxygen at 1 liter per minute via a nasal cannula without a physician's order. The Nursing Home Administrator confirmed the absence of the required order.
A resident with severe pain conditions experienced inadequate pain management due to the facility's failure to effectively administer prescribed medications and utilize non-pharmacological interventions. Despite having orders for routine and PRN pain medications, the resident's pain levels remained high, and there was a lack of physician notification for prolonged pain. Additionally, one PRN medication was unavailable, further limiting pain management options.
A resident with dementia and bilateral leg amputations had enabler bars installed without a documented risk-benefit analysis or consent, contrary to the facility's policy. The DON confirmed the absence of consent, acknowledging it was expected to be obtained.
A facility failed to act on a pharmacist's medication recommendations and did not conduct a monthly medication regimen review for a resident with anxiety disorder and hypertension. The physician did not respond to recommendations regarding medication monitoring and adjustments made in July, September, and November. Additionally, there was no evidence of a pharmacy recommendation for December, as confirmed by the DON and acknowledged by the Nursing Home Administrator.
The facility failed to properly label and store medications in the Evergreen Way/Stepping Stones treatment cart. Seven tubes of medication or creams were found in the cart's top drawer without proper packaging or labeling, with only four tubes having a resident's name. The facility's policy requires medications to be stored in their original packaging and labeled with appropriate instructions and expiration dates. The DON confirmed that the medications should have been stored correctly, indicating a breach of protocol.
Three residents who required staff assistance for bathing did not consistently receive showers or baths as scheduled, with documentation showing missed or 'Not applicable' entries on multiple dates. The DON acknowledged discrepancies between the reported shower schedules and electronic health records, confirming that residents were not assisted with bathing as expected.
Multiple residents did not receive their prescribed medications as ordered due to unavailability and delays in pharmacy delivery, as well as issues with order entry and documentation. The DON and NHA confirmed that staff were unaware of back-up pharmacy contracts and that pharmacy deliveries were not always timely, resulting in missed or delayed medication administration.
Staff failed to follow infection prevention protocols during an infectious disease outbreak, including not wearing masks while entering resident rooms and administering medications. An employee was also observed handling medications with bare hands, contrary to facility policy and infection control standards, as confirmed by the DON.
A resident with diabetes and a history of stroke was observed with a Foley catheter collection bag lying on the floor, contrary to facility policy requiring catheter equipment to be kept off the floor for infection control. Multiple staff passed by and observed the situation without intervening, and the DON confirmed the expectation that the collection container should not be on the floor.
A shortage of nursing staff led to missed and late medication administration for four residents on one unit. An LPN arrived late for her shift, and the RN Unit Manager, who was temporarily responsible for medication passes, was unable to administer medications on time due to other duties. As a result, residents with conditions such as diabetes, hypertension, Parkinson's disease, and congestive heart failure did not receive their medications as scheduled, with some doses being missed entirely or given hours late.
A resident with a history of heart failure and hypertension experienced vomiting and loose stools, but the RN Unit Manager did not document an assessment, vital signs, or physician notification in the clinical record. While Zofran was administered and recorded, there was no documentation of Immodium administration, and required documentation steps per facility policy were not followed.
A morning group activity was held in a lounge area that did not have enough space for all interested residents to participate or observe, resulting in some residents being displaced to the hallway or doorway. The area was also shared with a resident-use computer station, further limiting space. Staff confirmed the space was used due to repairs in the main activity room, and the administrator acknowledged that residents had to be rotated out due to limited capacity.
Required daily nurse staffing information was not posted in a clearly visible or prominent location, as it was temporarily placed on the inside of a door in the Human Resources Office among other postings during facility renovations. Staff confirmed this was not the usual location and acknowledged the posting should have been more accessible for residents and visitors.
Forest Park Nursing and Rehabilitation failed to provide timely emergency care to a resident due to inadequate training and orientation of agency staff. The resident, with a full code status, was found unresponsive, but confusion over a DNR bracelet and conflicting records delayed CPR initiation. Agency staff were unfamiliar with emergency procedures, placing other residents at risk.
Forest Park Nursing and Rehabilitation failed to comply with infection control protocols during a gastrointestinal outbreak. Staff did not adhere to PPE and hand hygiene requirements when entering rooms under 'Special Droplet/Contact Precautions.' Observations showed multiple staff members, including those providing direct care, not following the necessary precautions, leading to a deficiency in infection prevention and control.
Two residents experienced severe health declines due to the facility's failure to address changes in their conditions. One resident, with a history of hypertension and peripheral vascular disease, suffered from low oxygen levels and difficulty breathing, leading to cardiac arrest and death. Another resident, with pneumonitis and COVID-19, had inadequate oxygen management and lack of RN notification. These failures placed residents in Immediate Jeopardy.
A resident with a history of wandering and cognitive impairment eloped from the facility, found in the parking lot with low body temperature and abrasions. Despite having a security bracelet and frequent monitoring orders, the resident exited through a side door without a wander guard alarm. The care plan was not updated to reflect the resident's high elopement risk, and the facility failed to enforce policies preventing family members from obtaining door codes.
The facility failed to ensure a clean and homelike environment in several areas, including the multi-purpose room and four nursing units. Observations revealed dried spills, debris, and dead bugs on the floors. Interviews with housekeeping staff indicated insufficient staffing and unclear cleaning assignments. The DON expected adequate housekeeping but did not address the staffing issue.
A resident with normal pressure hydrocephalus and dementia was mistakenly administered Rytary, intended for another patient, due to a transcription error. The error was discovered after five days, and the resident experienced no adverse effects. The DON acknowledged the need for proper verification of medication orders.
Two residents with self-care deficits did not receive the scheduled number of showers per week as per facility standards. One resident with muscle weakness and impaired mobility reported fewer showers than scheduled, with documentation confirming missed showers. Another resident with hemiplegia also reported inconsistent showering, with documentation showing a missed shower. Facility staff confirmed the shower schedule but provided no explanation for the missed showers.
A resident with peripheral vascular disease and stage three chronic kidney disease missed two medical appointments due to the facility's failure to provide transportation. The facility's transport van was first unusable due to invalid registration and later inoperable, with no alternative transportation arranged.
The facility did not post updated daily nurse staffing information for two consecutive days. An observation revealed outdated staffing data, and interviews confirmed that the responsibility for posting lies with the night shift RN or HR employee. The posted information was confirmed to be outdated by the Nursing Home Administrator.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, with multiple issues observed in the kitchen and nourishment rooms, including improperly stored food, dirty equipment, and inadequate dishwashing temperatures.
The facility failed to ensure a clean, comfortable, and homelike environment for its residents, with multiple observations of unclean and damaged areas, including resident rooms, common areas, and shower rooms. Despite being aware of these issues, the facility did not adequately address them.
The facility failed to provide timely notifications to residents, their representatives, and the State Ombudsman before hospital transfers for seven residents. The DON and NHA confirmed the lack of required transfer notices and Ombudsman notifications, despite staff education on the matter.
The facility failed to provide residents or their representatives with a copy of the bed-hold policy upon transfer to a hospital or therapeutic leave. Seven residents reviewed for hospitalization did not receive the required bed-hold notice, despite the facility's policy mandating it at the time of transfer or within 24 hours if the transfer was an emergency. Interviews with the NHA and DON confirmed the facility's awareness of this issue and the lack of documentation for these transfers.
Failure to Follow Care Plan and Maintain Safe Bed Position Leads to Resident Fall and Head Laceration
Penalty
Summary
The facility failed to implement required safety interventions and supervision for a dependent resident, resulting in a fall with a scalp laceration. The resident had diagnoses including hemiplegia, hypertension, dementia, history of CVA, muscle weakness, abnormal posture, and spinal malformation, and was care planned as totally dependent for bed mobility and transfers, requiring a Hoyer lift with two-person assist and a regular scoop mattress with extensive assist of two. The care plan also identified the resident as at risk for falls, with an intervention to maintain the bed in a low position, and a task directing staff to place a body pillow on the right side at all times when the resident was in bed. Documentation on the day of the incident showed that the body pillow was not in place on the right side of the bed at 11:08 AM. The resident’s MDS and clinical record consistently documented that the resident did not roll, lean, or move in bed without maximal assistance and was dependent on staff for all bed mobility. Later that day, an unwitnessed fall occurred, and the resident was found prone on the floor between the bed and the outer wall with a frontal scalp laceration measuring approximately 4.0 cm by 4.0 cm by 0.1 cm, requiring 8 sutures in the ED. The incident report and staff statements confirmed that the resident required a mechanical lift with two-person assist, did not move in bed independently, and had no bed movement per nurse aides. Staff statements indicated that shortly before the fall the resident had been seen lying in the middle of the bed, with the bed at waist level, and a clean brief unfolded on the bed, suggesting care was being or had been provided; one aide reported seeing the resident “flip over” on the floor and trying unsuccessfully to pull her back, and another reported the bed was at waist level and the resident was wearing no brief. A nurse aide interview revealed that at the time of the fall the bed was in a tilted position, the resident was leaning off the bed, and there was no body pillow on the right side. The Nursing Home Administrator acknowledged that the bed was tilted up and that staff attempted to grab the resident but could not explain how the resident, who was documented as unable to move in bed without assistance, came to be leaning off the side of the bed. These findings support that the facility did not follow care-planned interventions, including maintaining the bed in low position and ensuring use of the body pillow, and did not provide adequate supervision to prevent the accident.
Failure to Provide Required Written Notice Before Room Change
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident with written notice, including the reason, before changing the resident’s room. Resident 6, who had diagnoses including dysphagia and GERD, was observed residing in the locked dementia unit. Review of the admission MDS showed a BIMS score of 15, indicating normal thinking and memory. A progress note dated February 13, 2026, documented that the resident’s room was changed, and a subsequent note on February 14, 2026, recorded that the resident was upset and did not agree with the room change. During interview, the resident stated that he did not give consent to move rooms and was not provided with written notice of the room change. Staff interviews confirmed that the room change was initiated because staff reported the resident was talking about getting his money and car and leaving the facility, and he was considered an elopement risk. The social worker reported meeting with the resident and the resident’s POA and deciding to move the resident to the locked unit, noting that the resident already had a wander guard and that the facility had prior issues with residents leaving while wearing wander guards. The NHA stated that, because it was a late Friday afternoon and the resident was upset and wanted to leave, they decided to place him in the locked unit so he would not be able to leave. The facility was unable to provide any documentation showing that written room change notification was given to the resident prior to the move.
Failure to Perform and Document Weekly Pressure Ulcer Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide and document necessary pressure ulcer treatment and services consistent with professional standards and facility policy for a resident with multiple pressure injuries. Facility policy required nurses to complete and document a full assessment of pressure sores, including location, stage, length, width, depth, and presence of exudate or necrotic tissue. The resident’s diagnoses included a pressure-induced deep tissue injury to the left heel, a stage 4 pressure ulcer to the sacrum, and paraplegia. Physician orders directed specific wound care to the sacral pressure ulcer and required a weekly body audit every Monday. However, Weekly Body Audit forms completed on three dates in December did not document the resident’s existing pressure ulcers in the section for alterations in skin integrity. Further review of the clinical record, including progress notes, showed no documented wound assessments with descriptions or measurements between mid-December and late December, when the resident was transferred to the hospital. After the resident’s return from the hospital on January 1, a readmission evaluation noted pressure ulcers on the coccyx, right heel, and left heel, but left blank the sections for length, width, depth, stage, and additional observations/comments. There were no documented assessments with descriptions or measurements of these pressure ulcers between the readmission date and mid-January, when the resident was again transferred to the hospital. During interviews, the DON acknowledged that the resident had refused services from the in-house wound consultant but allowed nursing staff to perform ordered wound care, and confirmed that nursing staff should have completed and documented full wound assessments, including measurements, at least weekly for residents with pressure ulcers.
Failure to Provide and Document Foley Catheter Care per Facility Policy
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for a resident with an indwelling Foley catheter. Facility policy on urinary catheter care, revised in September 2014, required staff to wash the genitalia and perineum with soap and water, rinse and dry the area, cleanse and rinse the catheter from the insertion site approximately four inches outward, and document the date and time catheter care was given, the name and title of the person providing care, and all assessment data obtained. Review of the resident care policies and clinical documentation showed that these required catheter care procedures and documentation elements were not present in the resident’s medical record. The resident involved had diagnoses including neuromuscular dysfunction of the bladder, urinary retention, and a cognitive communication deficit, and had an order for an indwelling Foley catheter with gravity drainage for urinary retention. The catheter was originally ordered in November 2025, with a current order dated in December 2025. Review of the clinical record, including physician orders and treatment administration records from early December 2025 through mid-January 2026, revealed no orders for catheter care and no documentation that catheter care or drainage bag emptying had been provided during that period. In interviews, the Nursing Home Administrator and Director of Nursing were informed of the concern, and the Nursing Home Administrator later confirmed that the resident did not have catheter care orders in place, despite the ongoing catheter order.
Failure to Provide Ordered Hipsters for Residents at Risk for Falls
Penalty
Summary
The facility failed to provide ordered hipster garments for three residents with fall histories, despite physician orders and care plans directing that they be encouraged to wear hipsters and that refusals be documented. Resident 1 had depressive and adjustment disorders, a history of falls, and a BIMS score of 11 indicating moderate cognitive impairment. Physician orders effective November 3, 2025, and re-entered January 5, 2026, required staff to encourage hipster use every shift and document refusals, and the resident’s care plan reflected this fall-risk intervention. On January 5, 2026, at approximately 11:00 AM, Resident 1 was observed in the lounge/dining area without hipsters. Resident 2 had dementia, atrial fibrillation, a history of falls, and a BIMS score of 99 indicating inability to complete the cognitive interview. An order effective December 5, 2025, and a care plan effective August 13, 2025, directed that Resident 2 be encouraged to wear hipsters every shift with refusals documented, yet this resident was also observed at the same time without hipsters. Resident 3 had dementia, depressive disorder, a history of falls, and a BIMS score of 2 indicating severe cognitive impairment. Physician orders effective February 17, 2025, and a second order written January 5, 2026, required that Resident 3 be encouraged to wear hipsters at all times, and the care plan mirrored this intervention. On January 5, 2026, at approximately 11:00 AM, Resident 3 was observed in the lounge/dining area without hipsters. A nursing assistant reported that residents did not have any hipsters in their rooms and stated that none of the residents refused hipsters; she also noted that Resident 3 was already up and groomed when she arrived. A laundry employee stated there were no hipsters available for these residents, though there might be some in a washer. Central supply staff later confirmed that multiple pairs of new hipsters in all sizes were locked in a cabinet in her office. The DON confirmed that no hipsters were present in the rooms of the three residents and stated that each resident should have two pairs, demonstrating that ordered and care-planned hipster use was not implemented for these residents.
Failure to Provide Private Closet Space in Semi-Private Rooms
Penalty
Summary
The facility failed to provide private closet space for residents in all 46 semi-private rooms, resulting in roommates’ clothing and personal items being intermingled. Observation of semi-private room closets on January 5, 2026, showed that each room had only one shared closet without any partition, causing roommates’ clothing to touch and personal items on the shelf and floor to be mixed together. A tour of all semi-private rooms confirmed that none of the closets contained a partition to separate residents’ belongings. In an interview on December 5, 2026, at 2:30 PM, the DON confirmed that no closets in the semi-private rooms had partitions to provide private closet space for individual residents. These findings demonstrate noncompliance with the requirement to ensure adequate and private closet space for each resident, as required under 28 Pa. Code 201.18(b)(2) Management.
Failure to Document and Complete Physician-Ordered Treatments and Monitoring
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for three residents. For one resident with hypertension and hyperlipidemia, multiple physician-ordered treatments and monitoring tasks, including weekly body audits, pressure wound care, catheter care, enhanced barrier precautions, monitoring for UTI symptoms, and use of offloading heel boots, were not documented as completed on several shifts. The Treatment Administration Record (TAR) lacked signatures on specific dates and shifts, indicating that these treatments may not have been performed as ordered. Two other residents, one with Alzheimer's Disease and hyperlipidemia and another with hypertension and bipolar disorder, also had missing documentation on their TARs. Orders for checking the placement of alarming security bracelets and monitoring for avoidance of laying flat due to shortness of breath were not signed off on multiple shifts. During an interview, the Nursing Home Administrator confirmed that treatments should be completed and documented as ordered, but was unable to verify completion due to lack of response from the assigned nurse.
CNA Worked with Expired Certification
Penalty
Summary
The facility failed to ensure that a nursing staff member maintained an active nurse aide certification as required by state law. Review of the employee file for one certified nursing assistant (CNA) showed that the facility had verified her certification status at the time of hire, with documentation indicating an expiration date of February 23, 2025. However, there was no updated verification in the file after this date. Further investigation revealed that the CNA's certification had expired, and she continued to work 98 shifts after the expiration date without a valid certification. This lapse was identified through a review of the Pennsylvania Department of Health Nurse Aide registry and the employee's work schedule.
Failure to Maintain Safe and Comfortable Spa Temperatures
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment in two of its three unit spas, specifically the Evergreen and Laurel Lane spas. Observations conducted in these areas revealed that the ambient temperatures were significantly above the required range, with readings of 85.8°F in the Laurel spa and 85°F in the Evergreen spa. Additionally, there was audible fan noise in both spas, and the spa showers were noted to be dry at the time of observation. These findings were corroborated by a resident who reported that the temperature in her bathroom and the spa area was uncomfortably hot. Interviews with staff and residents confirmed the elevated temperatures and discomfort in these areas. The issue was brought to the attention of the Nursing Home Administrator, but no further information or explanation was provided at the time. The failure to maintain appropriate temperature levels and a comfortable environment in these spa areas constitutes noncompliance with federal and state regulations regarding resident rights to a safe, clean, and homelike environment.
Plan Of Correction
1. Facility is unable to retroactively correct temperatures in Laurel Lane and Evergreen Spa. Facility had been taking random temperatures throughout the facility although none taken in resident bathrooms. Routine maintenance had not been conducted on exhaust belts. Maintenance Director is responsible for this routine. Vents had been cleaned. 2. Facility purchased 5 fans on 6/27/25 and placed in the facility, including Laurel Lane and Evergreen Spas. Residents and staff were encouraged to keep bathroom doors open when not in use. Maintenance Department changed out heat lamps and replaced them with regular light bulbs in resident bathrooms. Facility had a company out to check on air conditioning units as well as ventilation system. Exhaust belts were replaced. Portable A/C units purchased for Laurel Lane and Evergreen Spas were installed. 3. NHA/Designee will educate the Maintenance Department on the importance of maintaining comfortable and safe temperature levels in the facilities, including routine maintenance on the ventilation system including exhaust belts. Maintenance Director/designee will report quarterly task compliance to NHA to ensure tasks are being completed. 4. Maintenance Director/Designee will audit random facility temperatures of resident rooms and bathrooms and facility spa rooms 3 times a week for two months, then monthly for two months, to ensure temperatures are between 71 and 81. NHA will audit maintenance records quarterly to ensure ventilation system including exhaust belts is being maintained. Results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing ratios on multiple shifts between June 20 and June 23, 2025. Specifically, on the evening and night shifts of June 21, 2025, and the day and night shifts of June 22, 2025, the number of NAs scheduled did not meet the mandated ratios based on a resident census of 107. Staffing documents showed that the evening shift had 9.13 NAs instead of the required 9.73, and the night shift had 6.52 and 5.54 NAs on consecutive nights, both below the required 7.13. The day shift on June 22 had 10.62 NAs, which was also below the required 10.70. An interview with the Nursing Home Administrator confirmed that the facility was unable to fulfill the required staffing levels due to numerous call offs.
Plan Of Correction
1. Facility is unable to retroactively correct the nurse aide ratios for June 21 & 22, 2025. 2. Nursing Home Administrator/designee will have a daily staffing meeting with the Director of Nursing and facility Nursing Scheduler to review daily staffing schedules to ensure compliance with staffing regulations, discuss potential barriers to meeting required staffing ratios, and identify strategies to meet staffing ratios including but not limited to recruitment efforts, bonus structure, use of agency, and overtime hours. 3. Nursing Home Administrator/designee will educate Director of Nursing and facility Nursing Scheduler on P5520 and the importance of ensuring compliance with nurse aide ratios as mandated by state laws regarding mandated minimum staffing requirements. 4. Nursing Home Administrator/designee will audit daily nursing staffing ratios to ensure nurse aide ratios are in compliance with mandated state laws regarding minimum staffing ratios. These audits will be conducted weekly for 4 weeks and monthly for 2 months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct nursing care per resident per day for two out of four days reviewed. Specifically, staffing records and nursing schedules showed that on June 21, 2025, only 3.01 hours of direct care per resident were provided, and on June 22, 2025, only 3.17 hours were provided. This shortfall was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the facility did not meet the required minimum for those days. No additional information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
P 5640 1. Facility is unable to retroactively correct the minimal direct care hours for June 21 & 22, 2025. 2. Nursing Home Administrator will have a daily staffing meeting with the Director of Nursing and facility Nursing Scheduler to review daily staffing schedules to ensure compliance with staffing regulations, discuss potential barriers to meeting required staffing ratios, and identify strategies to meet staffing ratios including but not limited to recruitment efforts, bonus structure, use of agency, and overtime hours. 3. Nursing Home Administrator/designee will educate the Director of Nursing and facility Nursing Scheduler on P5640 and the importance of ensuring compliance with a minimum of 3.2 hours of direct resident care as mandated by state laws regarding mandated minimum staffing requirements. 4. Nursing Home Administrator will audit daily nursing staffing ratios to ensure the facility is in compliance with mandated state laws regarding a minimum of 3.2 hours of direct resident care hours. These audits will be conducted weekly for 4 weeks and monthly for 2 months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported in a timely manner for two residents. According to facility policy, suspicions of abuse, neglect, exploitation, or misappropriation of resident property must be reported immediately to the administrator and other officials, with 'immediately' defined as within two hours for abuse or serious bodily injury, or within 24 hours for other allegations. On June 7, 2025, a housekeeper observed a possible inappropriate interaction between two residents and informed a nurse aide, who then witnessed one resident with her hand on another resident's penis. The nurse aide reported the incident to a registered nurse, who stated he was not the supervisor and directed her to inform the supervisor, but there is no evidence the supervisor was notified at that time. The manager on duty was informed by the nurse aide, but assumed the supervisor would handle the situation. The administrator was not made aware of the incident until two days later, on June 9, 2025. Interviews with staff revealed confusion regarding reporting responsibilities and a lack of clear communication, resulting in a delay in notifying the appropriate authorities about the alleged abuse. The nursing supervisor denied any knowledge of the incident, and the administrator confirmed she was not informed until after the required reporting timeframe had passed. The facility's failure to promptly report the alleged abuse as required by policy and regulation led to the deficiency.
Failure to Maintain Resident Dignity and Confidentiality
Penalty
Summary
The facility failed to promote care for residents in a manner that enhances their dignity, as evidenced by several observations and staff interviews. Specifically, staff members were observed assisting residents with meals while standing over them, rather than being at eye-level, which is contrary to the facility's policy on dignity. This was observed with multiple residents, including one who was seated in a chair and another who was lying in bed. Staff interviews confirmed that the expectation was to be at eye-level with residents during meal assistance, but this was not consistently practiced. Additionally, the facility did not adequately protect residents' confidential clinical information. Signs indicating specific care instructions were openly posted in residents' rooms, such as instructions to keep the head of the bed elevated or not to leave wipes at the bedside. These signs were visible to anyone entering the room, which is against the facility's policy. Furthermore, a resident's urinary catheter drainage bag was visible from the hallway, lacking a dignity cover to conceal it from public view. The Nursing Home Administrator acknowledged these practices were not in line with the facility's expectations for maintaining resident dignity.
Failure to Follow Care Plans and Document Treatments
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for four residents. Resident 5, diagnosed with vascular dementia and congestive heart failure, had a consultative gastrointestinal appointment due to signs of dysphagia. Recommendations included a barium swallow test, continuation of a soft diet, and a dental consult for dentures. Despite persistent coughing episodes during meals, no further gastrointestinal appointments, dental consults, or speech therapy were scheduled for Resident 5. Resident 64, with diagnoses including muscle contracture and functional quadriplegia, had wound treatments documented as not completed on specific dates in January and February 2025. The Treatment Administration Record (TAR) indicated the treatments were not administered, but the progress notes lacked explanations for these omissions. The Director of Nursing (DON) could not provide reasons for the lack of documentation or completion of the wound treatments. Resident 68, diagnosed with cerebral infarction and type 2 diabetes, had insulin orders without parameters for withholding administration. Insulin doses were not administered on several occasions due to low blood sugar, but there was no documentation of physician notification. Resident 88, with anxiety disorder and psoriasis, had an order for compression stockings that were not applied as prescribed. The resident was observed without stockings, and staff incorrectly documented that the order was followed. The DON later revealed that the resident had been refusing the stockings, but this was not documented in the progress notes.
Failure to Monitor Resident's Nutritional Status
Penalty
Summary
The facility failed to monitor the nutritional status of a resident, identified as Resident 72, who was reviewed for nutrition. The resident had diagnoses including hypotension and atrial fibrillation. A full nutrition assessment conducted by the dietitian noted a significant undesired weight loss of 25% in one month and recommended weekly weight monitoring for four weeks. Despite an order for weekly weights starting on September 14, 2024, the resident's Medication Administration Record (MAR) showed that weights were not obtained on the specified dates of September 14, 28, and October 5, 2024. The comprehensive care plan included an intervention for weights as ordered, initiated on July 9, 2024. The Director of Nursing was unsure why the weights were not obtained, and the Nursing Home Administrator expected the weights to have been taken as ordered.
Failure to Monitor Psychotropic Medication Effects and Behaviors
Penalty
Summary
The facility failed to adequately monitor possible side effects and target behaviors for two residents receiving psychotropic medications. Resident 68, diagnosed with depression, anxiety, and cerebral infarction, had an order for lorazepam to be administered as needed for anxiety. However, the facility did not document any non-pharmacological interventions attempted prior to administering lorazepam on several occasions. Additionally, there was no documentation of identified target behaviors, behavior monitoring, or side effect monitoring related to the use of lorazepam. During an interview, the Director of Nursing confirmed that the staff should have documented these interventions and monitoring, and acknowledged that the order was entered incorrectly, preventing proper documentation. Resident 80, diagnosed with major depressive disorder and dementia, had orders for Seroquel, buspirone, and mirtazapine, along with orders for side effect and behavior monitoring every shift. However, the facility failed to document side effect and behavior monitoring on multiple dates and shifts. During an interview, the Director of Nursing stated that it was the facility's expectation for such monitoring to be conducted as ordered, but no additional information was available regarding the missing documentation.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to store food items in accordance with professional standards for food service safety in the main kitchen and three nourishment areas. During an observation of the dry storage area, it was found that a bag of egg noodles and a bag of spiral pasta were open without an open date or use by date. Additionally, ten boxes of fudge round cookies were not dated, and a box of potatoes was covered with sprouts and appeared to be old. The Foodservice Director acknowledged that the potatoes should be discarded and preferred storing them in the walk-in refrigerator to maintain freshness. Further observations in the Laurel Lane, Chapel, and Evergreen/Stepping Stone pantry areas revealed multiple instances of open juices and fortified nutritional drinks without open dates. Additionally, bins containing individually labeled snacks lacked expiration dates. The Foodservice Director confirmed that snacks should be labeled with replenishment dates to indicate expiration, and juices should be labeled when opened, as they have specific guidelines for disposal after a certain period. The Nursing Home Administrator stated that it was the facility's expectation for food and beverages to be labeled and dated per facility policy and professional standards.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish and implement an antibiotic stewardship program to monitor the use of antibiotics, as required by their policy. The policy, last revised in December 2016, stated that antibiotics should be prescribed and administered under the guidance of the facility's antibiotic stewardship program, with the purpose of monitoring antibiotic use in residents. However, as of March 6, 2025, the facility could not provide evidence of the program's implementation, including documentation of tracking antibiotics used, duration of use, and monitoring culture and sensitivity of identified organisms to ensure prescribed antibiotic effectiveness. During a staff interview, the Nursing Home Administrator acknowledged that it was the facility's expectation to have such a program in place.
Failure to Provide Complete Transfer Notifications
Penalty
Summary
The facility failed to provide timely and complete written notifications to residents and their representatives regarding transfers to the hospital, as required by policy and regulations. Specifically, for two residents reviewed, the facility did not include necessary details such as the reason for transfer, date, location, and appeal rights in the transfer notices. Additionally, the notices lacked the mailing addresses for the Office of the State Long-Term Care Ombudsman and other relevant advocacy agencies. The transfer notices for one resident were not signed by the resident or their representative, and there was no documentation of verbal communication regarding the transfer details. The facility also failed to report the transfers to the Ombudsman, as confirmed by the Nursing Home Administrator (NHA) during interviews. The NHA, who began working at the facility after the incidents, acknowledged the absence of documentation and confirmed that the required information was not included in the transfer notices. The facility's policy, last reviewed in February 2025, mandates that written information be provided to residents and their representatives prior to a transfer, but this was not adhered to in the cases reviewed.
Failure to Provide Bed-Hold Notifications
Penalty
Summary
The facility failed to provide the required bed-hold notifications to residents and their representatives upon transfer to a hospital, as evidenced by the cases of two residents. The facility's policy, titled Bed-Holds and Returns, mandates that written information be given to residents and their representatives prior to a transfer, detailing the rights and limitations regarding bed-holds, the reserve bed payment policy for Medicaid residents, and the facility per diem rate for non-Medicaid residents. However, for Resident 21, who was transferred to the hospital on two occasions, the bed-hold notifications did not include the bed-hold reserve payment rate. This omission was confirmed by the Nursing Home Administrator during an interview. Additionally, Resident 80, who was transferred to the hospital, did not receive any bed-hold notification, as confirmed by a review of the clinical record and an interview with the Nursing Home Administrator and Director of Nursing. The facility acknowledged that it is their expectation to provide such notifications, but no additional information was available to explain the oversight. The failure to provide these notifications is a violation of the facility's policy and state regulations, as noted in the report.
Inaccurate Resident Assessments Lead to Documentation Deficiencies
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, leading to deficiencies in their care documentation. Resident 64, diagnosed with muscle contracture, functional quadriplegia, and depression, was on a turning and repositioning program as part of his pain management since admission. However, his Admission and 5 Day MDS assessments inaccurately marked that he did not receive non-medication interventions for pain and was not on a turning/repositioning program. This discrepancy was later corrected by the Licensed Practical Nurse Assessment Coordinator after it was identified. Similarly, Resident 72, who had diagnoses of hypotension and atrial fibrillation, experienced an un-witnessed fall from bed on a specific date, which was not initially documented in the Quarterly MDS assessment. The sections regarding falls since admission and the number of falls were incorrectly marked as 'No,' failing to capture the fall incident. This error was subsequently corrected to reflect the resident's fall with no injury. The Nursing Home Administrator acknowledged the expectation for accurate coding in both cases.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that the care plans for two residents were reviewed and revised appropriately. Resident 65, who has diagnoses including congestive heart failure and difficulty walking, was observed using a rolling walker, which was not documented in her care plan. The care plan had a focus area on requiring assistance for transferring due to an unsteady gait, but it lacked mention of the rolling walker. The Nursing Home Administrator confirmed that the rolling walker was previously included in the care plan but was removed during a revision, and the previous version could not be retrieved. Resident 88, diagnosed with anxiety disorder and psoriasis, experienced an unwitnessed fall and had a care plan intervention for a fall mat on the left side of the bed. However, during observations, no fall mat was present, and electronic correspondence from the Nursing Home Administrator indicated that the fall mat was being removed from the care plan as the resident transferred independently. The Nursing Home Administrator expected the fall mat to have been removed from the care plan if it was not in use, indicating a failure to update the care plan to reflect the current status of interventions.
Failure to Follow Professional Standards in Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards during medication preparation and administration for two residents and treatment administration for another resident. Specifically, during a medication pass observation, a Licensed Practical Nurse (LPN) did not cleanse the rubber seal of insulin pens before attaching new sterile needles for two residents. Additionally, the LPN administered insulin to one resident without wearing gloves, contrary to the facility's infection control procedures. The LPN involved in the medication pass confirmed that he did not clean the insulin pens before attaching the needles, as he believed the pens were a closed system and did not require cleaning. He also did not wear gloves while administering insulin, under the assumption that gloves were unnecessary if a person self-administers insulin. The Nursing Home Administrator confirmed that the insulin pens should have been cleaned and gloves should have been worn during administration. In a separate incident, another LPN used a tube of Santyl labeled with a different resident's name during a dressing change for a resident with multiple pressure ulcers. This was confirmed by the LPN, another nurse, and the Director of Nursing. The Director of Nursing acknowledged that the correct tube of Santyl should have been used for the resident's treatment.
Failure to Follow Pressure Ulcer Care Protocol
Penalty
Summary
The facility failed to ensure that a resident received necessary treatment and services consistent with professional standards of practice for pressure ulcer care. Specifically, the facility did not adhere to its policy for dressing changes, which requires cleansing the wound with the ordered cleanser, using clean gauze for each stroke, and changing gloves between cleansing and applying treatment. During an observation, a Licensed Practical Nurse (LPN) was seen cleansing all wounds with normal saline solution and a gauze pad, applying Santyl to the sacral wound with a tongue depressor, and applying zinc oxide ointment to the buttock wounds without changing gloves between these steps. The resident involved had a medical history that included cerebral infarction, type 2 diabetes mellitus, and a liver transplant. The resident had multiple pressure ulcers: a stage 2 ulcer on the right buttock, a stage 3 ulcer on the left buttock, and an unstageable ulcer on the sacrum. The physician's orders for the resident included applying zinc oxide ointment to the buttocks every shift and cleansing the sacrum with normal saline, applying Santyl, and covering with a dry sterile dressing daily. The Director of Nursing confirmed that the LPN should have changed gloves and washed hands between cleansing the wound and applying the treatment.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for a resident who was using oxygen. The facility's policy on oxygen administration requires verification of a physician's order for the procedure. However, a review of the resident's clinical record revealed no physician's order for the oxygen administration, despite the resident receiving oxygen at 1 liter per minute via a nasal cannula. The resident had diagnoses including hypertension, atrial fibrillation, and cerebral infarction. Observations confirmed the resident was receiving oxygen without an order, and the Nursing Home Administrator acknowledged that an order should have been in place.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident 64, who required such services. The resident was admitted with diagnoses including muscle contracture, functional quadriplegia, and depression. Despite having orders for both routine and PRN pain medications, the resident consistently reported high pain levels, often rated at 8 out of 10, which were not effectively managed by the medications administered. The facility's policy required physician notification for prolonged, unrelieved pain, but this was not consistently done. The resident's clinical records showed multiple instances where pain levels remained high despite the administration of PRN oxycodone, and no further interventions were documented. Non-pharmacological interventions were not effectively utilized or documented, and there was a lack of physician notification regarding the resident's ongoing pain. Additionally, one of the prescribed PRN medications, hydromorphone, was unavailable due to the lack of a current prescription, further limiting the facility's ability to manage the resident's pain effectively. Interviews with staff revealed a lack of clarity and consistency in administering pain medications, with some medications not being available and non-pharmacological interventions not being effectively implemented. The Director of Nursing acknowledged the deficiencies in pain management and the failure to notify the physician as required by the care plan and facility policy. The facility's failure to provide adequate pain management and follow its own policies resulted in prolonged, unrelieved pain for the resident.
Failure to Obtain Consent for Enabler Bar Use
Penalty
Summary
The facility failed to complete a risk-benefit analysis and obtain consent for the use of enabler bars for a resident. The facility's policy, last reviewed on February 3, 2025, requires an interdisciplinary assessment and consent from the resident or their legal representative before using side rails. However, for one resident, who had diagnoses including dementia and bilateral leg amputations, the facility did not have a documented consent for the use of enabler bars. During an observation on March 3, 2025, enabler bars were noted in the resident's room, but the clinical record lacked any consent documentation. An email from the DON confirmed the absence of a signed consent, and during an interview, both the Nursing Home Administrator and the DON acknowledged that obtaining consent was the facility's expectation. This oversight was identified as a deficiency under the relevant Pennsylvania codes for management and nursing services.
Failure to Act on Pharmacist's Recommendations and Conduct Monthly Medication Review
Penalty
Summary
The facility failed to act upon the licensed pharmacist's medication recommendations and did not provide a monthly medication regimen review for a resident. The facility's policy requires the consultant pharmacist to review each resident's medication regimen monthly, and for the physician to either accept and act upon the pharmacist's suggestions or provide an explanation for any disagreement. However, for one resident with diagnoses including anxiety disorder and hypertension, the physician did not respond to the pharmacist's recommendations made in July, September, and November 2024. These recommendations included conducting a comprehensive metabolic panel for lisinopril, evaluating the use of PRN psychotropic drugs, considering a gradual dose reduction for several medications, and assessing the necessity of long-term pain management medications. Additionally, the facility was unable to provide evidence of a pharmacy recommendation for December 2024 for the same resident. The Director of Nursing confirmed the absence of the December 2024 recommendation and the lack of physician responses to the pharmacist's recommendations from previous months. The Nursing Home Administrator acknowledged that the resident should have had a pharmacy recommendation completed in December 2024 and expected the physician to have responded to the recommendations from July, September, and November 2024.
Improper Labeling and Storage of Medications
Penalty
Summary
The facility failed to properly label and store prescribed medications or preventative creams in one of the two treatment carts observed, specifically the Evergreen Way/Stepping Stones cart. During an observation, it was found that seven tubes of medication or preventative creams were placed in the top drawer of the cart without being stored in a box or bag labeled with a resident's name. Out of these, four tubes had a resident's name on them, indicating a partial compliance with labeling requirements. The facility's policy on the storage of medications mandates that drugs and biologicals should be stored in the packaging or containers in which they are received, and only the issuing pharmacy is authorized to transfer medications between containers. Additionally, the policy requires that drugs and biologicals be labeled according to professional principles, including appropriate instructions and expiration dates. The Director of Nursing confirmed during an interview that the treatment creams and medications should have been stored in their proper packaging or individual bags with a resident's name clearly indicated, highlighting a deviation from the established protocols.
Failure to Provide Scheduled Bathing Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide scheduled assistance with activities of daily living, specifically bathing or showering, for three residents who required staff support. Resident 4, who was care planned to receive limited assistance with bathing, reported not receiving showers or baths twice a week as scheduled. Documentation for Resident 4 showed missing or marked 'Not applicable' for several scheduled shower dates. Resident 12, requiring extensive assistance for bathing, also reported not receiving showers or baths twice a week, with documentation missing for multiple scheduled dates. Resident 13, who required limited assistance, stated she did not receive showers regularly, and her records similarly showed missed or 'Not applicable' entries for scheduled bathing days. A review of the facility's report sheet indicated specific shower schedules for each resident, but discrepancies were found between these schedules and the electronic health records. The DON confirmed these inconsistencies and stated that it was the facility's expectation for residents to receive assistance with bathing as scheduled. The deficiency was cited under 28 Pa code 211.12(d)(1)(5) for nursing services.
Failure to Provide Timely Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident, as evidenced by multiple instances where medications were not available, not administered as ordered, or not properly documented for four residents. For one resident with a history of cerebral infarction, liver transplant, and respiratory failure, there were several occasions where numerous medications were coded as unavailable and awaiting pharmacy delivery, both after hospitalization and during routine care. Progress notes confirmed that these medications were not on hand and were pending delivery, and the DON acknowledged that the medications may not have been available in the facility’s back-up supply. Another resident with chronic ulcer and hypertension experienced delays and discrepancies in medication administration following hospital discharge. The medication was not started at the correct time per hospital instructions, and there were issues with order entry and clarification, resulting in delayed and partial dosing. Progress notes and MAR documentation indicated that medications were unavailable and that clarification from the pharmacy was needed, with the DON confirming that the correct dosage was eventually given but not within the ordered timeframe. Additional residents, including one with kidney failure and another with chronic kidney disease and hypertension, also experienced missed or delayed medication doses due to unavailability and issues with pharmacy delivery. Progress notes repeatedly documented that medications were not available and were being awaited from the pharmacy. During interviews, the DON and NHA confirmed that staff were not aware of any back-up pharmacy contracts and had not utilized them, and that pharmacy deliveries were not always timely, leading to missed or delayed medication administration for multiple residents.
Failure to Maintain Infection Control During Outbreak and Medication Administration
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program on two unit hallways, Evergreen Way and Laurel Lane, during an infectious disease outbreak. Despite posted signage and confirmation from the Nursing Home Administrator that masks were required, observations revealed that two employees were not wearing masks while entering multiple resident rooms and providing care, including medication administration. The Director of Nursing confirmed that staff were expected to wear masks in the building. Additionally, infection control procedures were not followed during medication administration. Employee 1 was observed dispensing medication tablets from multidose containers directly into her ungloved hand before placing them into medication cups for two residents. The facility's policy required staff to follow infection control procedures, including the use of gloves when handling medications. The Director of Nursing confirmed that staff were not permitted to handle medications with bare hands, indicating a failure to adhere to established protocols.
Failure to Maintain Catheter Collection Bag Off Floor
Penalty
Summary
The facility failed to provide appropriate care and services for an indwelling urinary catheter for one resident. According to the facility's own policy, catheter tubing and drainage bags are to be kept off the floor to maintain infection control. However, during multiple observations, the resident's Foley catheter collection container was seen lying on the floor, visible from the hallway, and in plain sight of several staff members who passed by the room. The resident involved had diagnoses including type two diabetes mellitus and a history of cerebral infarct. During a staff interview, the Director of Nursing confirmed that the expectation was for the collection container to be kept off the floor.
Failure to Provide Sufficient Nursing Staff Resulting in Missed and Late Medication Administration
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff to ensure timely administration of medications on one unit, resulting in missed or late medication doses for four residents. On the morning in question, the scheduled LPN for the Laurel Lane unit arrived late for her shift, and the RN Unit Manager, who was temporarily assigned to cover medication administration, was unable to begin medication passes promptly due to her other managerial responsibilities. As a result, only two residents received their morning medications before the LPN arrived between 9:00 AM and 9:30 AM, significantly later than the scheduled 7:00 AM shift start. Several residents experienced delays or missed doses of critical medications. One resident with hypertension and type 2 diabetes did not receive prescribed insulin with breakfast or lunch, as required, and did not receive any insulin until 2:29 PM, well after both meals. Another resident with hypertension and diabetes missed the scheduled 8:00 AM dose of hydralazine and did not receive morning medications until 11:49 AM. A third resident with Parkinson's disease missed the 8:00 AM dose of carbidopa-levodopa, receiving morning medications at 11:55 AM. Additionally, a resident with congestive heart failure and diabetes did not receive the lunch dose of insulin until more than an hour after the meal began. Staff interviews confirmed that the LPN was frequently late, and the RN Unit Manager was unable to fulfill both her administrative duties and medication administration responsibilities simultaneously. The Director of Nursing stated that the facility's expectation is to have sufficient staff to provide medications to residents in a timely manner. Facility policy requires medications to be administered within one hour of the prescribed time, which was not met in these instances.
Incomplete Documentation of Change in Condition and Physician Notification
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the medical record for a resident who experienced a change in medical condition. Specifically, a resident with a history of congestive heart failure and hypertension exhibited vomiting and loose stools on the morning in question. Although the Director of Nursing confirmed that the Registered Nurse Unit Manager was notified and performed an assessment, there was no documentation of this assessment in the clinical record. Additionally, there was no record of vital signs being taken or documented for the resident on that day, and no documentation that the attending physician was notified of the change in condition. Further review of the resident's medication administration record showed that as-needed Zofran was administered and documented, but there was no documentation of Immodium administration despite it being noted on a handwritten report sheet. Facility policy and staff education require that any change in a resident's condition be assessed, documented, and reported to the physician, but these steps were not fully documented in this case. The Director of Nursing confirmed that the expected documentation was missing.
Insufficient Space Provided for Resident Activities
Penalty
Summary
The facility failed to provide sufficient space for residents to participate in and observe a scheduled activity, specifically the morning Bean Bag Toss held in the Florida Room lounge. Fourteen residents were seated closely together at one end of the room, with one resident sitting in the doorway and another later observed in the hallway due to lack of space. An additional resident was using a computer station in the same area, which further limited available space for the activity. Residents reported having to move to allow others to participate, and one resident expressed hope to rejoin the activity after being displaced. Another resident noted that the room was often too crowded for full participation and that activities interfered with his ability to use the computer station. Staff interviews confirmed that the Florida Room was being used for morning activities due to ongoing repairs to the heating system in the designated Activity Room. The main dining room was used for afternoon activities, but could not be used in the morning as it interfered with dining staff preparations. The Nursing Home Administrator acknowledged that the temporary space did not accommodate all residents wishing to participate or observe, and confirmed that residents were being rotated out due to space limitations. The deficiency was cited under 28 Pa. Code 201.14(a) and 201.18(e)(1) for failing to provide adequate space for resident activities.
Failure to Prominently Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information in a prominent and clearly visible location for residents and visitors. On observation, the staffing posting was found on the upper left-hand corner of the fully opened door of the Human Resources Office, surrounded by several other postings, making it not easily visible. Staff interviews confirmed that this was a temporary placement due to ongoing facility renovations and newly painted walls, and that the posting was usually displayed in the entrance hallway. The Nursing Home Administrator acknowledged that the posting should have been in a clearly visible area and attributed the issue to the process of relocating items after renovations. No specific residents or patient medical histories were involved or mentioned in relation to this deficiency.
Failure to Provide Timely Emergency Care Due to Inadequate Staff Training
Penalty
Summary
Forest Park Nursing and Rehabilitation was found to be non-compliant with federal and state regulations due to a failure to protect residents from neglect. The facility did not provide adequate orientation and training to agency staff, which resulted in a delay in emergency services for a resident who became unresponsive. The resident, who had a history of alcoholic cirrhosis, congestive heart failure, Type 2 Diabetes Mellitus, and pneumonia, was found unresponsive and without a pulse. Despite having a POLST form indicating a full code status, there was confusion among staff due to the presence of a DNR bracelet and conflicting information in the resident's electronic record. The incident involved multiple staff members, including an LPN and an RN, who were agency staff. The LPN assessed the resident and informed the RN supervisor of the resident's condition, but there was a lack of follow-up and coordination in responding to the emergency. The RN supervisor, upon finding the resident unresponsive, did not immediately initiate CPR and instead left the room to obtain a crash cart. This delay, coupled with the absence of staff in the resident's room when EMS arrived, contributed to the failure to provide timely emergency care. Interviews with staff revealed that agency personnel were not familiar with the facility's emergency procedures, including the location of crash carts and oxygen supplies. Additionally, there was no system in place to ensure that agency staff were oriented to the facility's policies and procedures. This lack of training and orientation placed 48 other residents at risk, as they would require emergency intervention if found unresponsive.
Plan Of Correction
1. Facility is unable to retroactively correct issue for Resident #1. 2. DON/Designee audited current resident code status to ensure the order and POLST match on 2/13/25. There are no residents with hospital wrist bands and no special instructions in PCC regarding code status. DON/Designee provided immediate orientation/education to licensed agency and facility staff currently working in the facility on 2/13/25 regarding facility policies on resident code status, copy of floor plan including location of crash carts, oxygen, and other emergency supplies as well as how to meet EMS at the front door after calling 911 if receptionist is not on duty. Education included the following information: if a resident has change in condition, the nurse refers to the order and the POLST. If there is no order and no POLST, resident is automatic full code. If resident is a full code and CPR is to be initiated, code is called immediately. All available licensed staff are to be present and CPR initiated and not stopped until EMS arrives and instructed to do so. Do not freely type a special instruction in PCC regarding code status. When a resident is admitted or readmitted to facility from the hospital, all hospital bracelets are to be removed. This education/orientation was forwarded to agencies 2/14/25 for signatures prior to start of shift. DON/Designee will provide orientation/education to any additional licensed agency and facility staff prior to the start of their shift to include facility policies on resident code status, copy of floor plan including location of crash carts, oxygen, and other emergency supplies as well as how to meet EMS at the front door after calling 911 if receptionist is not on duty. Education will include the following information: if a resident has change in condition, the nurse refers to the order and the POLST. If there is no order and no POLST, resident is automatic full code. If resident is a full code and CPR is to be initiated, code is called immediately. All available licensed staff are to be present and CPR initiated and not stopped until EMS arrives and instructed to do so. Do not freely type a special instruction in PCC regarding code status. When a resident is admitted or readmitted to facility from the hospital, all hospital bracelets are to be removed. Directed in-service was conducted by approved company for F-tag 600 Freedom from Abuse, Neglect, and Exploitation will be conducted on 2/27/25 for licensed nursing staff. Staff will show evidence of understanding by completion of quiz. Staff that cannot attend directed in-service will be provided with education and test to complete prior to working on next scheduled shift. 3. HR Director/Designee will review schedule daily to ensure licensed agency and staff scheduled have completed the orientation or will complete prior to start of shift for new agency staff. As part of new admission process, licensed nurse will review code status documentation to ensure facility code status policy is followed. As part of the post admission record review for new admissions, the IDT will review new admission records to ensure code status documentation reflects resident's correct code status and the facility code status/POLST process was appropriately followed. 4. DON/Designee will audit 10 resident charts weekly for 2 months, then monthly for 3 months to ensure residents have code status in order and if there is a POLST that it matches the order. NHA/Designee will audit licensed agency staff for completed orientation weekly for 2 months, then monthly for 2 months. Results of audit will be reviewed by QAPI committee for any recommendations. DON/Designee will provide orientation/education to any additional licensed agency and facility staff prior to the start of their shift to include facility policies on resident code status, copy of floor plan including location of crash carts, oxygen, and other emergency supplies as well as how to meet EMS at the front door after calling 911 if receptionist is not on duty. Education will include the following information: if a resident has change in condition, the nurse refers to the order and the POLST. If there is no order and no POLST, resident is automatic full code. If resident is a full code and CPR is to be initiated, code is called immediately. All available licensed staff are to be present and CPR initiated and not stopped until EMS arrives and instructed to do so. Do not freely type a special instruction in PCC regarding code status. When a resident is admitted or readmitted to facility from the hospital, all hospital bracelets are to be removed.
Removal Plan
- DON/Designee will provide orientation/education to licensed agency and facility staff to include facility policies on resident code status, copy of floor plan including location of crash carts, oxygen, and other emergency supplies as well as how to meet EMS at the front door after calling 911 if receptionist is not on duty.
- Education will include information: if a resident has change in condition, the nurse refers to the order and the POLST. If there is no order and no POLST, resident is automatic full code. If resident is a full code and CPR is to be initiated, code is called immediately, all available licensed staff are to be present and CPR initiated and not stopped until EMS arrives and instructed to do so.
- Do not freely type a special instruction in PCC regarding code status.
- When a resident is admitted or readmitted to facility from the hospital, all hospital bracelets are to be removed.
- Human Resources Director/Designee will review schedule to ensure licensed agency and staff scheduled have completed the orientation or will complete prior to start of shift for new agency staff.
- This education/orientation will be forwarded to agencies for signatures prior to start of shift.
- DON/Designee will audit current resident code status to ensure the order and POLST match, there are no residents with hospital wrist bands and no special instructions in PCC regarding code status.
- DON/Designee will audit resident charts to ensure resident have code status in order and if there is a POLST that it matches the order.
- NHA/Designee will audit licensed agency staff for completed orientation.
- Results of audit will be reviewed by QAPI committee for any recommendations.
Infection Control Deficiency at Forest Park Nursing and Rehabilitation
Penalty
Summary
Forest Park Nursing and Rehabilitation was found to be non-compliant with infection prevention and control requirements as outlined in 42 CFR Part 483.80. The facility failed to implement its infection control policies effectively, particularly during an outbreak of gastrointestinal symptoms among residents. The facility's policy on 'Isolation - Categories of Transmission-Based Precautions' was not adhered to, as staff did not follow the necessary precautions to prevent the spread of infection. Observations revealed that staff members, including Employees 1, 2, 3, 4, and 5, did not don personal protective equipment (PPE) such as gowns, gloves, or eye protection when entering rooms marked for 'Special Droplet/Contact Precautions.' Additionally, these employees failed to perform hand hygiene before and after entering the rooms. This lack of adherence to infection control protocols was observed across multiple units, including Laurel Lane, Evergreen, Stepping Stone, and Dementia units. The Director of Nursing confirmed that the facility had experienced an outbreak of gastrointestinal symptoms, prompting the implementation of contact precautions. However, staff interviews and observations indicated a widespread failure to comply with the facility's infection control policies. The Nursing Home Administrator acknowledged that it was the facility's expectation for staff to follow these protocols, yet the observed actions demonstrated a significant lapse in infection control practices.
Plan Of Correction
1. Director of Nursing/designee-initiated education for facility and agency staff on following isolation precautions including proper PPE usage. Director of Nursing/designee will conduct initial direct observation and audit to ensure staff can demonstrate proper PPE usage for the following affected residents: Resident # 17, 3. 1, 2, 4, 5. 2. Director of Nursing/designee will conduct a facility wide audit on current residents who are on isolation precautions to ensure proper isolation precautions are being followed including proper use of PPE as required by their specified isolation precautions via direct observation. 3. Director of Nursing/designee will review and update signage for droplet and contact precautions for isolation requirements as recommended by CDC guidelines. 4. Director of Nursing/Designee will audit and review residents needing isolation to ensure that staff are following transmission-based precautions including proper use of PPE required for resident specific isolation via direction observation. These audits will be conducted over all shifts weekly for four weeks and monthly for two months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee for review and recommendations.
Failure to Address Change in Condition Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure proper care and services were provided after a change in condition for two residents, leading to severe consequences. Resident 4 experienced a significant decline in health, with symptoms including low blood oxygen levels and difficulty breathing, which were not promptly addressed by the nursing staff. Despite the resident's oxygen saturation dropping to critical levels, the Licensed Practical Nurse (LPN) on duty did not notify the Registered Nurse (RN) supervisor or the attending physician, resulting in the resident's condition worsening to the point of requiring an emergency hospital transfer. Upon arrival at the hospital, Resident 4 was found to be in a critical state, suffering from cardiac arrest and subsequently passing away. Resident 5, who had a history of pneumonitis, antimicrobial resistance, and COVID-19, also experienced a change in condition that was inadequately managed. The resident's oxygen saturation levels dropped significantly, and although supplemental oxygen was administered, there was no evidence that the RN was informed or that a proper assessment was conducted. Additionally, the resident's medication administration record showed no documentation of nebulizer treatments or supplemental oxygen being administered as ordered, indicating a lapse in following the prescribed care plan. The failure to notify the RN supervisor and/or the attending physician of the changes in condition for both residents placed them and other residents on the unit in an Immediate Jeopardy situation. The lack of timely medical intervention and proper documentation contributed to the deterioration of the residents' health, highlighting significant deficiencies in the facility's adherence to care protocols and communication procedures among the nursing staff.
Plan Of Correction
1. Facility cannot retroactively address changes in condition for Residents #4 and 5. 2. Facility wide audit was completed on 12/6/24 of current residents by review of the facility's 24-hour shift report to ensure that any resident with a change in condition has had an RN assessment completed and documented with notification of the physician and responsible party as appropriate. 3. Education was provided to employee 4 verbally on 11/27/24 and in written form on 12/2/24. Education has been given to licensed nursing staff on change in condition protocol including the need for LPNs and RNs to notify the RN supervisor. RN assessment will be conducted. Physician and resident representative notification and MD orders. Any new/agency staff will be educated on the same protocol. Licensed staff will review the 24-hour shift report as part of the shift-to-shift report to ensure any resident change in condition has been properly followed up on to include RN assessment and required notifications. Directed in-service has been scheduled for December 26, 2024 for licensed nursing staff. This directed in-service will be taped for education purposes. 4. The Director of Nursing/Designee will review the 24-hour shift report for any changes in condition and will ensure that an RN assessment, responsible party, and physician notification was completed weekly for four weeks then monthly for two months and ongoing as needed. Results of audits will be reviewed by QAPI committee for compliance and recommendations.
Removal Plan
- Education was provided to Employee 4 verbally and in written form.
- Education has been given to licensed nursing staff on change in condition protocol including the need for LPNs and RN's as charge nurses to notify the RN Supervisor immediately, including Physician notification and orders. Any New/Agency Staff will be educated on the same protocol on arrival.
- Facility wide audit will be completed of current residents by review of the facility's 24 hour shift report to ensure that any resident with a change in condition has had an RN assessment with notification of the physician.
- Every shift the Director of Nursing or designee will review the 24 hour shift report for any changes in condition and will ensure that an RN assessment and physician notification was completed for four weeks.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent the elopement of a resident identified as being at risk for elopement and exhibiting exit-seeking behaviors. The resident, who had diagnoses including encephalopathy, mild cognitive impairment, and alcohol abuse, was found lying in the parking lot of the facility, medically compromised with a low body temperature and abrasions. Despite having orders for an alarming security bracelet and frequent monitoring, the resident managed to exit the facility through a side door that did not have a wander guard alarm, indicating a lapse in supervision and safety measures. The resident's clinical record showed a history of wandering risk, with assessments indicating a high risk for elopement. However, the care plan was not updated to reflect this risk until two days after the elopement incident. The resident had previously exhibited exit-seeking behavior, setting off door alarms, and was noted to have increased behaviors on the day of the incident. The facility's failure to update the care plan and implement effective interventions contributed to the resident's ability to leave the facility unsupervised. Interviews with the Director of Nursing revealed that the side door used by the resident to exit was primarily used by staff and some family members who had obtained the door code. The door had an alarm that could be bypassed with a code, and it is believed the resident followed a visitor out. The facility's policy prohibited sharing door codes with family members, yet this was not enforced, allowing the resident to elope. The facility's oversight in monitoring and securing exit points, along with inadequate supervision, placed the resident and others at risk for elopement.
Removal Plan
- The code to the side door was changed. The new code was not given to staff or visitors.
- All staff and families have been notified that that door is no longer in use. The door has been closed via signage to noticeably display its lack of service as an exit/entry and only to be used as an emergency exit.
- All staff have been educated on awareness of residents' whereabouts when entering or leaving an exit area.
- Signs have been placed stating the door is presently not in use as an exit/entry and only to be used as an emergency exit and that anyone seeking entryway or exit should go to the main entrance.
- Education included that staff are not to provide the code to doors to family members. A letter has also been sent to all family members that they are only to use the main entrance to enter or exit the facility.
- All residents assessed as elopement risk have been identified and their wander guards checked for functionality.
- Audits will be done weekly on the resident with wander guards for placement and function and also of the exit doors for function.
- Ensure that any resident that is at risk is secured from exiting from the side door.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in several areas, including the multi-purpose room and four nursing units: Evergreen, Laurel Lane, Stepping Stones, and Chapelwood. Observations on October 8, 2024, revealed dried, dark spills and miscellaneous debris on the floors of these areas, as well as dead bugs in the multi-purpose room and its hallway. These conditions were noted during multiple observations throughout the day, indicating a persistent issue with cleanliness. Interviews with two housekeeping employees revealed that there was insufficient staffing to complete all assigned cleaning tasks before the end of their shifts. Both employees stated that the multi-purpose hallway and room were not part of their cleaning assignments, and there was uncertainty about who was responsible for these areas. The Director of Nursing acknowledged the expectation for adequate housekeeping but did not provide a solution to the staffing issue.
Medication Transcription Error Leads to Incorrect Administration
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards of practice for a resident diagnosed with normal pressure hydrocephalus and dementia. The resident returned from a neurology appointment with recommendations to start Rytary and Gabapentin. However, a transcription error occurred, and the resident was mistakenly administered Rytary, which was intended for another patient, for five days. This error was discovered by nursing staff, and the physician was notified. The Director of Nursing acknowledged that the medication order should have been appropriately verified. The error was identified when nursing staff reviewed the neurology consultation report, which included a printed prescription for another patient. Despite the error, the resident suffered no negative outcomes, and the resident's representative was informed of the mistake.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to maintain adequate personal hygiene and grooming for residents who were dependent on staff for assistance with activities of daily living. Specifically, two residents, identified as Resident 1 and Resident 3, did not receive the scheduled number of showers per week as per the facility's standard. Resident 1, who had a self-care deficit related to muscle weakness and impaired mobility, reported receiving fewer showers than the two per week he was supposed to receive. Documentation confirmed that showers were not recorded on several scheduled days, with no refusals noted. Similarly, Resident 3, who had a self-care deficit due to physical limitations and hemiplegia following a cerebrovascular disease, also reported not consistently receiving the scheduled two showers per week. Documentation showed a missed shower on a scheduled day without any noted refusals. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the facility's standard for shower frequency and the scheduled shower days for both residents, but no explanation was provided for the missed showers.
Failure to Provide Transportation Services for Resident
Penalty
Summary
The facility failed to provide necessary transportation services for Resident 5, who has diagnoses including peripheral vascular disease and stage three chronic kidney disease. Resident 5 submitted a grievance after the facility was unable to transport her to a scheduled doctor appointment and a surgical appointment. The first missed appointment on July 2, 2024, was due to the facility's transportation van lacking valid Pennsylvania Department of Transportation registration, rendering it unusable. Consequently, Resident 5 missed her pre-surgical vein mapping procedure. The second missed appointment on July 8, 2024, occurred because the facility's transportation vehicle was inoperable and unable to start. Despite the maintenance personnel restoring the vehicle to operational status later that day, it was too late for Resident 5 to attend her scheduled surgical appointment. The facility did not arrange alternative transportation methods, resulting in the rescheduling of Resident 5's surgical appointment. The Director of Nursing acknowledged the expectation that the transport vehicle should have valid registration and be operational for resident transportation.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the daily posting of nursing staffing information for two consecutive days, specifically on June 16 and 17, 2024. During an observation on June 17, 2024, at approximately 12:00 PM, it was noted that the posted nurse staffing information was outdated, showing the date of June 15, 2024. An interview with the Director of Nursing at approximately 1:10 PM on the same day revealed that the responsibility for posting the daily nurse staffing information lies with either the night shift Registered Nurse or a Human Resources employee. The Nursing Home Administrator confirmed at approximately 1:15 PM that the posted information was indeed dated incorrectly for June 15, 2024, instead of being updated daily as required.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. Observations revealed multiple issues in the kitchen and nourishment rooms, including a black substance on the floor, improperly stored food items, and debris on dishes and storage carts. Additionally, the food preparation area had a heavy build-up of grease and debris, and the cooks' cooler contained improperly dated food items. The nourishment rooms had dirty refrigerators and microwaves, with food debris and sticky substances present. The ice machine had black spots on the inside lid, and the ice scoop was not stored properly. The dishwashing machine was found to be operating at inadequate temperatures, with the wash temperature at 130 degrees Fahrenheit and the rinse temperature at 160 degrees Fahrenheit, both below the required levels. The temperature logs showed inconsistencies and alterations, and there was no indication that the machine was taken out of use despite the low temperatures. The facility's policy required the machine to be stopped if temperatures were not met, but this was not followed. Interviews with staff, including the Certified Dietary Manager and Maintenance Worker, confirmed the issues with the dishwashing machine and the need for an outside service provider to address the problem. Follow-up observations showed that some issues, such as the black substance on the ice machine lid and the sticky residue in the nourishment room refrigerators, remained unresolved. The Nursing Home Administrator and Director of Nursing acknowledged the concerns and confirmed that they expected food to be properly stored, labeled, and dated according to facility policy and guidelines.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of unclean and damaged areas. Resident 9's wheelchair was found with dry dusty debris and dried food on multiple occasions. Resident 15's room had several issues, including a closet door off track, missing window blind slats, food debris on the wheelchair, brown sticky substances on the chair rail and wall, peeling baseboard molding, stains on the wall, and a strong odor of urine in the bathroom with brown splatters and a chipped toilet tank cover. Despite some cleaning efforts, many of these issues persisted over several days of observation. Additionally, the common areas and other resident rooms on the Chapelwood unit had various maintenance issues, such as a discolored hole in the ceiling, brown smears on furniture, disconnected closet doors, falling baseboards, and a sunken area in the hallway. The NHA confirmed that there were no pending work orders for these issues. The Laurel Lane shower room was observed to have feces on the floor on multiple occasions, and Resident 39 reported encountering this issue several times. The Evergreen Unit also had cleanliness issues, with a brown substance splattered on the wall near Resident 207's nightstand, which remained unaddressed over several days. Resident 407's room had blind slats lying on the floor, which were not removed despite being reported to the NHA and DON. Interviews with the NHA and DON revealed that they were aware of these issues and acknowledged that they should have been corrected. However, the observations indicated that the facility did not maintain a clean and homelike environment for its residents, leading to the identified deficiencies.
Failure to Provide Transfer Notifications
Penalty
Summary
The facility failed to provide timely notification to residents, their representatives, and the State Long-Term Care Ombudsman before transferring residents to the hospital. This deficiency was identified for seven out of ten residents reviewed for hospitalization. The clinical records of these residents revealed that they were transferred to the hospital for various medical conditions, including chest pain, changes in condition, and other health issues, but there was no documentation of transfer notices or notifications to the Ombudsman being provided as required. For instance, Resident 4 was transferred to the hospital for chest pain but neither the resident nor the resident's representative received a transfer notice, and the Ombudsman was not notified. Similar deficiencies were found for Residents 32, 35, 63, 71, 72, and 89, who were transferred to the hospital on multiple occasions without the required notifications. The Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed during interviews that the facility did not provide the necessary transfer notices or Ombudsman notifications for these residents. The DON and NHA acknowledged that the facility was aware of the failure to conduct the required notifications at the time of the transfers. Despite staff education being provided, the facility could not produce documentation to show that the notifications had been made. This lack of compliance with notification requirements was consistent across multiple residents and hospital transfers, indicating a systemic issue within the facility's processes.
Failure to Provide Bed-Hold Policy Notices
Penalty
Summary
The facility failed to provide residents or their representatives with a copy of the bed-hold policy upon transfer to a hospital or therapeutic leave. This deficiency was identified through clinical record reviews, facility policy reviews, and staff interviews. Specifically, seven out of ten residents reviewed for hospitalization did not receive the required bed-hold notice. The facility's policy, last revised in March 2022, mandates that all residents or their representatives be given written information regarding the bed-hold policy at the time of transfer or within 24 hours if the transfer was an emergency. However, this policy was not followed for Residents 4, 32, 35, 63, 71, 72, and 89 during their respective hospital transfers between October 2023 and March 2024. For instance, Resident 4, who has diagnoses including hypothyroidism and vascular dementia, was transferred to a hospital emergency room on October 1, 2023, due to chest pain. The facility could not provide documentation that Resident 4 or their representative received the bed-hold policy notice. Similar deficiencies were found for Resident 32, who was transferred to the hospital multiple times in January 2024 due to a change in condition, and Resident 35, who was transferred on February 2, 2024. In each case, the facility failed to provide the required bed-hold notice. Further examples include Resident 63, who was admitted to the hospital on January 23, 2024, and Resident 71, who was transferred on January 5, 2024, due to possible pneumonia. Both residents' records lacked evidence of the bed-hold policy being provided. Resident 72, transferred on December 5, 2023, and Resident 89, admitted to the hospital on December 12, 2023, and March 8, 2024, also did not receive the bed-hold policy notice. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed the facility's awareness of this issue and the lack of documentation for these transfers.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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